SUD Treatment Providers Split on Buprenorphine Flexibilities Nixed by Biden

At Landmark Recovery’s nine inpatient recovery centers across the U.S., patients battling opioid use disorder (OUD) only get access to buprenorphine for short stints, usually as a detox medication. But Senior Medical Director Melvin Pohl would like to start offering the drug as part of long-term treatment, with patients being referred to community providers who could help them stay in recovery after discharge.

That plan is dependent on a few policy changes from the federal government: Pohl wants to see better access to buprenorphine, which means making it easier for clinicians to prescribe the medication-assisted treatment drug.

Medication-assisted treatment with buprenorphine is largely considered the gold standard for treating individuals with OUD. Clinicians who want to prescribe the drug have to get a so-called X-waiver, which entails an eight-hour course and sometimes a 60- to 90-day wait to receive the waiver after the course has been completed and a license application has been submitted.


Still, Pohl said he had mixed feelings when the Trump administration announced plans in January to remove some buprenorphine certification requirements. The relaxed rules would have allowed any physician with a DEA prescriber license to prescribe buprenorphine to up to 30 in-state patients without going through the typical eight-hour training process. Plus, hospital-based physicians would have automatically been allowed to treat more than 30 people. Meanwhile, the policy changes didn’t apply to nurse practitioners or physician assistants.

With those relaxed educational requirements, more providers would likely have chosen to prescribe the MAT drug, making it easier for Landmark’s patients to find doctors in their home communities post-discharge.

While increased access would be a positive, Pohl said he thinks prescribers should have to go through some amount of education for the sake of patient safety.


“It was like, gosh, so that means you can go to your family doctor, who has no training in buprenorphine, and get a script? I don’t think that’s great. Maybe the eight hour requirement is too burdensome, and streamlining the process makes sense,” Pohl told Behavioral Health Business. “If you give buprenorphine within the first 24 hours of using an opiate, you’ll precipitate withdrawal. To simply expect that an untrained practitioner is going to be sufficient to prescribe the medication makes me very nervous.”

Pohl’s concerns were quickly alleviated, though, when the Biden administration nixed Trump’s relaxation of the buprenorphine rules in late January, citing Congress’ sole authority to make such changes. If and when Congress does so, Pohl hopes lawmakers will opt for a happy medium, ensuring prescribers receive some buprenorphine training but reducing burden by shortening the course to two or four hours.

“We really messed up with opioids,” he said. “We horribly overprescribed indiscriminately. So let’s not make the mistake with buprenorphine. Let’s not have a culture that’s awash with buprenorphine who aren’t accessing any sort of recovery.”

Annie Peters, the director of research and education at the National Association of Addiction Treatment Providers (NAATP), said she’s heard from many behavioral health providers on both sides of the issue.

“The concern about over prescribing is a fear: Sure, there would be more prescribing, but the prevailing notion is that [it] would lead to a decrease in overdose deaths,” Peters told BHB.

She noted that medication is only one part of what MAT should entail and that the larger provider community wants people to get the right wraparound services.

“We want people to transform their lives; But in order to do that, they have to be alive,” Peters said. “So, anything that helps them and that can save lives is something we’d support.”

Similarly, Recovery Centers of America Chief Science Officer Deni Carise said she hopes the new administration moves quickly to eliminate the eight-hour training and other overly restrictive parts of the X-waiver. COVID-19 has only led to an increase in overdose deaths, and 40% of U.S. counties do not have a single health provider authorized to prescribe buprenorphine.

“Like with any medical disorder, we have to be able to offer all of the options for treatment that have been shown to work,” Carise told BHB. “Why don’t we feel like we have to limit prescriptions for other opioids? It just seems very capricious that we have these requirements and the cap [on number of patients prescribers can serve].”

That cap is another major roadblock to treatment access. Prescribers have a 30-patient limit in their first years after getting their X-waiver. That’s a bigger issue than the eight-hour educational course in the eyes of David Hayden, senior VP of clinical services at Spero Health. He said he hopes the Biden administration and Congress will reduce the amount of time providers must wait before being able to prescribe to a higher number of patients.

“We have a lot of clinics in very rural areas in Kentucky, Tennessee and Ohio where it’s hard to find to find a provider [and], when you say, ‘You can only see 30 patients in a month,’ they want to do that,” Hayden told BHB. “[The flexibility proposed by Trump] was a step in the right direction, but it was a half step. It wasn’t as much as I think is required [to open up access].”

Written by Lisa Gillespie

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