Of the two sets of recent legal changes, the Mainstreaming Act “will have a bigger impact,” predicted Thakrar. The removal of the X-waiver requirement is intended to increase the universe of health care professionals who prescribe buprenorphine, which, unlike methadone, is often covered by non-governmental health insurance. Even before the end of the X-waiver, accessing buprenorphine presented fewer challenges to OUD patients. Patients can be treated in a primary care setting rather than a methadone clinic and can obtain their medicine at a pharmacy for one to four weeks.
“Buprenorphine is safer than other opioids that doctors routinely prescribe, but the X-waiver signaled that there is something scary about the drug. Dropping the waiver helps destigmatize buprenorphine,” Lowenstein said.
“[Now] if a provider is approached by a patient who requests buprenorphine, they can prescribe it right away rather than waiting to apply for a waiver,” said LDI Senior Fellow Shoshana V. Aronowitz, an Assistant Professor of Family and Community health at Penn’s School of Nursing.
“[However], existing studies using data from the waiver era show that half of providers with the X-waiver did not prescribe buprenorphine and the other half mostly prescribed well below the limits of concurrent patients,” noted Bao. She added, “The hurdle is greater for providers in a practice that has not yet started treating OUD because the stigma is greater and there is concern that treating OUD patients might drive away non-OUD patients.”
One improvement proposed by both Thakrar and Lowenstein would be to increase the use of telehealth by buprenorphine prescribers. “This would go a long way toward improving access,” Thakrar said.
Thakrar also recommends a more fundamental shift that might increase the use of all forms of medication treatments for opioid disorders: educating medical students and residents about these treatments. “There’s a risk that current providers don’t understand that addiction is treatable,” Thakrar said.