Article Commentary: It Will End in Tiers: A Strategy to Include “Dabblers” in the Buprenorphine Workforce after the X-Waiver

Abstract

Buprenorphine is one of the gold standard medication treatments for opioid use disorder (OUD), with proven effectiveness in preventing overdose, increasing abstinence, and improving quality of life. In the United States, buprenorphine can be legally prescribed and administered in office-based settings from clinicians who are specially credentialed to provide that care under the X-waiver. We believe the X-waiver will ultimately be repealed, but there is a need for a variety of strategies to create a new treatment system after the X-waiver. Building a new tier of treatment capacity will require educational outreach, systems strategies, and enhanced payments.

Prescribe to Save Lives: Improving Buprenorphine Prescribing Among HIV Clinicians

“…42 Partly because of this regulatory barrier, nationally over 90% of clinicians have not attended training. 44 Previous incentive strategies to motivate clinician attendance to buprenorphine trainings have included integration within graduate medical education, which led to 27% trainees obtaining X-waiver 45 or providing a $750 financial compensation for training time that led to 89% completion of X-waiver training, but low, highly variable rates of prescribing buprenorphine. 46 Even though practice guidelines have removed the mandatory to attend a buprenorphine training before getting an X-waiver, our findings suggest that our isolated intervention may be an additional strategy to encourage HIV clinicians to obtain their X-waiver and prescribe buprenorphine.…”

Federally Qualified Health Centers Can Expand Rural Access to Buprenorphine for Opioid Use Disorder in Arizona

“…Emergency department bridge programs and OTP-OBOT hub and spoke models provide compelling blueprints. 58 Additional access opportunities include the continued use of telehealth for buprenorphine induction and maintenance, as implemented during COVID-19. 59 Telehealth offers unique opportunities for creative solutions, including connecting individuals to MOUD via navigators at harm reduction services.…”

Are x‐waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x‐waiver trainings

“…Unfortunately, in the United States, only a relatively small number of clinicians are responsible for the majority of B‐MOUD prescribed 17–19 . Despite national priorities to expand the number of x‐waivered clinicians who prescribe B‐MOUD, 20,21 the number of clinicians obtaining x‐waivers has remained modest, many x‐waivered clinicians do not prescribe any B‐MOUD and those that do prescribe to few patients 17–19,22–27 . Prior research has indicated that training requirements to apply for and obtain an x‐waiver are burdensome 21,28–30 .…”

“…Despite national priorities to expand the number of x‐waivered clinicians who prescribe B‐MOUD, 20,21 the number of clinicians obtaining x‐waivers has remained modest, many x‐waivered clinicians do not prescribe any B‐MOUD and those that do prescribe to few patients 17–19,22–27 . Prior research has indicated that training requirements to apply for and obtain an x‐waiver are burdensome 21,28–30 . In an attempt to address barriers to B‐MOUD prescribing, in 2021, the US waived several requirements to submit an NOI to obtain the x‐wavier—including the educational requirement—if the applicant intends to treat less than 30 patients at any one time.…”

“…These ongoing implementation processes after the pieces of training may also have assisted the participants during any disruption in OUD care caused by COVID‐19 as less than a third of trainees in our survey reported change in practice during COVID‐19 44,45 . As the US reduces training requirements to obtain the x‐waiver, particularly for those clinicians who want to “dabble” in B‐MOUD, it may be that ongoing mentoring through services such as the provider clinical support system (PCSS) and expert external facilitation to overcome local barriers to care—such of those of ADaPT‐OUD and SCOUTT—become even more important 21,35–39 . Similar to the intentions of several other large health care systems, the VHA has a vested interest in addressing OUD and implementing MOUD care, and this investment of not only training but also mentoring and ongoing facilitation, maybe just as important 38,39,46 …”