By Dorothy Brooks
One of the most vexing medical and behavioral health (BH) issues emergency clinicians confront is opioid use disorder (OUD). In some cases, OUD is the primary complaint, but the issue also arises regularly in patients who have presented to the ED for treatment of another potentially related medical problem.1
Regardless of the circumstances, experts maintain there is a unique opportunity for EDs to help these patients, considering the scope of the opioid problem and the continually rising number of overdose deaths.2 But initiating treatment for OUD has been a consistent challenge, primarily because of the X waiver. Clinicians were required to obtain this waiver to prescribe buprenorphine, the most commonly used evidence-based treatment for OUD.
The American College of Emergency Physicians (ACEP) and other groups have long advocated for the elimination of the X waiver requirement. Finally, this advocacy paid off, as the Substance Abuse and Mental Health Services Administration and the DEA issued guidance to that effect in the Consolidated Appropriations Act of 2023 in January. However, still unclear is what this move will mean for EDs that have been reluctant to initiate patients with OUD on medication-assisted treatment (MAT) with buprenorphine.
Alexis LaPietra, DO, FACEP, system chief for pain management and addiction management at St. Joseph’s Health in Paterson, NJ, and Rachel Haroz, MD, FAACT, division head of toxicology and addiction medicine at Cooper Medical School of Rowan University in Camden, NJ, jointly answered questions about the significance of the move to drop the X waiver, and what other barriers remain.
LaPietra and Haroz argue that eliminating the X waiver normalizes buprenorphine use ED providers. They see it as a good thing that buprenorphine will no longer be shrouded in mystery as a “restricted medication.” Rather, it can be used now universally as an evidence-based treatment of opioid withdrawal and OUD. However, the duo also note applying for the X waiver was never that hard.
“In fact, in 2021, the eight-hour education [X waiver requirement] was removed for physicians with a 30-patient limit ... yet the amount of prescribing increased only minimally,” LaPietra and Haroz observe. “Therefore, it behooves us to consider that there are many other barriers to prescribing buprenorphine.”3
For instance, LaPietra and Haroz suggest a consistent lack of universal substance use education in medical school and residency programs “perpetuates a reluctance to engage, diagnose, treat, and appropriately refer this patient population.”
In addition, they note continued silos that keep substance use treatment outside mainstream healthcare tend to limit the kind of collaboration and streamlined referral processes needed between EDs and outpatient providers.
“Hopefully, there will be practitioners willing to step outside their comfort zone and utilize this life-saving medication with the X waiver gone,” they say. “There will be education made readily available in the coming months to help ED practitioners understand and appreciate the mortality benefit linked to buprenorphine prescribing. This, however, is only a first step.”
LaPietra and Haroz note data supporting buprenorphine use for OUD is solid, and emergency medicine societies have unanimously published recommendations supporting this approach.4 However, they note ED prescribing remains relatively uncommon, and it lags behind these recommendations. “Requiring a special license to prescribe a medication separated this process from mainstream medicine and was, in itself, stigmatizing,” they observe. “While the removal of the X waiver is certainly a step in the right direction to boost and support prescribing, the stigma runs deep.”
For instance, LaPietra and Haroz explain OUD is a chronic medical disease, with considerable evidence supporting its pathophysiologic process and treatment success with buprenorphine. “However, unlike other disease processes, the practice of prescribing does not follow the evidence,” they say. “Patients with OUD have been marginalized, vilified, and continue to have evidence-based, life-saving care withheld. The ED is their safety net, and emergency physicians bear the responsibility to right this wrong. The hope is our healthcare systems, communities, and families will then follow suit.”
REFERENCES
1. O’Reilly LM, Dalal AI, Maag S, et al. Computer adaptive testing to assess impairing behavioral health problems in emergency department patients with somatic complaints. J Am Coll Emerg Physicians Open 2022;3:e12804.
2. Centers for Disease Control & Prevention. Drug overdose. Death rate maps & graphs. Last reviewed June 2, 2022.
3. Brooks D. Feds ease X-waiver training requirements, emergency providers advocate further action. ED Management. July 1, 2021.
4. American College of Medical Toxicology. ACMT position statement buprenorphine administration in the emergency department.
The X Waiver Is Gone — Now What?
Now that the X waiver has been eliminated, what other steps are needed to make medication-assisted treatment widely available in EDs? Experts offer the following recommendations:
• Universally incorporate substance use education into medical school and residency curricula nationally. This must address pathophysiology, treatment, harm reduction, and a patient-centered approach.
• Integrate substance use disorder treatment into mainstream medicine by specifically housing it within the healthcare system and allowing for multidisciplinary collaboration on care between outpatient and inpatient addiction facilities and the medical system. The process for referral to care must be as easy for patients with OUD as it is for patients with other chronic medical diseases, such as diabetes and hypertension.
• Revamp pharmacy wholesale regulations that limit the availability of buprenorphine in community pharmacies nationwide, affecting the most vulnerable communities. Changes are needed to allow for better access.
• Make trained and supervised substance use navigators part of the ED treatment team. Their job should entail engagement, screening, and referral, as well as addressing social determinants of health that directly affect medication and follow-up.
• Make medical staff aware that harm reduction is an effective morbidity and mortality-reducing intervention. Translate patient autonomy into OUD care by ensuring people can access clean supplies, naloxone, and safe injecting education to lower the risk of HIV, hepatitis, severe bacterial disease, and overdose death.
A lack of universal education in medical school and residency programs might perpetuate a reluctance to engage, diagnose, treat, and appropriately refer patients with opioid use disorder. Silos that keep substance use treatment outside mainstream healthcare can limit the collaboration and streamlined referral processes needed between EDs and outpatient providers.
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