Get your X-waiver, prescribe buprenorphine
In late April, the U.S. Department of Health and Human Services released new buprenorphine practice guidelines that remove the need for an 8-hour training course previously required to get a waiver to administer the addiction medication. Emergency physicians have cited this training as a barrier to treating more people with opioid use disorders.
The new guidelines exempt emergency physicians and other eligible practitioners from federal certification requirements related to training, counseling and other services that are part of the process for obtaining a waiver (known as the X-waiver). If providers utilize the exception of the practice guidelines, they may only prescribe up to 30 patients at a time. These 30 patients are counted against the provider limit until they are transitioned to a community provider or 30 days from the last prescription if not transitioned.
There is no cost to get an X-waiver beyond your time. It takes just a few minutes.
Need waiver instructions? got you covered.
In conjunction with Richmond-area Medication-Assisted Therapy (MAT) program Clean Slate, VACEP’s Joran Sequeira and Jessie Nguyen have been working on making the waiver process as seamless as possible for all EPs. The waiver form is easy and takes just a few minutes. If you are a practicing physician, you have all the information you need at your fingertips to signup. Click here to start (opens in a new window; keep this window open and follow along below).
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We’ve created a helpful one-pager that can be printed and shared with your EP colleagues. Download it for free here.
1. The first question: Do you work for the US military, Veterans Administration, Indian Health Service, or otherwise work as a Direct Federal Employee? Unless this applies, Click No.
2. Click which type of practitioner you are, and enter your medical license number (not NPI) and your DEA number.
3. You don't have to do the 8-hour waiver for prescribing for 30 patients, so it is important how you fill out the next part.
> Click NO for "I am board certified in addiction medicine…”
> Click YES for "I provide medication-assisted treatment with covered medications..."
4. Then check the button "Although I am eligible for 100-patient level, I only wish to apply for 30-patient level.” Click NEXT.
5. Fill out your name and other info, and in 1C, choose “Emergency Medicine.” Fill out the address for your primary location. For 2A (Is this a FQHC?), select NO unless you are one.
6. Question 6 should already be checked as New Notification to treat 30 patients.
7. Check the box for question 7.
8. For question 8, Certification of Qualifying Criteria, simply check the box for “SAMHSA/HHS Buprenorphine practice guideline exemption (April 2021)…”
9. For question 9, check the two boxes. 9B should already have "I certify that I will not exceed 30 patients..." checked off.
10. 10A and 10B is your personal choice, if you want your name to be released.
For the last part, check the box, sign your name and reenter the DEA number. Click Submit.
You will get the following Error message, but this is a system error that has not yet been modified to not expect attachments.
Error: Your waiver has been successfully submitted but there was a problem with one or more of your files and they were not uploaded.
Note: The waiver process can take up to 45 days for processing. You will be notified via email of your waiver status, so please check your inbox and your email junk folder for a notification from infobuprenorphine@samhsa.hhs.gov. You can also look up if you have been certified by going to the DEA website and entering your last name, here.
Tips on prescribing Suboxone/buprenorphine from Stephen Popovich, medical director at the Richmond region CleanSlate Centers.
- Patients with Suboxone (buprenorphine/naloxone) as a 3-7 day bridge to MAT are twice as likely to engage in outpatient treatment.
- A warm handoff made with a scheduled follow-up appointment is better than just giving the phone number. But giving the phone number is better than nothing.
- You can prescribe the pill or the film. The pill is lower cost when paying cash. GoodRx coupons work for both. In Virginia, Medicaid only covers the Suboxone brand. Write in notes to pharmacy: "Rx may be replaced with equivalent formulary or cheaper option in pill or film form."
- I routinely warn new patients to expect that there may be problems at the pharmacy and with contact information to get in touch with my office quickly if there is a problem. Most commonly, there is a brand vs. generic issue when a pharmacist is unfamiliar with these prescriptions. Most problems are solved by asking them to submit it as brand name or vice versa. Patients should always be able to request to pay cash and not use their insurance.
- Some patients will try to convince you to prescribe the mono-product (buprenorphine, brand name Subutex). This is relatively safe to do but is a higher risk for diversion/tampering. Be aware that very few addiction treatment programs prescribe this due to the low risk of adverse events to oral naloxone.
