Good News for Correctional Providers: Prescribing Buprenorphine Just Got Simpler
Earlier this week, the Department of Health and Human Services announced a new practice guideline that removes barriers for providers when obtaining the “X-waiver” needed for prescribing buprenorphine for opioid use disorder. This change is a monumental step in expanding access to treatment for people with OUD and in saving lives, especially for individuals who are incarcerated. And it is welcome news to correctional health providers, who care for many patients with OUD at risk for postdischarge overdose and death.
In contrast to the now-rescinded HHS practice guideline, the new guideline includes not only physicians, but also nurse practitioners, physician assistants, certified nurse midwives, certified clinical nurse specialists, and certified registered nurse anesthetists. The new practice guideline makes it much simpler to prescribe buprenorphine by omitting the training and complicated SAMHSA and Drug Enforcement Administration applications previously required.
Obtaining an X-Waiver
To obtain the waiver, a provider must submit a notice of intent, with specific statutorily required certifications, to SAMHSA. Once SAMHSA approves the waiver request and notifies the DEA of that approval, DEA will issue an X-waiver identification number authorizing that provider to treat OUD patients with buprenorphine. For information on how to submit an NOI, contact SAMHSA at 866-287-2728 or email@example.com. SAMHSA also provides this quick start guide as well as FAQs.
The exemption allows providers to use buprenorphine to treat up to 30 patients without having to obtain certain training-related certifications. It also allows providers to prescribe buprenorphine without certifying as to their capacity to provide counseling and ancillary services. For providers who reach the 30-patient limit, new slots will open once patients are discharged from their care, i.e., released from jail or prison. Providers who fulfill the prior training requirements can request increases in the patient limits.
The exemption for the waiver requirement will allow correctional providers who hold DEA licenses to prescribe buprenorphine for patients currently receiving it, to initiate it for maintenance, or to use it to withdraw patients from opioids, e.g., patients who do not wish to be maintained. The exemption will likely improve access to postrelease treatment by community providers, as well.
People with OUD who return to their communities after incarceration have a high risk of fatal and nonfatal overdoses. Treating them while in custody, including with buprenorphine, can literally save lives, as is supported by robust research. There are other benefits to providing incarcerated individuals access to OUD medication treatment while they are in custody, such as decreased illicit drug use and fewer disciplinary issues.
Buprenorphine is an FDA-approved, evidence-based, and life-saving treatment for OUD. While the benefits of providing access to medication treatment for OUD in custody are well-established, one of the biggest barriers is the X-waiver requirements for buprenorphine. This is concerning not only for people who were not in treatment in the community, but especially for those who were in treatment with buprenorphine; because of the X-waiver requirements, many people stable on treatment are not able to continue their therapy in custody. Furthermore, pregnant people with OUD should not go through withdrawal. Buprenorphine is a safe and effective treatment for that population, as well.
Correctional providers will no longer need to go through this extra step and can prescribe buprenorphine for their patients who need it. But we still have a long way to go.
More Change Still Needed
First, the suspension of the X-requirements is not permanent. We need legislation that will formalize the change.
Second, we need to continue efforts to implement OUD treatment in custody settings so that treatment is patient-centered, evidence-based, and linked to community treatment when patients leave prison or jail.
Third, although buprenorphine is safe and effective for OUD treatment, it does not work for everyone. Just as some patients with hypertension may respond better to a calcium channel blocker than a beta blocker, people with OUD have different treatment success with buprenorphine, methadone, or naltrexone.
We would not deny insulin to a patient with diabetes. Nor should we deny treatment to individuals with OUD.
Medication-assisted treatment save lives. We need regulatory changes and implementation strategies that can ensure access to all FDA-approved treatment options.
By Kevin Fiscella, MD, MPH, CCHP, and Carolyn Sufrin, MD, PhD. Dr. Fiscella is the American Society of Addiction Medicine liaison to the NCCHC Board of Representatives; Dr. Sufrin is the American College of Obstetricians and Gynecologists liaison.
For more information, see Jail-Based MAT: Promising Practices, Guidelines and Resources published by NCCHC and the National Sheriffs’ Association.