The End of the X-Waiver Is a Chance to Advance Health Equity

    On January 12, the federal government announced an important change to drug policy that should enable greatly expanded access to buprenorphine, a crucial opioid use disorder medication. This change could stem the course of our nation’s devastating opioid-involved overdose epidemic. And it’s a step toward redressing policies that have harmed lowerincome communities as well as Black, Indigenous and other people of color.

    Of the three medications approved for the treatment of opioid use disorder, methadone and buprenorphine are the most commonly prescribed. Both are proven to be effective, and greatly reduce a person’s risk of dying by overdose.

    Methadone, however, is tightly restricted; federal law permits it to be prescribed and administered only in specialized addiction treatment settings known as opioid treatment programs, or methadone clinics.

    The X-waiver created a number of needless and harmful barriers to access.

    Buprenorphine, on the other hand, may be prescribed in any setting. Many formulations can be self-administered. But until recently, health care providers had to obtain a Drug Addiction Treatment Act Waiver—commonly called an X-waiver—to prescribe it.

    The X-waiver created a number of needless and harmful barriers to access. These included the eight-to-24 hours of additional training required for prescribers; additional administrative hurdles; and imposed limitations on the number of patients a provider could treat.

    Passage of the 2023 Omnibus Bill—which included the Mainstreaming Addiction Treatment (MAT) Act, first introduced in Congress in 2019—has now finally resulted in elimination of the X-waiver. This is critical at a time when overdose deaths have been surging for more than a decade.

    In recent years, our nation has lost the annual equivalent of a mid-sized city to drug overdose, culminating with more than 100,000 overdose deaths in 2021. It is important to highlight that the rate of death has not been distributed evenly. Overdose death rates are disproportionately high in communities of color and communities experiencing high poverty rates. These concentrations of overdose deaths are the direct result of decades-long, racist social policies that structurally disadvantage these communities.

    The barriers created by the X-waiver requirement served to ration effective treatment for opioid use disorder, thereby reinforcing structural racism and redlining policies in our health and public health systems.

    It is now incumbent on the entire health care field to maximize this opportunity to advance health equity.

    Buprenorphine has been far more accessible to whiter and wealthier communities, which have benefited from more prescribers willing to obtain an X-waiver. Meanwhile, communities that are predominantly Black, Brown or experiencing poverty have tended to have very limited access to buprenorphine. Methadone, which is subject to requirements like frequent attendance at clinics, has long been the only option—a high-barrier one—for many members of these communities.

    The elimination of the X-waiver therefore has the potential to advance health equity across the country. But this will only be achieved if providers and public health agencies actively ensure that buprenorphine is provided equally in financially disadvantaged communities and for people of color.

    It is now incumbent on the entire health care field to maximize this opportunity. We must ensure that critical treatments are not hindered by barriers, and that lifesaving care is accessible to everyone in need.



    Photograph of Suboxone tablets by Supertheman via Wikimedia Commons/Creative Commons 3.0

    • Dr. Chinazo Cunningham is the commissioner of the New York State Office of Addiction Services and Supports (OASAS). She has more than 20 years’ experience in research, care and program-development that focuses on people who use drugs. She lives in New York.

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