As People Who Use Drugs, We Urge Biden to End the Buprenorphine X-Waiver

In late January, the Biden Administration walked back one of the biggest steps toward opening access to medications for opioid use disorder (MOUD) in recent history. The administration stated that it would not be releasing practice guidelines announced by the Department for Health and Human Services in the dying days of the Trump administration.

These guidelines would have allowed any physician with a DEA narcotics prescribing license to prescribe buprenorphine to up to 30 patients without the need to acquire an “X-waiver.” The X-waiver, a DEA requirement long opposed by harm reductionists and now most major medical associations, mandates special training for prescribers, paid for out-of-pocket, before they are licensed to write buprenorphine prescriptions, under heavy regulatory scrutiny, for a limited number of patients.

In April 2020, Urban Survivors Union (USU), the national drug-user union we represent, called for removal of the X-waiver and other barriers to buprenorphine and methadone access during COVID-19 in a sign-on letter. Over 140 organizations signed on—including the ICRC (International Certification and Reciprocity Consortium), the body which certifies all clinicians who work in opioid treatment programs—as well as many prominent individuals, such as former “drug czar” Michael Botticelli.

Our statements continue to meet the same paternalistic and mistaken assumptions that drug users have faced for centuries.

Despite such widespread support, our letter drew sharp criticism from several high-ranking officials, including the head of AATOD (The American Association for the Treatment of Opioid Dependence), an organization that represents more than 1,000 opioid treatment programs (OTPs, often known as methadone clinics) in the US. The board’s president stated, “A number of policy groups are making recommendations about OTP operations without understanding the mechanics of how OTPs function.”

This statement could not be further from the truth. Not only have many of our members been attending opioid treatment clinics for decades, but some are current or former opioid treatment professionals and subject matter experts. Our statements continue to meet the same paternalistic and mistaken assumptions that drug users have faced for centuries. In a time when a larger portion of Americans are dying from drug poisoning than any other point in history, those who claim to care about human life need to be thinking of ways to increase safety, not diminish it. This safety goal ought to be shared regardless of one’s political affiliation or economic bent.

Contrary to the claims of SAMSHA (the Substance Abuse and Mental Health Services Administration), the X-waiver has not decreased stigma or increased overall access to treatment. Neither did it prevent an imagined diversion problem. The X-waiver simply erected another blockade against MOUD, and people die all the time because they can’t access these gold-standard medications.

At the heart of these barriers to humane healthcare is stigma, both explicit and implicit. We believe that the best way to fight that stigma is to uphold and genuinely listen to the voices of people who are stigmatized. As history shows, rights revolutions are always begun by those who are the most impacted.

For this reason, we call  for a compassionate response from the Biden administration to our brothers and sisters who are dying in record numbers during COVID and beyond. We urge our government not to allow political affiliation to interfere with an opportunity to save lives. Regardless of whether the impetus came from the Health Department, the Justice Department or Richard Simmons, we at USU would support repealing the X-waiver.

We believe that buprenorphine can be delivered in a way that is informed, careful and safe, and that this would be best accomplished by removing the badge of stigma that the doctors and patients involved with these medications wear. Medications for substance use disorders need to come out of the siloed, shadowy zone that our regulatory system has shoved them into—and into the light of mainstream medicine where science prevails.

Until the US decides to stop this barbaric “War on Drugs”—a war on us—methadone and buprenorphine are the closest things we have to a safe supply of opioids. This simple fact refutes arguments about the need for specialized education that only the X-waiver can bring, or about how repealing the waiver will only bolster stigma by causing bad actors to make buprenorphine more available than ever.

The double standard here is stigma.

Not only is the addiction education that most doctors receive stigmatizing, but no similar training is required to prescribe morphine, dilaudid, oxycodone, or any other opioid agonist medication besides buprenorphine and methadone. Training on how to prescribe opioid treatment medications should be no different from training on how to prescribe any opioid.

The double standard here is stigma. Regardless of how it is sliced, applying a different set of rules to addiction treatment drugs than to the rest of medicine will only serve to vilify people in need and keep addiction health care on the fringe.

As for the fear of diversion, most people who do divert these medications are simply helping folks who are seeking treatment that is out of reach. The evidence shows that between 70 and 90 percent of diverted medications are going to friends or family members in withdrawal, or to others who cannot access treatment due to the classist way services are delivered. The X-waiver is creating the very problem it seeks to solve.

The American Medical Association acknowledged this when it wrote in June 2020 that, “[r]estrictions on [medication-assisted treatment] arising from the waiver requirement may actually increase the likelihood of diversion. Diversion of buprenorphine, where it exists, is more likely to be a symptom of inadequate access to MAT than due to a behavioral pattern of compulsive drug use in the face of continued harm that characterizes addiction.”

The American Medical Association is far from alone.Most major medical associations, as well as PEW trusts, a bipartisan research think tank, have called for removal of the X-waiver.

A statement from the Center for Popular Democracy’s cuts to the heart of the matter: “Medication Assisted Treatments like buprenorphine should just be referred to as medicine. There should be no special barriers that keep life saving medication out of the hands of people who need it. The X waiver creates stigma and kills. President Biden must permanently remove this ridiculous relic of the 1990’s War on Drugs.”

“When I told her the stigma I face being on MAT, she said, ’But you’re a person on MAT who’s still alive to talk about it.”

The words of our own leadership team member Dinah Ortiz, who has successfully been on MOUD for over a decade, are particularly poignant. “ I’ve been on Suboxone for over 10 years,” she said. “It saved my life. Had it not been for Suboxone I wouldn’t be alive today. I was a bag away from the grave because it was around then that fentanyl started appearing in heroin.”

“I’m thankful not only for Suboxone but for my doctor, who I’ve been with since day one, who has been my rock,” Ortiz continued. “When I told her the stigma I face being on MAT, she said, ’But you’re a person on MAT who’s still alive to talk about it.”

The defamation of MOUD treatment, which has continued for over 50 years, must end. Crossing off at least one unnecessary hurdle, as Trump’s Health and Human Services department, attempted to do was a step in that direction—possibly the one thing the Trump administration got right.


The Path Forward

It is our hope that the Biden administration, despite its current silence, will take a rational approach to regulating these medications—one that is informed by both science and the lived experience of those of us most impacted.

Opioid-involved poisoning is now the leading cause of accidental death for Americans under the age of 50, and it is time for our health care system and physician education programs to address this reality. If we were truly solutions-focused, we would make addiction medicine required learning for any doctor with a license to prescribe.

We need serious, innovative reforms, and any future regulatory change that claims to be aimed at increasing access to treatment must include methadone.

This administration should not only do away with the X-waiver and expand education; it should put a stop to the double standard of additional restrictions surrounding buprenorphine’s older sister, methadone.

Amid the unprecedented COVID-19 pandemic, inadequate loosening of restrictions has left many people who use drugs with a choice between daily exposure to a virus in overcrowded clinics and debilitating withdrawal. Exposing people to a life-threatening disease, every day for months on end, just because they take methadone is an unconscionable human rights violation.

We need serious, innovative reforms. We need to build on programs like the one in New York city that delivers mobile methadone, and any future regulatory change that claims to be aimed at increasing access to treatment must include methadone. The medication has much more data to support it than buprenorphine, and an anecdotally wider group of drug users who stand to benefit from it. It also happens to cost much less. Rational treatment of this issue must weigh the relatively small risk of harmful diversion or overmedication against the real, constant risk of death that those of us who use heroin and fentanyl face.

As people who use drugs and are deeply impacted by opioid regulations, we at USU have every right to call for systemic change. We are not the ill-informed, incapable people this culture or some in power would believe us to be—nor are we diseased, hijacked brains in need of a parental figure to guide us, as drug courts and treatment providers assume.

Rather, we are experts in this subject matter. We understand opioids, treatment and the related science. We will never cease to fight for a country where the Declaration of Human Rights is more than a list of platitudes, a world where drug users have the same right to health and safety as every other person.


Photograph by Gage Skidmore via Flickr/Creative Commons 2.0

Aaron Ferguson, Dinah Ortiz & Caty Simon

Aaron is on the leadership team of the Urban Survivors Union, a national group of advocates for drug-user health. Aaron is also a regional impact manager with Community Medical Services, a national harm reduction-informed provider of medications for people with opioid use disorder. Aaron works to advocate for and implement methadone and buprenorphine treatments in jails, prisons, inpatient rehab settings and communities in general. Dinah is on the leadership team of the Urban Survivors Union. She is a writer and activist who has dedicated her time to advocating to end the stigma surrounding PWUD and PWID. She has spent over eight years advocating for marginalized parents in a variety of contexts, and contributing to Rise magazine, The Chronicle for Social Change and other publications. She has appeared on dozens of panels nationwide to discuss the racial disparities in the child welfare system. Caty is on the leadership team of the Urban Survivors Union. She is the co-editor of Tits and Sass, a long-running media site by and for sex workers. Her writing has appeared in The Forward, AlterNet, Vice, Refinery29, the Raw Story, make/shift magazine and HTMLGiant. She is a small-town activist with history working in drug users’ unions, harm reduction, low-income rights and mad movement campaigns.

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