X-Waiver Training Requirement Relaxation Did Not Change Prescribing Practices

The relaxation of X-waiver training requirements in the United States was not associated with an increase in the number of clinicians prescribing buprenorphine or the number of patients receiving buprenorphine, according to study findings published in JAMA Network Open.

On April 28, 2021, the X-waiver training requirements for buprenorphine prescribers were relaxed, allowing clinicians to prescribe buprenorphine for up to 30 patients with opioid use disorder (OUD) if they successfully applied for a training exemption. Although the X-waiver requirements were formally repealed with the Consolidated Appropriations Act on December 29, 2022, it remains unclear as to whether relaxation of the requirements resulted in any changes to buprenorphine prescribing practices.

To address this knowledge gap, researchers conducted a cross-sectional study using data collected between May 1, 2020 and May 31, 2022 from the HEALing Communities Study (HCS) – a 4-year trial that tested community interventions to reduce opioid overdose deaths across 4 US states (ie, Kentucky, Massachusetts, New York, and Ohio). The primary outcomes of interest were changes in 1) the total number of X-waivered clinicians, 2) the number of X-waivered clinicians prescribing buprenorphine, or 3) the number of patients receiving buprenorphine following the X-waiver relaxation. The researchers used June 2021 as the first month in which policy changes could affect outcomes.

Across the 4 states, 347,863 individuals were located in Massachusetts, 815,794 individuals were in Kentucky, 971,460 individuals were in New York, and 1,623,958 individuals were located in Ohio. Age and sex distributions were similar across states, and the majority of each community consisted of non-Hispanic White individuals.

Following relaxation of X-waiver requirements, the researchers found that communities in all 4 states experienced temporal increases in the total number of X-waivered clinicians. The number of W-waivered clinicians per month increased by an additional 3.1 (95% CI, 2.6-3.7) in Kentucky, 3.0 (95% CI, 1.8-4.2) in Massachusetts, 3.6 (95% CI, 1.8-5.4) in New York, and 2.9 (95% CI, 0.0-5.8) in Ohio. These numbers exceeded the projected trends for growth following policy change.

Despite the immediate increases in the number of X-waivered clinicians, the number of these X-waivered clinicians who actually prescribed buprenorphine did not substantially change. Only communities in Kentucky demonstrated an increase in the number of X-waivered clinicians prescribing buprenorphine following the policy change (relative increase, 3.2%; 95% CI, 1.5%-4.9%).

Immediately following the policy change, the number of patients receiving buprenorphine increased by 7.1 patients per month (95% CI, 4.5-9.7) in Massachusetts communities and decreased by 34.0 patients per month (95% CI, 11.9-56.2) in Ohio. By May 2022, only Massachusetts had a 1.7% (95% CI, 0.8-2.6) increase in patients receiving buprenorphine compared to expected trends. All other states showed no significant change following the X-waiver relaxation.

“Whether completely removing the X-waiver will have different outcomes remains to be seen, though our findings suggest that increases in buprenorphine prescribing observed with this policy change may be less pronounced than hoped for,” the researchers concluded.

Study limitations include the lack of data on buprenorphine administered in treatment facilities rather than prescriptions and the limited generalizability beyond the 4 states evaluated. Additionally, it is possible that outcomes will continue to change over time based on the short study period and updated policies regarding buprenorphine prescribing.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.

This article originally appeared on Psychiatry Advisor