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1/ The end of the X waiver is exciting news. The question is how much of a difference will this make in buprenorphine treatment access? To answer that question we must ask ourselves how many providers are out there for whom the waiver is the only remaining barrier to prescribing?
2/ The answer is we don't know. What we do know is that there have been many valiant, expansive, and well-organized efforts in last years to help providers who wanted waivers get them. In my state of NC there have been too many free in-person and online waiver trainings to count.
3/ That leads me to think that there may not be many providers left for whom the waiver was the last remaining barrier. But I could be wrong. Certainly I would expect there to be geographic variation based on local efforts to get providers waivered and support them prescribing.
4/ For those of us who have argued against the waiver requirement, it's a shame to think that efforts to get providers waivered could've been focusing on the many remaining barriers to treatment: prior authorization, low reimbursement, lack of specialty consultation, etc.
5/ Yes, let's celebrate this development. While I don't think we'll see a large immediate jump in buprenorphine prescribing, I do think we'll see an increase trend moving forward, especially as prescribing becomes less monitored by regulators and less stigmatized by providers.
6/ But let's also now shift our focus to the other barriers to treatment. I mentioned some provider-side barriers above. On patients' side, it's almost impossible to start and stay in addiction treatment without safe housing, enough food, meaningful activities and social support.
7/ To the extent buprenorphine does become more available, we must understand how this affects drug use. There are risks and possible benefits to diverted buprenorphine. In NC, it's now uncommon to see a patient come for buprenorphine treatment who hasn't used it illicitly.
8/ Providers have never needed waivers to prescribe buprenorphine for pain (one of the many absurdities of this regulatory regime). That said, I wonder if the end of the waiver wo;; lead providers be more willing to prescribe the naloxone formulations for off-label uses (pain).
9/ Those are some thoughts from working in the addiction field for almost 14 years, first in community organizing then in policy then in research and treatment. I remember first hearing about bupe when I was organizing in 2007 in NYC, though I didn't know anyone who took it.
10/ That'll bring me to my last point: don't forget about methadone. It's cheap, safe and effective. The X waiver doesn't compare to the massive regulatory mountains patients and providers must scale to access this treatment that was saving lives long before bupe made its debut.
