Published On February 25, 2021
THE ARRIVAL OF THE COVID-19 PANDEMIC only exacerbated the ongoing opioid crisis. Treatment disruptions, lack of access to mental health services, job losses and overall stress have increased the risk of opioid use and relapse. Between July 2019 and June 2020, fatal drug overdoses soared, with more than 81,000 deaths—the highest ever recorded in a 12-month period—reports the Centers for Disease Control and Prevention. A February study in JAMA Psychiatry showed that emergency department visits for opioid overdoses were almost 30% higher in 2020 than in 2019. And Alister Martin, an emergency physician at Massachusetts General Hospital, has observed an increase in people struggling with opioid use disorder. Yet patients often arrive at the ED only after exhausting other options.
But it’s once patients get to the ED that medicine often falls short, says Martin. That’s because most emergency physicians can’t prescribe buprenorphine, a drug that reduces craving for opioids and makes patients much more likely to stay in outpatient treatment programs, especially when it’s started in the ED. To write prescriptions for this controlled substance, providers must first obtain a so-called X-waiver, which requires a minimum of eight hours of training. (Once training is completed, the federal Drug Enforcement Administration issues physicians an identification number beginning with the letter X, hence the waiver’s nickname.) Yet only 1% of U.S. emergency physicians have the waiver.
During the pandemic, just as the need for treatment for opioid use disorder (OUD) has spiked, buprenorphine prescriptions have fallen by 25%, according to forthcoming estimates. “Subsequently, four out of five patients with opioid use disorder do not currently have access to treatment with buprenorphine,” Martin and his colleagues, including three other MGH physicians, wrote in a December 2020 briefing memo that they submitted to an advisory group in the Biden administration transition team. “In the midst of the COVID-19 pandemic, which has exacerbated the opioid crisis, the burdens imposed by the X-waiver requirement are causing more harm than good.” The memo also noted that the current system has a disproportionate impact on nonwhites: “Black people with opioid use disorder are at higher risk of COVID-19 mortality.”
Then in January, at the very end of the Trump administration, federal health authorities announced that they were largely doing away with the requirement that would-be prescribers obtain the X-waiver—exactly what physicians and policy experts in the “X the X-waiver” movement had been hoping for. The Department of Health and Human Services would allow doctors with a DEA narcotics prescribing license to prescribe buprenorphine without the training.
But just as quickly, the Biden administration reinstated the X-waiver requirement amid concerns about whether the agency had the regulatory authority to make such a change. Moreover, in the face of the opioid crisis, in part fueled by physician overprescribing, there were worries about making it easier to prescribe a controlled substance. Yet on the campaign trail, Biden had also called for eliminating the X-waiver, and advocates for prescribing buprenorphine hope the issue will be revisited.
In the meantime, grassroots efforts to encourage emergency physicians to get the waiver have become all the more important. When Martin was an MGH resident in 2015, he says that barely anyone in the MGH emergency department had the waiver and that he was frustrated by how little could be done for patients desperately in need of treatment. Yet it was unsurprising that few physicians were able or willing to take a day to do the training required for an X-waiver. Martin founded a program called Get Waivered, a production of the MGH Center for Innovation in Digital HealthCare, to make it easier.
To build participation, the campaign encouraged physicians who had done the training to wear Get Waivered lapel pins, and it established a website that clearly outlined what was required to get the waiver. Get Waivered also helped create protocols for using ED-administered buprenorphine as a bridge to treatment for OUD. Martin and his colleagues invited patients who had successfully undergone medication-assisted therapy to return to talk about their experiences. These and other steps helped convince MGH doctors to get their X-waiver, and by 2019, 95% of the hospital’s emergency physicians had the waiver and were able to prescribe buprenorphine.
The planned next phase of the Get Waivered campaign—packing auditoriums to get hundreds of practitioners waivered at once—was disrupted by the arrival of COVID-19. So over the past year, Shuhan He, an attending physician at MGH and digital growth director of Get Waivered, has taken the program virtual. He set up targeted ads on Facebook and educational platforms used by physicians, and enlisted “brand ambassadors” to share their experiences on social media. He helped create massive online classes that have had as many as 1,200 attendees who can get the waiver without setting foot in a physical classroom. One attending physician took the course at home while caring for her newborn. “Doing it this way just makes life easier,” he says. “Physicians and other providers want to do the right thing, but the barrier to entry—and the hassle—has been high.”
Martin, who hopes the X-waiver may yet be eliminated, has been heartened by the success of Get Waivered. But he remains frustrated about the obstacles to treating patients with OUD. “Think about all the patients who keep asking for our help,” he says. “Most are young and have their whole lives ahead of them, and in almost any other situation we would be able to give them evidence-based treatment. So when talking about why this needs to be done, I always ask, ‘Are you okay with the status quo?’ And no one is.”
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