When the X-Waiver gets X’ed: Implications for hospitalists


There are two pandemics permeating the United States: COVID-19 and addiction. To date, more than 468,000 people have died from COVID-19 in the U.S. In the 12-month period ending in May 2020, over 80,000 died from a drug related cause – the highest number ever recorded in a year. Many of these deaths involved opioids.

COVID-19 has worsened outcomes for people with addiction. There is less access to treatment, increased isolation, and worsening psychosocial and economic stressors. These factors may drive new, increased, or more risky substance use and return to use for people in recovery. As hospitalists, we have been responders in both COVID-19 and our country’s worsening overdose and addiction crisis.

Table 1. Resources for buprenorphine education

In December 2020’s Journal of Hospital Medicine article “Converging Crises: Caring for hospitalized adults with substance use disorder in the time of COVID-19”, Dr. Honora Englander and her coauthors called on hospitalists to actively engage patients with substance use disorders during hospitalization. The article highlights the colliding crises of addiction and COVID-19 and provides eight practical approaches for hospitalists to address substance use disorders during the pandemic, including initiating buprenorphine for opioid withdrawal and prescribing it for opioid use disorder (OUD) treatment.

Buprenorphine effectively treats opioid withdrawal, reduces OUD-related mortality, and decreases hospital readmissions related to OUD. To prescribe buprenorphine for OUD in the outpatient setting or on hospital discharge, providers need an X-Waiver. The X-Waiver is a result of the Drug Addiction Treatment Act 2000 (DATA 2000), which was enacted in 2000. It permits physicians to prescribe buprenorphine for OUD treatment after an 8-hour training. In 2016, the Comprehensive Addiction and Recovery Act extended buprenorphine prescribing to physician assistants (PAs) and advanced-practice nurses (APNs). However, PAs and APNs are required to complete a 24-hour training to receive the waiver.

Dr. Richard Bottner

On Jan. 14, 2021, the U.S. Department of Health and Human Services under the Trump administration announced it was removing the X-Waiver training previously required for physicians to prescribe this life-saving medication. However, on Jan. 20, 2021, the Biden administration froze the training requirement removal pending a 60-day review. The excitement about the waiver’s eradication further dampened on Jan. 25, when the plan was halted due to procedural factors coupled with the concern that HHS may not have the authority to void requirements mandated by Congress.

Many of us continue to be hopeful that the X-Waiver will soon be gone. The Substance Abuse and Mental Health Services Administration has committed to working with federal agencies to increase access to buprenorphine. The Biden administration also committed to addressing our country’s addiction crisis, including a plan to “make effective prevention, treatment, and recovery services available to all, including through a $125 billion federal investment.”

Despite the pause on HHS’s recent attempt to “X the X-Waiver,” we now have renewed attention and interest in this critical issue and an opportunity for greater and longer-lasting legislative impact. SHM supports that Congress repeal the legislative requirement for buprenorphine training dictated by DATA 2000 so that it cannot be rolled back by future administrations. To further increase access to buprenorphine treatment, the training requirement should be removed for all providers who care for individuals with OUD.

The X-Waiver has been a barrier to hospitalist adoption of this critical, life-saving medication. HHS’s stance to nix the waiver, though fleeting, should be interpreted as an urgent call to the medical community, including us as hospitalists, to learn about buprenorphine with the many resources available (see table 1). As hospital medicine providers, we can order buprenorphine for patients with OUD during hospitalization. It is discharge prescriptions that have been limited to providers with an X-Waiver.

Dr. Marlene Martin

What can we do now to prepare for the eventual X-Waiver training removal? We can start by educating ourselves with the resources listed in table 1. Those of us who are already buprenorphine champions could lead trainings in our home institutions. In a future without the waiver there will be more flexibility to develop hospitalist-focused buprenorphine trainings, as the previous ones were geared for outpatient providers. Hospitalist organizations could support hospitalist-specific buprenorphine trainings and extend the models to include additional medications for addiction.

There is a large body of evidence regarding buprenorphine’s safety and efficacy in OUD treatment. With a worsening overdose crisis, there have been increasing opioid-related hospitalizations. When new medications for diabetes, hypertension, or DVT treatment become available, as hospitalists we incorporate them into our toolbox. As buprenorphine becomes more accessible, we can be leaders in further adopting it (and other substance use disorder medications while we are at it) as our standard of care for people with OUD.

Dr. Bottner is a physician assistant in the Division of Hospital Medicine at Dell Medical School at The University of Texas at Austin and director of the hospital’s Buprenorphine Team. Dr. Martin is a board-certified addiction medicine physician and hospitalist at University of California, San Francisco, and director of the Addiction Care Team at San Francisco General Hospital. Dr. Bottner and Dr. Martin colead the SHM Substance Use Disorder Special Interest Group.

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