The X-Waiver Needs to Go

BARRIERS TO MEDICATION-ASSISTED TREATMENT PREVENT EMERGENCY PHYSICIANS FROM SAVING MORE LIVES

Mark Rosenberg, DO, MBA

This past year was the deadli-

est year in U.S. history. While most people are understandably focused on COVID-19, many of our other healthcare challenges did not diminish and some have been getting much worse. We experienced a record-breaking year for drug overdose deaths in 2020 and a large proportion of those tragedies can be traced to opioids.

Today alone, about 130 people will not survive an opioid overdose. Safe and effective treatment options, such as buprenorphine administered through medication-assisted treatment (MAT), can be lifesaving when it is able to be used in the nation's emergency departments. This is especially important because more patients are relying on emergency physicians for care than ever before. However, barriers to medication-assisted treatment are preventing emergency departments from saving more lives.

Emergency physicians are often the best or only option for many patients, and we are at the center of solutions to many of the nation's biggest health challenges, especially the opioid crisis. Emergency departments are following the successful example of states like Colorado, which reduced prescribing of these medicines by 20% by prioritizing alternatives to opioids. And across the country, a growing number of emergency physicians want to administer medication-assisted treatment as an early intervention that can help patients enter long-term treatment in their communities.

Extensive experience and data show that buprenorphine is one of the most effective treatments for people with opioid use disorder. This medication can cut the risk of overdose death in half. And patients started on buprenorphine in the emergency department are twice as likely to remain in treatment, which is a significant challenge for people struggling with addiction, particularly in communities with limited treatment options outside of the emergency department. Congressional action is critical to addressing the hurdles that block access to medicationassisted treatment in the emergency department. A principal barrier is the "X-waiver." Prescribing clinicians must obtain an X-waiver, the mandatory but onerous certification that includes completion of eight to 24 hours of additional training. This requirement isn't necessary for any other prescribed medication. Momentum is growing to address this barrier. This week, emergency physicians are in Washington, D.C. to advocate for the passage of the bipartisan Mainstreaming Addiction Treatment (MAT) Act (H.R. 1384/S. 445), legislation that removes this bureaucratic hurdle and would improve patient access to treatment for opioid use disorder by eliminating the X-waiver requirement for prescribing physicians.

The Biden administration took a step in the right direction earlier this year by loosening the burdensome training requirements for clinicians treating 30 or fewer patients. But the continued presence of the X-waiver perpetuates the stigma associated with these treatments, which also plays a role in preventing clinicians from prescribing buprenorphine to patients. As a result, this treatment remains unnecessarily isolated from normal healthcare delivery. Another issue is that clinicians must still complete the registration process for the waiver through the Drug Enforcement Agency, which can take months—time that we cannot afford to take right now as CDC data show that we just experienced the largest annual increase in drug overdose deaths in at least a half-century.

The MAT Act treats buprenorphine like any other essential medication. The bill also calls for a national education campaign to encourage health professionals to better integrate substance

abuse treatment into practice, provide training modules, and highlight available resources to improve the way we approach opioid emergencies.

Emergency physicians are leading efforts to improve the way we address the opioid epidemic across the country. Increasing patient access to care for opioid use disorder and reducing stigma around treating it in the emergency department are major priorities for us and other advocates. Beyond just legislation, evidencebased substance use disorder clinical practice guidelines, training courses for physicians, and advocacy for changes that improve physician training and patient care related to treating and preventing opioid misuse and overdose are all essential.

While there is much more to ending the opioid crisis than medication-assisted treatment, passing the MAT Act to encourage access to a vital treatment is an important step forward that we should take immediately. The sooner treatment is started, the easier it is to maintain and the more likely it is that a recovery plan can succeed.

Mark Rosenberg, DO, MBA, is the president of the American College of Emergency Physicians. This commentary originally appeared in Medpage Today in July.