Tucked away in a 1,600-page spending bill passed by Congress in December are several paragraphs that, Colorado experts say, will open up a key opioid treatment to more patients and shift America closer to modernizing medical treatment for addiction.
For more than two decades, health care providers have had to get additional training and a special waiver to dispense buprenorphine, a medication used to help treat people with opioid addictions. The regulations not only limited who could prescribe the drug but also created a sense of mystery, complication and stigma around it, further curtailing its use even as the country struggled against years of spiraling opioid deaths.
But thanks to a relative blip in a roughly $1.7 trillion bill, the requirement — known to providers as the X-Waiver — is gone. Substance-use treatment experts and physicians had long lobbied for its elimination, and several — in interviews and on social media — said they hoped it was a sign that federal officials were on a path to expand access to other treatment medicines, too. In the short term, the waiver’s disappearance will mean less work for doctors and more medicine out the door. But the larger, more lasting impact, experts said, is the signal the move sends: that American health care is beginning to better fold addiction treatment into the medical mainstream.
“(Ending the waiver) stops setting aside buprenorphine as another medicine that needs some kind of special understanding in order to utilize it clinically,” said Josh Blum, a Denver Health physician and past president of the Colorado chapter of the American Society of Addiction Medicine. “And that requirement made a lot of people shy away from ever using it or considering it. It sort of perpetuated this history of keeping substance-use disorder treatment apart or siloed or separated out from general medical care. From a physician standpoint, that’s the most important.”
The waiver was well-intended but misguided, experts said. Buprenorphine is an opioid, which raises fears of misuse, and it’s used by addiction physicians to bind to opioid receptors in the brain, blunting the withdrawals and cravings. It’s weaker and safer than its cousin, methadone, or its illicit relatives like heroin or counterfeit fentanyl. It was already less controlled than methadone, too, and federal officials further loosened training requirements in 2021. The waiver’s final elimination — which came virtually overnight, with no wind-down period — was inevitable, and welcomed.
“Frankly, good effing riddance,” said Tyler Coyle, an addiction treatment physician at the University of Colorado School of Medicine who helps oversee the training of future Colorado physicians.
Coyle said the amount of work needed to obtain the waiver meant that even providers who jumped through the hoops to get it were reticent to use it. The waiver created an air of hesitation and fear about buprenorphine, he said. Its elimination will nix that feeling, he said, for future generations of providers to come.
Blum and Coyle hope that the waiver’s elimination means that federal regulators will now unwind requirements around methadone. It’s considered the most effective opioid treatment medication, particularly amid the influx of fentanyl into the drug supply. But it’s also long been the most tightly controlled, requiring patients to pick up doses in person at specially approved clinics with little margin for error. Like the X-Waiver, federal regulators loosened some methadone requirements because of pandemic disruption.
Those changes, coupled with what happened to the X-Waiver last month, is a hopeful sign for addiction specialists eager to see further changes to treatment.
“There already is a trend towards that,” Blum said. “Really when you think about what we’re talking about is a trend away from perfection and toward a harm reduction approach to addiction treatment.”