Today, any health care provider with a license from the U.S. Drug Enforcement Administration (DEA) to prescribe controlled substances can write a prescription for an opioid painkiller. But that same health care professional cannot prescribe one of the three main drugs used to manage opioid dependence without first undergoing hours of training and receiving approval from the DEA. As opioid overdoses kill approximately 48,000 Americans a year—130 each day—Congress has an opportunity to eliminate these outdated requirements and help expand access to lifesaving care.
Bipartisan bills in both the House and Senate would remove the federal rule requiring doctors, nurse practitioners, and physician assistants to attend training and obtain DEA approval (known as an “X waiver”) before prescribing buprenorphine for patients with OUD. Buprenorphine, which helps alleviate painful symptoms associated with the disorder, is one of the drugs approved by the Food and Drug Administration to be used in conjunction with behavioral therapies—an approach known as medication-assisted treatment, or MAT. The gold standard of care for managing patients with opioid use disorder, MAT helps individuals stay in treatment longer, reduces illicit opioid use and infectious disease transmission, and decreases overdose deaths.
The bills seek to address two critical challenges. Today, only 1 in 9 Americans with a substance use disorder receives any kind of care. And as of 2017, 44 percent of U.S. counties had no physician authorized to prescribe buprenorphine, which translates into 20 million Americans living in areas where no doctor has been granted a DEA waiver.
This lack of access to treatment for OUD in the United States is partly due to the mandatory training and waiver requirements for prescribing buprenorphine for OUD—restrictions that significantly limit the availability of care in comparison to countries that don’t impose similar rules. For example, physicians in France—including those practicing in offices and not only those working in specialized addiction treatment facilities—have been free to prescribe buprenorphine for OUD without any further education or licensing since 1995. In just a few years, French office-based prescribers were writing more than 90 percent of all buprenorphine prescriptions, more than two-thirds of people struggling with OUD were given medication, and overdose deaths in France decreased by 79 percent.
In addition to limiting the number of U.S. health care professionals who can prescribe buprenorphine, the mandated training may also be redundant for providers who already participate in continuing medical education (CME) courses, which many states require to maintain a medical license. Thirty-seven states require practitioners to take opioid-specific CMEs, covering issues such as pain management, prescribing, and addiction. The elimination of education requirements beyond CMEs could encourage these providers to begin treating patients whom they otherwise couldn’t help. What’s more, existing trainings supported by the Substance Abuse and Mental Health Services Administration, including the agency’s Providers Clinical Support System (PCSS), would still be available to providers looking for more support before prescribing, even if the training wasn’t required. PCSS has been integral to recruiting experienced clinicians to serve as mentors for providers interested in treating patients with substance use disorder.
Furthermore, the current constraints on buprenorphine prescribing reinforce the idea that addiction treatment differs from traditional medical care. Eliminating the training and waiver could help put addiction on the same footing as diabetes and other diseases that require medical care, which might encourage more health care providers to incorporate addiction treatment into their practices.
Finally, some people with OUD obtain buprenorphine indirectly, from an acquaintance with a prescription or by purchasing it illicitly—a practice known as diversion. One study indicated that the primary reason for buprenorphine diversion was demand from those seeking to manage their OUD who were unable to access treatment. According to the DEA, increasing buprenorphine prescribing may be an effective way to prevent diversion.
The opioid crisis continues to devastate communities across the country. Yet we currently allow the counterproductive combination of authorizing health care providers to prescribe opioids—but not medication to manage opioid use disorder. Both House and Senate bills would address this inconsistency by removing barriers to care and expanding access to effective care for OUD. Congress should pass this legislation, and prescribers throughout the nation should make substance use treatment more readily available to patients in need.
Allan Coukell is senior director with The Pew Charitable Trusts’ health programs.