Ending the X-Waiver Doesn’t End OUD-Meds Stigma in Health Care

    Many health care organizations have praised, as they should, the repeal of the X-waiver that unjustifiably restricted buprenorphine prescribing. Buprenorphine and methadone are the “gold standard” medications for opioid use disorder (MOUD). But while much commentary has suggested that this change, mandated by Section 1262 of the Consolidated Appropriations Act, 2023, will automatically mainstream MOUD access, reality is far more complicated.

    If history is to be believed, change will be slow at best. Just look at what happened—or didn’t—after the passage of other pioneering laws in this area, such as the Hughes Act of 1970 and the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).

    The sad fact is, there is too little will to improve the medical treatment of people who use drugs or are in recovery (PWUD/IR). Why is there such little will? The answer is cultural stigma. 

    All United States residents with a TV or internet connection are bombarded with news stories, depicting people who use drugs as deviants who break into homes, rob people and commit other crimes. This is a message that has percolated from legislators, members of law enforcement and health care professionals, too—even if many are now actively trying to undo the damage their colleagues have done.

    Opioids are discussed as the scariest of all drugs. Inflammatory and misleading articles proclaim fentanyl seizures as capable of murdering thousands or even millions of people, or spread the myth that you can overdose just by touching fentanyl. Some states, like Virginia, are working to pass legislation that would classify fentanyl as a “weapon of terrorism”, and members of Congress and 18 state and territory attorney generals have called upon the federal government to treat illicitly manufactured fentanyl as a “weapon of mass destruction.”

    And no matter how expert in their field, we know that health care workers are not immune from this media bombardment. How do we know? Because we have the data. 

    Only 24 percent of health care professionals believe MOUD should be made available in health care settings.

    Elevyst and Pennsylvania Recovery Organizations Alliance (PRO-A), along with data powerhouse RIWI, just released the largest study to date examining endorsed and perceived drug-use and recovery stigma, expressed by US health care workers as compared to non-health care workers.

    Between June 9 and June 24, 2022, 24,733 respondents opted in to our survey, including 5,708 health care professionals. We found that over 80 percent of health care workers support the integration of harm reduction strategies into the places where health care is delivered. 

    Unfortunately, a lack of support for MOUD persists. Only 24 percent of health care professionals believe MOUD should be made available in health care settings. This finding aligns with our prior work, which found only 28 percent of respondents viewed people who take medications for their addiction as “always in recovery.”

    When it comes to opioid use disorder, the myth of “trading one drug for another” is deeply ingrained in medical culture—even when that drug is FDA-approved and has robust research to support its life-changing and life-saving impact. This is reflected in another recent study in the International Journal of Drug Policy, demonstrating that only around 13 percent of people with OUD in the US actually received MOUD.

    One standout finding from our report was that health care professionals who spent the most time caring for PWUD/IR had a much greater belief that a person who used drugs problematically can definitely maintain recovery—and a much greater belief that the cause of substance use disorders has more to do with external factors (things that can be changed) versus internal factors (things that cannot be changed). 

    The message here is that instead of driving PWUD/IR away from our systems of care, we should do the opposite: Welcome them in, embrace them, and deliver the kind of care and compassion that should be afforded to any patient.

    While the end of the X-waiver paves the way for successful changes, it is nowhere near sufficient. Physicians who wrongly assume that buprenorphine (Suboxone) is a drug for hedonistic enjoyment or a form of “enabling” will still never prescribe it for OUD.

    Substance use, substance use disorder, harm reduction and recovery need a committed educational module, woven into the fabric of every medical school.

    It is certainly possible that, for a sliver of physicians, the extra effort to get the X-waiver was truly the only barrier. It is also true that physicians will no longer be limited to 30, 100, or 275 MOUD patients at a time. But what is really needed is cultural change.

    How can cultural change be possible? It has to start with education that leads to behavioral change. Addiction in general is treated as a footnote in the medical curriculum, and is not given much more attention by any other health care field besides psychology or social work. Substance use, substance use disorder, harm reduction and recovery need a committed educational module, woven into the fabric of every medical school.

    Perhaps most importantly, PWUD/IR must be treated as a protected class in the health care environment, similar to race, class or gender. Discrimination must never be tolerated. When a health care student, such as a medical student or resident, degrades or dehumanizes a person because of their status as a PWUD/IR, that student should be addressed accordingly. Using terms like “drug seeker” or “addict” should be no more acceptable than other kinds of slurs.

    It is a long road before PWUD/IR begin to get the respect and consideration they deserve. It’s crucial to recognize that a single advancement under law is just one small step on that journey.



    Sean Fogler is the cofounder of Elevyst, which produced the new report. Rory Fleming was one of the report’s writers.

    Photograph via PxHere/Public Domain

    • Sean is a physician living in long-term recovery. He is the cofounder of Elevyst, a public health consulting group, and co-chair of the Health Justice for Pennsylvania Coalition.


      Rory is the founding attorney of Fleming Law LLC, an immigration law boutique in Philadelphia. He has worked for a variety of criminal justice and harm reduction nonprofits, including Law Enforcement Action Partnership and Harvard Law School’s Fair Punishment Project, and provided campaign services for over a dozen district attorney campaigns. His articles have appeared in the Atlantic, Slate and many other outlets.


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