Update: On Jan. 27, 2021, the Office of National Drug Control Policy (ONDCP) notified stakeholders that the earlier announcement from the Department of Health and Human Services (HHS) that physicians will no longer have to obtain a federal waiver to prescribe the opioid use disorder treatment buprenorphine to patients – as described in this blog – will not be issued at this time. ONDCP noted that it will continue to work with HHS to “examine ways to increase access to buprenorphine, reduce overdose rates, and save lives.” NASHP will continue to update state policy leaders as these federal actions evolve.
Under new US Department of Health and Human Services practice guidelines, physicians will no longer have to go through the cumbersome process of obtaining a federal waiver to prescribe the opioid use disorder (OUD) treatment buprenorphine to patients.
Because the waiver requirement was previously required for physicians in order to prescribe the medication component of OUD treatment services according to federal law, states similarly imposed this requirement in their own approaches and may need to take steps to re-align policy with the new federal guideline:
- States that integrated buprenorphine prescribing practices into their licensing regulations for prescribers may need to amend regulations to reflect changes to physician requirements. In some states, such regulations are also intended to promote prescribing safety, requiring that providers document connections to counseling and other supports, an effort designed to minimize potential diversion of buprenorphine. States could take steps to maintain – or even strengthen – these requirements, as diverted buprenorphine remains a concern to public safety policymakers.
- As states have worked to build treatment capacity for OUD, they have integrated the required training for the waiver into their efforts, often partnering with professional associations to provide the in-person training hours. States have also dedicated funding to these trainings in both state budgets and via State Opioid Response (SOR) grant dollars. Because waiver trainings will now only be required for non-physician prescribers, states may need to quickly shift training plans and provider association partners.
- Reimbursement for these services may be administratively tied to the requirement to have a waivered prescriber among OUD care team members. As states have developed Medicaid waiver demonstrations and amended state plans to include OUD treatment services, language requiring waivered prescribers was incorporated to align with the federal policy. All of these documents, directives, and billing practices will need to be amended by states to ensure that physicians – now without the waiver – can seek reimbursement.
States can leverage this policy change to address many of the challenges that were previously posed by the waiver requirement in expanding access to this life-saving treatment:
- By allowing all licensed physicians to prescribe buprenorphine to a maximum of 30 patients in their first year, this policy change helps to normalize OUD treatment as part of health care, reflecting a long trend of integrating behavioral health and primary care practices. This helps to create administrative ease for providers and payers and reduces logistical barriers for patients.
- Stigma regarding OUD has long posed a challenge for states in their efforts to expand treatment capacity, and this change at the federal level represents a sanctioning and approval of this component of treatment that may help to alleviate that stigma.
- Emergency departments have been increasing their efforts to transition individuals who use opioids and have overdosed to buprenorphine, though this approach previously required that a waivered prescriber be present at all times in the hospital setting. All emergency department physicians will now be able to administer buprenorphine onsite if necessary.
While this change opens up opportunities for physicians to expand their OUD treatment services, it also leaves many practical questions unanswered. Non-waivered physicians who previously did not obtain the waiver and who decide to begin prescribing buprenorphine in light of this new policy may want additional guidance from their states to feel comfortable prescribing, particularly for non-waiver education and billing practices.
The National Academy for State Health Policy (NASHP) will continue to follow policy changes in the treatment of OUD as they emerge from Congress and the incoming Biden Administration.