X the X-Waiver: How Congress can facilitate treatment for opioid abuse

Next month will mark a full calendar year since the lives of millions of Americans were turned upside down as a result of the COVID-19 pandemic. However, even as the coronavirus continues to ravage communities across the country, another public health crisis is still devastating American families: our nation’s fatal addiction to opioids. In 2019, nearly 50,000 Americans lost their lives to an opioid overdose — a 136 percent increase just since 2010. 

There’s alarming new evidence that overdose rates have jumped even further since the March 2020 COVID-19 emergency declaration. According to the most recent available data from the Centers for Disease Control and Prevention (CDC), both April and May saw the largest monthly increases in opioid deaths on record. It’s easy to understand how the stress, dislocation and uncertainty caused by the pandemic would be devastating for those suffering from substance use disorders. People across the country are in pain and too many are dying.

The good news is that safe and effective treatment options exist, but Congress must act to ensure these options are more widely available. One type of medication for opioid use disorder, called buprenorphine, helps diminish the effects of physical dependence on opioids, such as withdrawal symptoms and cravings. Experts worldwide, including the National Institute on Drug Abuse, agree that buprenorphine is a safe, effective treatment for opioid use disorder. 

In the United States, however, medical practitioners are limited in how they can prescribe this lifesaving treatment. The Drug Addiction Treatment Act of 2000 requires that practitioners apply for a waiver, commonly known as the X-Waiver, in order to legally treat patients for opioid use disorder using buprenorphine. Practitioners must complete between eight and 24 hours of specialized training before they can apply for this waiver and, even after receiving it, are restricted in the number of patients they can treat. 

When it comes to the powerful opioids that have created this crisis of addiction, prescribers do not need any kind of waiver to prescribe these deadly drugs. Yet, the law demands that prescribers get a waiver to prescribe the safer medication that serves to treat opioid use disorder. In fact, buprenorphine is the only drug for which the law requires prescribers to provide proof of special training in order to prescribe. The law is, frankly, upside down. 

This X-Waiver requirement not only erects a barrier that limits the number of prescribers treating patients, but also creates a stigma against the use of buprenorphine for treatment. As a result, less than 6 percent of practitioners are certified to prescribe it. This has led to a significant treatment shortage across the country, especially in rural America. A 2020 Department of Health and Human Services (HHS) report found that 40 percent of counties did not have a single provider who could legally prescribe buprenorphine. 

As the attorneys general of Oklahoma and North Carolina, we see the cost of addiction among our constituents every day. In North Carolina, 64 out of 100 counties are considered “high need for treatment services,” and in Oklahoma, 59 of 77 counties have the same distinction. Unfortunately, only 1 in 5 individuals with an opioid use disorder is receiving the treatment they need. Clearly, despite all the attention paid to the opioid epidemic in recent years, more needs to be done, especially in the wake of the COVID-19 pandemic.

In 2018 and 2019, we joined our colleagues at the National Association of Attorneys General (NAAG) in calling on Congress to eliminate these unnecessary burdens by supporting either the Mainstreaming Addiction Treatment (MAT) Act or the Comprehensive Addiction and Recovery Act (CARA) 2.0. Both bills would have eliminated the X-Waiver requirement and had bipartisan support in the 116th Congress, as well as the support of a broad coalition of organizations. 

Tackling the Drug Enforcement Administration’s X-Waiver also has received bipartisan support within the executive branch. Under the Trump administration, HHS issued guidelines to create an exemption for certain X-Waiver requirements. Although those guidelines were recently set aside by the Biden administration for procedural reasons, the new administration has expressed its support to “find ways to lift burdensome restrictions on medications for opioid use disorder treatment.”

America’s opioid crisis is worse than ever. The nation cannot wait any longer to expand access to lifesaving treatment and bring hope to millions of Americans who are working on their path to recovery. We must take decisive action on behalf of Americans’ public health. By eliminating the X-Waiver for good, the 117th Congress can take a simple step that will save countless lives.

Mike Hunter, a Republican, is the attorney general of Oklahoma. Josh Stein, a Democrat, is the attorney general of North Carolina. Both serve on the National Association of Attorneys General Executive Committee.