Eliminate exemption X for the prescription of buprenorphine?


The federal government has relaxed restrictions on the “X waiver” that doctors need to prescribe buprenorphine and other drug treatments for opioid use disorder (OUD), but Kristin Mack, DO, wants it more – she would like to see the waiver eliminated entirely.

“It has to be treated like any other chronic illness,” Mack, a family doctor in Ticonderoga, New York, said in a telephone interview. Requiring the waiver “reduces our patients’ access to this type of treatment, which has good evidence behind it.”

Mack is the author of a resolution that will be presented at the next meeting of the Congress of Delegates of the American Academy of Family Physicians; the resolution calls on the AAFP to lobby for waiver X to be removed. The delegates meeting would normally have taken place this month in conjunction with the AAFP’s FMX meeting, but it has been postponed until next spring due to the COVID-19 pandemic.

Previously, GPs who wanted to treat OUD patients with drugs, especially buprenorphine, had to get a waiver, which required them to undergo an 8-hour training course and offer patient counseling. In January, the outgoing Trump administration issued guidelines eliminating the waiver for physicians who were treating no more than 30 OUD patients at a time, as long as they were prescribing buprenorphine and not methadone. Physicians using the Exemption X exemption should put an “X” on the prescription, clearly indicate that the prescription is for an opioid use disorder, and keep separate records for patients treated for the prescription. a TOU.

In April, the Biden administration issued similar guidelines and added physician assistants, nurse practitioners, clinical nurse specialists, certified nurse anesthetists and certified nurse midwives to the list of clinicians eligible for the exemption. The new guidelines also eliminated the requirements for prescribers to complete an 8-hour training course and offer counseling to OUD patients. Those who wish to treat more than 30 patients must still obtain a waiver.

Mack’s resolution notes that “there is overwhelming evidence showing that drugs for opioid use disorder (ODD) reduce drug use, rates of illness, overdoses, deaths, spending on drugs. health and crime “and that” despite such compelling evidence, 90% of OCD patients in the United States do not have access to MOUD and only 23% of publicly funded treatment programs offer an approved MOUD by the FDA and less than 50% of private sector treatment programs offer an FDA approved MOUD.

He asks the AAFP to “advocate for the elimination of waiver X and to oppose any additional future requirements that would limit the ability to prescribe buprenorphine.”

If the exemption were removed, would that not allow untrained doctors to prescribe buprenorphine? “We’ve been talking with graduate medical degree programs in terms of residency programs, and we’re looking to ‘require’ that this training be done as part of the training programs,” Mack said. “As we move forward we see young interns and people new to the profession doing exactly what we hope for the future, which is treating it as a chronic illness on a visit. regular in the office, and not for it to be “sub-specialized.” So it’s my ideal situation, it is to see all the family doctors able to do it. “

Treating patients for opioid addiction is very rewarding, said Mack, who obtained his own X waiver shortly after completing his residency in 2014 and is now helping train other physicians who want the waiver.

“Throughout my career, I have been able to establish some of my best trusting relationships with [OUD] patients when I see them frequently and give them medication, “she said. And the financial barriers of addiction disappear for them.”

The ability to provide MOUD is important for doctors in rural areas like hers, she added.

“My patients don’t have other places to go,” she said. “We work really hard with community resources to provide advice and things like that. But if I were to say to someone, “Oh, you have to go to a city for an hour to get treatment” and then they have to be seen monthly, that’s just not an option. And rural communities are among the hardest hit by the opioid epidemic. “

When asked about the idea of ​​eliminating the waiver, a spokesperson for the Substance Abuse and Mental Health Services Administration (SAMHSA) noted that the waiver was established under the Drug Addiction Treatment Act of 2000 – also known as name of DATA 2000 Act – and Congress would need to write a new law if it wanted to remove the waiver.

The spokesperson also noted that in April 2020, the law was adjusted to allow the telemedicine prescribing of buprenorphine, including by telephone, in accordance with guidelines issued jointly by the Drug Enforcement Administration and SAMHSA.

“SAMHSA will refrain from commenting on actions planned by Congress,” its spokesperson said.

  • Joyce Frieden oversees the coverage of MedPage Today in Washington, including articles about Congress, the White House, the Supreme Court, health professional associations and federal agencies. She has 35 years of experience in health policy. To follow

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