After X-ing the X-Waiver: Will More Physicians Prescribe Buprenorphine?

The U.S. Department of Health and Human Services (HHS) overturned their longstanding requirement that physicians must receive approval and undergo training to prescribe buprenorphine, the topline treatment for opioid use disorder (OUD). This is an historic shift in policy, and its importance cannot be overstated. Last week, there were fewer than 100,000 waivered providers. Now, over one million active physicians are permitted to prescribe buprenorphine to up to 30 patients at any one time (hospital-based physicians who initiate buprenorphine treatment are not subject to the 30-patient limit).

The buprenorphine waiver long served as an undue barrier to substance use treatment, but its removal is only a step. In the U.S., a minority of providers treat the majority of patients seeking buprenorphine treatment. Even among waivered physicians, the median number of monthly patients treated with buprenorphine was 8.3. There are at least two reasons why this trend may continue. 

First, nurse practitioners and physician assistants are notably absent from the list of approved providers. Advanced practitioners have been a key part of combatting the opioid epidemic, treating vulnerable and/or hard-to-reach populations. For example, advanced practitioners play an inordinate role in treating patients in federally qualified health centers, which cater to Medicaid and uninsured populations.

The second reason is stigma. The fact is, many physicians will still be hesitant to prescribe buprenorphine. Numerous surveys of primary care physicians highlight why, with respondents citing concerns about diversion, safety risks, practice disruptions, and a lack of expertise. Another survey suggests that negative beliefs about patients with OUD—over three-quarters of primary care physicians said they would be unwilling to work closely with a person with OUD, while two-thirds believed that people with OUD are more dangerous than the general population.

Yet the vast majority of physicians believe that they hold responsibility in addressing the opioid epidemic. Thus, an unwillingness to prescribe buprenorphine may not stem from stigma per se, but instead from the fact that stigma is systemic and baked into incentives, financial and otherwise. For example, caring for patients with substance use disorders may require expensive shifts in practice design and new personnel, like care coordinators and licensed clinical social workers, but reimbursement is often inadequate (Medicaid is the largest payer for substance use treatments in the U.S.). In order for this policy shift to translate into better access to treatment, payers and health systems should consider the resources that providers need to treat substance use disorders adequately.

For too many physicians, addressing the opioid epidemic has been important in theory but rare in practice. Let HHS’s historic decision to remove the buprenorphine waiver serve as a call to arms—patients have a right to access evidence-based practices like buprenorphine, while physicians have the responsibility to provide it.