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Addiction patients face blocks to care

Physicians no longer need an X-waiver to prescribe buprenorphine. So why are providers still hesitating to treat addiction patients? 
By admin
Mar 14, 2023, 3:04 PM

As opioid addiction fatalities climbed in the past twenty years, the federal government restricted access to Buprenorphine, a medication considered the gold standard of care for opioid use disorder. Many claimed the waiver created an unnecessary obstacle.  

“It made no sense that doctors and nurses could prescribe opioids, yet faced separate restrictions on prescribing medication to treat those struggling with opioid addiction,” said Senator Maggie Hassan (D-New Hampshire) of the X-waiver. 

After a long-fought bi-partisan push, President Biden removed the X-waiver requirement in 2023 through the Mainstreaming Addiction Treatment (MAT) Act  which mandated 

  • Physicians no longer need a waiver to prescribe buprenorphine for opioid use disorder  
  • Physicians are no longer limited in the number of opioid use disorder patients they can take on 

Making treatment more accessible to patients is especially important for communities where doctors with the X-waiver were few and far between.  

 Dr. Raul Gupta, MD, director of the White House Office of Drug Control Policy, said that when a patient with opioid use disorder sought help from him, he had to refer the patient “to a specialist nearly 100 miles away.” 

“But he provided for his family of four working at a small business in town on minimum wage, and my referral meant he would need to take time off work and spend money on gas to get there.” 

The patient sought illicit drugs and died in hospital from an overdose.  

Stories like these are not uncommon. About 75% of drug-related deaths in 2020 involved an opioid and the rate of deaths involving an opioid increased 30% from 2019 to 2020.  

MAT Act increases access to care … in theory 

While the removal of the X-waiver makes it legally easier for doctors to prescribe opioid addiction treatment, many providers are still choosing not to. 

“Just the process associated with taking care of our patients with a substance use disorder made us feel like, ‘boy, this is dangerous stuff,'” Dr. Bobby Mukkamala, MD, chair of  the American Medical Association (AMA) task force on substance use disorder, told NPR. 

He says the legacy of the X-waiver is enough to deter providers and on top of that, most clinicians are inexperienced and untrained in dealing with opioid use disorder patients. The AMA and American Society of Addiction Medicine have launched online resources to help providers get more training in addiction treatment and opioid use disorder.  

History shows us that training isn’t enough to expand care. From 2016 to 2022 Rhode Island required all doctors in the state to obtain an X-waiver, physicians capable of prescribing buprenorphine increased by 200%, but patients receiving treatment increased by only 8%.  

Providers want social resources to prescribe addiction medication 

Another study corroborated the Rhode Island example with findings that showed “not educated enough about Opioid Use Disorder” came low on the list of reasons physicians are hesitant to prescribe opioid addiction treatment drugs. 

Of the physicians surveyed that had the waiver but not prescribing to capacity (52%), 18.4% said they would increase prescribing if provided with information about local counseling resources and 12.5% said they would increase prescribing if paired with an experienced provider.  

Implementing support groups for patients and mentorship programs for physicians might be essential to bridging the gap between patients and providers.  

Sarah Wakeman, MD, medical director for substance use disorder at Mass General Brigham suggests introducing insurance reimbursement to non-clinician healthcare providers essential to addiction care, like recovery coaches and case managers.  

The fact that primary care providers have no legal barrier in prescribing addiction medication already has the potential to revolutionize addiction care in the U.S., but it might just be the first step.   

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