Late on the afternoon of December 23, the U.S. House of Representatives passed the approximately 1.7 trillion‐dollar omnibus spending package, which now awaits President Biden’s signature. As is usually the case with such legislative monstrosities, the bill contains a few positive features and many negative ones. One positive part is that it repeals the so‐called “X‑waiver” (an X is added to the DEA narcotics prescribing license), which the Drug Enforcement Administration has long required health care practitioners to apply for to prescribe the Schedule III opioid buprenorphine as medication‐assisted treatment for substance use disorder. Inexplicably, health care practitioners have not needed an X‑waiver to prescribe the drug to treat pain. The X‑waiver requirement, which also limits the number of patients providers can treat, discouraged many practitioners from treating addiction.
Buprenorphine and methadone are both effective for treating opioid addiction, with some patients responding better to buprenorphine and others responding better to methadone. Unfortunately, the Drug Enforcement Administration regulates methadone outpatient treatment programs (OTPs) and requires most patients to take the methadone in the presence of clinic staff. Buprenorphine, on the other hand, is prescribed as a take‐home medication by health care providers in their medical clinics.
In response to the COVID emergency, the DEA, in conjunction with the Substance Abuse and Mental Health Services Administration, permitted OTPs to disburse up to 28 days of take‐home methadone to “stable patients” and 14 days of take‐home methadone “less stable” patients. The success of the take‐home program led the SAMHSA to extend it to one year past the date when the President declares an end to the COVID Public Health Emergency.
I and many others have called on Congress to end the DEA’s requirement that healthcare providers apply for an X‑waiver on their narcotics license to treat substance use disorder. By including the Mainstream Addiction Treatment Act (MAT Act) within the giant omnibus bill that Congress just passed, Congress finally removed the X‑waiver requirement and, along with it, any limits on the number of patients practitioners are allowed to treat. The act also makes it easier to prescribe buprenorphine using telemedicine.
Unfortunately, a fly in the ointment is that the omnibus bill also contained the Medication Access and Training Expansion (MATE) Act which, among other things, will require all healthcare practitioners who apply for or seek to renew their DEA narcotics prescribing license to take an 8‑hour government‐approved course in understanding and treating addiction. This unnecessary burden might provide money-making opportunities to organizations that offer courses. Still, it may make many healthcare practitioners not renew or seek a narcotics prescribing license, making it even more difficult for patients in pain to get relief.
In a July letter to the Chair and Ranking Members of the Senate Health, Education, Labor, and Pensions Committee, the President of the American Medical Association rightly opposed the 8‑hour course requirement, stating:
There could be serious unintended consequences for patient care were many physicians to forgo registration with the DEA to prescribe controlled substances instead of taking the eight‐hour training. This could have the opposite of the MATE Act’s intended effect by leading to fewer instead of more physicians and other health professionals having the ability to treat opioid and other SUDs with evidence‐based medications. It could lead to less access for patients with psychiatric and other mental health conditions that are effectively managed with controlled substances having access to medically necessary care. There could be severe consequences for patients with painful conditions or postoperative pain obtaining effective pain control as far fewer physicians may be able to prescribe any scheduled medications for them. In addition, physicians who continue to be registered with the DEA could be inundated by patients who could no longer be treated by their usual source of care.
Many states, including my state of Arizona, impose their own course requirements on licensed healthcare practitioners who wish to prescribe controlled substances. In Arizona, practitioners must take a 3‑hour course every two years. The letter from the AMA mentioned this:
There is no evidence showing that a one‐time mandated education requirement, as the MATE Act requires, will have the result that we all want, which is improving patient outcomes and stopping patients from dying from a drug‐related overdose. In response to increasing numbers of people dying from a drug related overdose, beginning in 2016–2017, states began enacting mandates to restrict opioid prescribing, require use of state prescription drug monitoring programs and require prescribers to take specific continuing medical education (CME) classes. These policy interventions have not had a positive effect on reducing drug‐related overdose or increasing access to evidence‐based treatment for SUDs. This includes the 40 states with mandated CME requirements. A one‐time training mandate for SUDs, no matter how well‐intentioned, will not have meaningful impact on reducing drug‐related overdose for the same reasons state‐level CME mandates have not had the desired effect.
Sadly, but not uncharacteristically, lawmakers give with one hand and take away with the other.
#Reprinted with permission. Dr. Singer's original blog post can be read here.
