Eliminating the buprenorphine DEA X waiver is critical to promote health equity (2024)

Expanding access to nurse-managed medication for opioid use disorder (2021) provides an assessment of challenges that advanced practices nurses (APRNs) experience in providing buprenorphine, a partial opioid agonist, and life-saving treatment for Opioid Use Disorder (OUD). While Cos et al. (2021) put forward recommendations to facilitate nursing contributions, eliminating the required DEA X waiver to prescribe buprenorphine was only briefly mentioned.

The importance, rationale, and urgency of eliminating the X waiver warrants further emphasis as an antiracist policy approach. In the context of COVID-19, opioid overdose rates have reached an all-time high. The most striking rise occurs in Black Americans, who have experienced a 40% increase in overdose deaths due to treatment barriers (Larochelle et al., 2021). Systemic and other forms of racism result in Black Americans being 77% less likely to receive buprenorphine treatment than White Americans (Lagisetty et al., 2019). The regulation of buprenorphine via the X waiver makes treatment for people historically marginalized with structural and social determinants of health unnecessarily burdensome and, in some cases, entirely out of reach.

Additionally, the specialty DEA X-waiver fails to consider the safety profile and the protection buprenorphine offers for opioid overdose (Fiscella et al., 2019). Eliminating excessive buprenorphine regulations has reduced opioid overdose deaths by nearly 80% in France (Fiscella et al., 2019). Removing the DEA X waiver is critical to further the success of buprenorphine to treat OUD, promote health equity, and actualize the contributions of APRNs.

Indeed, encouraging the elimination of racist policies such as the DEA X waiver is a critical response to the Future of Nursing report (2021), which calls for nurses to improve the health of the populous, striving towards healthcare equity. The X waiver exacerbated health disparities by reinforcing and perpetuating inequitable OUD care for Black Americans. Understanding the underpinnings of racially-based drug policies over the past century illuminates the reasons for the OUD treatment gap in Black Americans and how the X waiver reinforces structural racism.

Racism and the Dual OUD Treatment Paradigms

In 1914 the Harrison Narcotics Tax Act imposed taxes on persons who produce, import, manufacture, compound, dispense, or distribute opium and its derivatives. Although, on the surface, the act does not appear problematic, its implementation and associated legislation resulted in three critical results. First, it prohibited clinicians from prescribing opioids to treat OUD, allowing opioid prescribing only for pain. A prescribing delineation that clinically is a false dichotomy and disadvantages Black Americans who are less likely to have their pain complaints believed or treated. Secondly, the criminal justice system enforced violations of the restrictions on opioid prescribing, resulting in accelerated drug-related arrests, including prescribing clinicians who became less willing and able to treat pain or addiction. At the same time, racist propaganda became common equating Chinese people with opium, Black people with cocaine, and Mexican people with cannabis. The early racial stereotyping of drug use began to inform policing and later the classification of which drugs were deemed medical or illicit by the Drug Enforcement Agency. Lastly, the implementation of the Harrison Act, set the stage for addiction to be treated and viewed as distinctly different than other chronic conditions.

It was not until the 1970s that a collection of acts passed by Congress (Controlled Substance Act (1970), Methadone Control Act (1973), and Narcotic Addict Treatment Act (1974)) legally permitted medication treatment for opioid addiction in the form of methadone within opioid treatment programs. Simultaneously in the early 1970s, the so-called War on Drugs began, increasing political and media attention linking crime and drug use. Methadone treatment programs were promoted as an evidence-based treatment for addiction and as a means to decrease crime, commencing the dual medical and punitive/legal paradigms of addressing drug use.

Thirty years later, the Drug Addiction Treatment Act (DATA 2000) was passed as the second modification of the Harrison Act permitting buprenorphine to treat addiction. Buprenorphine prescribing through X waiver legislation expanded to Advanced Practice Nurses and Physician Assistants under the Comprehensive Recovery Care Act (2016) and SUPPORT (2018), allowing for immense contributions of APRNs to OUD care. The collection of these congressional acts expanded OUD treatment while retaining substantial restrictions and requirements to prescribing controlled substances to treat addiction.

Expert testimony supporting the passing of DATA 2000 relied on the idea that methadone was inappropriate for the “suburban spread of narcotic addiction” (). Although race is not directly named in these early buprenorphine testimonies, racialized terms and images describing a new wave of people with addiction were ubiquitous in the media (). The white-washing of buprenorphine and the opioid epidemic racially divided OUD treatment from the beginning (). Early data after DATA 2000 showed that 91% of the patients treated with buprenorphine were White, college-educated, employed, and dependent on prescription rather than illicit opioids ().

The lens of racial inequity shines a bright light on the two dominant and divergent treatment paradigms for OUD. Despite similar rates of drug use among Black and White individuals, research consistently demonstrates responses to drug use vary widely due to racism. For White Americans, OUD is a medical diagnosis requiring evidence-based treatments that is accessible and affordable. Whereas for Black Americans, OUD is considered a legal problem and is “treated” with police encounters, arrests, and incarceration. Black Americans are six times more likely to be incarcerated than their White counterparts (Khatri et al., 2021). Notably, policies that focus on legal actions result in limited access to buprenorphine and are ineffective in reducing drug use or its adverse health outcomes (Khatri et al., 2021).

The Policy Climate is ready for change

In 2021, the National Academies of Medicine convened to outline high-priority evidence-based recommendations for policy change and action. Elimination of the DEA X waiver and decriminalizing drug use were emphasized as policy priorities. As recently as January 2021, attempts were made to eliminate the X waiver but were later put on hold because of the need for legislative change. In April 2021, new buprenorphine guidelines were released by the Health and Human Service administration, removing the education requirement to treat up 30 patients for OUD. Still, the X waiver itself and many related stipulations remain. The educational reduction to obtaining the X waiver is insufficient to eliminate the enormous OUD treatment gap and will not address health disparities.

It is paramount that the United States take new and accelerated approaches to expand buprenorphine treatment and promote health equity. The X waiver legislation reinforces operationalizing of addiction treatment as different from other chronic disease forms by requiring alternative regulatory and treatment approaches, fueling treatment hesitancy and stigma. The X waiver partially facilitates treatment primarily for White Americans while acting as a barrier to treatment for Black Americans. The Future of Nursing report (2021) stresses the professional responsibility of nurses to advocate for addressing policies that drive health inequities. The elimination of the DEA X waiver is a critical aspect part of striving toward antiracist OUD care.

Funding

Katie Fitzgerald Jones is a 2021-2023 Jonas Mental Health Scholar and a fellow in the American Academy of Nursing Jonas Policy Scholars program. Katie Fitzgerald Jones funded by the National Institute of Nursing Research Ruth L. Kirschstein National Research Service Award (F31NR019929) as a predoctoral fellow.

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