In late April, the Biden Administration announced new flexibilities to make it easier for eligible clinicians to prescribe the medication-assisted treatment (MAT) drug buprenorphine.
The changes allow doctors and certain clinicians registered by the U.S. Food and Drug Administration (FDA) to automatically administer buprenorphine to up to 30 patients at a time. Previously, clinicians had to complete extra hours of training and receive a special certification called an X-waiver before they were allowed to administer the MAT drug.
The rule change applies to eligible doctors, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists and certified nurse midwives.
Considering the spike in the number of overdose deaths amid the pandemic, there’s hope that the new flexibilities could be a useful tool for combating the nation’s substance use disorder (SUD) epidemic. However, lack of true mental health parity and lingering stigma surrounding MAT might still get in the way of progress toward that goal.
According to provisional data released recently by the Centers for Disease Control and Prevention (CDC), 2020 saw more than 93,000 overdose deaths, many of which were opioid-related. That’s the highest annual number on record.
MAT is considered the gold standard for opioid use disorder (OUD) treatment, and buprenorphine MAT is one of the most successful types, as it is safer and less addictive than alternatives such as methadone MAT.
The drug, which is an opioid itself, is used in combination with counseling and therapy to help individuals manage withdrawal symptoms, in addition to reducing cravings for opioids and the feelings of elation associated with taking them. However, MAT has historically been difficult for patients to access.
Only about one third of private SUD providers have made MAT medications for OUD available. Additionally, staffing shortages remain a major barrier to offering MAT.
“One of the crucial pieces of addiction treatment is expanding access to medication-assisted treatment,” Annie Peters, the director of research and education for the National Association of Addiction Treatment Providers (NAATP), told Behavioral Health Business. “One of those pieces was the X-waiver, where providers needed to get special training for prescribing specifically buprenorphine products, which have a lot of evidence behind them as being helpful for OUD.”
But when it comes to whether the new MAT rules will be helpful in expanding SUD access, NAATP Director of Public Policy Mark Dunn said the jury is still very much out. He believes remaining barriers still pose a bigger access issue than X-waivers.
“Reimbursement rates, for example, are a huge problem,” Dunn told BHB. “The fact that the Mental Health Addiction and Parity Act is not applied to Medicare and Medicaid is another huge problem.”
By law, the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires insurers to cover behavioral benefits no more restrictively than medical and surgical services. However, data has shown that disparities in coverage still exist.
When it comes to Medicare and Medicaid, those disparities are even more pronounced, as MHPAEA does not apply to Medicare. Meanwhile, MPHAEA applies to some but not all Medicaid programs; it varies from state to state. Additionally, there’s little information on how much parity is actually implemented on behalf of enrollees, according to research done by the nonpartisan Medicaid and CHIP Payment and Access Commission.
“There are many reasons that … access to care [is impacted],” Dunn said. “While eliminating the X-waiver is one positive step, I don’t think by itself it’s going to have a huge impact on accessibility.”
Still, he’s hopeful that the Biden administration will take additional steps to improve behavioral health parity and accessibility, given President Biden’s track record and the fact that his son, Hunter, has been public about his own experiences with SUD.
“We are pleased that the president has a long history of involvement and understanding of substance use disorders, being very vocal about the problems he’s had within his own family,” Dunn said. “He’s been very supportive as a senator and as vice president of the treatment field, so we are optimistic and hopeful that his administration will make major strides toward … enforcing the Parity Act.”
Another lingering MAT access issue that exists is stigma. Peters, who welcomes the new buprenorphine flexibilities, said more clinician and community education could help reduce stigma associated with the drug and prompt more providers to prescribe it.
“The concern around buprenorphine — and this still exists in some sectors of the addiction treatment community — is the idea of using an opiate to treat an opiate,” she said. “But … the prevailing notion is that the benefits of expansion outweigh the risks.”
In terms of what the buprenorphine flexibilities mean for behavioral health providers, the new rules aren’t likely to change much as it relates to business operations, according to Elijah Wilder, regional medical officer for Franklin, Tennessee-based Landmark Recovery, which has 11 locations across eight states. Instead, they’ll change the patient experience.
“The aforementioned policy changes will not significantly change things as far as the day-to-day operations in our facilities right now,” Wilder said in a statement to BHB. “However, the changes will help make buprenorphine treatment more accessible prior to and after leaving care at our facility, and may come into play when we plan to transition to providing buprenorphine maintenance treatment in the near future.”
Wilder said he hopes the relaxations are further proof of policymakers’ commitment to taking concrete steps to tackle SUD — and that the addiction treatment industry has earned a guaranteed seat at the policy reform table.
“Unfortunately, addiction has shown no signs of stopping,” Wilder added in his statement. “This appears to be a long-term issue that will require long-term solutions, and input from medical providers and addiction specialists will be invaluable and necessary to develop effective policies and plans for moving forward.”
Meanwhile, Jack O’Donnell, who is the Tucson, Arizona-based CEO of C4 Recovery Foundation, told BHB the new flexibilities could help providers bring on new clients and grow their footprints — though doing so is admittedly a tall order given the nationwide shortage of behavioral health providers.
“If you’re expanding the number of people that can prescribe these medications, it obviously opens up more opportunities for those businesses that might want to have six, seven or eight [facilities] spread throughout a city,” he said.
C4 is an Algonquin, Illinois-based business consultancy for SUD treatment providers. It also works with health care systems and policymakers.
Overall, 37% of Americans live in areas where there is a shortage of behavioral health services such as SUD treatment, according to a report from the not-for-profit civic initiative USAFacts. There’s also a shortage of buprenorphine prescribers.
“Take a city like Tucson, going back a few years,” he said. “I don’t think that there were more than five or six doctors that … had the ability to prescribe the right medications. If you can expand who can prescribe [buprenorphine], I think it’s going to make it easier for people to expand their businesses and serve different geographical areas within a given city or state.”
O’Donnell said the new flexibilities will likely benefit overlooked populations such as single mothers, homeless people and incarcerated individuals the most. Overall, he believes that the new guidelines can help improve MAT access.
“I do think all providers can probably improve [their services] … and MAT, if done properly, offers an opportunity to do a better job treating the general population,” he said.