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September 5, 2019

Reducing Barriers to Treatment for Patients with Opioid Use Disorder

As an emergency physician, you have undoubtedly seen first-hand the devastating effects that the opioid crisis has had on our communities. However, there are currently obstacles—including numerous regulatory and administrative road blocks—that hinder your ability to appropriately treat patients with opioid-use disorder and that contribute to the stigma and misperceptions that exist around this disease.

Emergency physicians have seen great results with utilizing buprenorphine to help start patients on the path towards recovery. ACEP strongly believe that initiating medication-assisted treatment (MAT) in the emergency department (ED) helps individuals stay in treatment longer, reduces illegal opioid use and infectious disease transmission, and decreases overdose deaths.

Despite the effectiveness of MAT, there are currently significant barriers to its use. The greatest barrier is the federal “X-waiver” requirement which mandates that physicians wishing to prescribe buprenorphine outside of opioid treatment programs must take an eight-hour course and receive a waiver from the Drug Enforcement Administration (DEA). The presence of this X-waiver requirement has led to misperception that buprenorphine is fundamentally different from other medications—including narcotics—that physicians are trained to prescribe. As a result, some physicians have been hesitant to pursue the waiver or engage in treatment of patients with opioid use disorder at all. Removing the X-waiver would require legislation from Congress, and ACEP supports bipartisan legislation in the U.S House of Representatives and the U.S. Senate that would accomplish that goal. With respect to federal regs, we also strongly support a modification to the current “three-day rule,” which requires providers to administer buprenorphine one day at a time, and forces patients come back to the ED or other settings each day to receive treatment. EDs (even without having clinicians with X-waivers) should be able to dispense a three-day supply of buprenorphine or administer a dose which will last for at least three days

ACEP has actively worked to promote the use of MAT in the ED and reduce barriers to treatment of opioid use disorder. In addition to advocating for Congress to remove the X-waiver and pushing for regulatory changes to the “three-day rule,” ACEP also:

  • Offers an emergency-medicine specific X-waiver training course (including one at ACEP19 in Denver);
  • Provides clinical tools for emergency physicians to improve decision making and clinical practices; and
  • Operates the EQUAL Network Opioid Initiative, which engages emergency clinicians and leverages emergency departments to improve clinical outcomes.

Most recently, we responded to a request for information from the Department of Health and Human Services (HHS) on how to ensure appropriate patient access to opioid treatments.

There is also potential that Medicare may eventually pay for MAT in the ED. As noted in a previous blog post, the Centers for Medicare & Medicaid Services (CMS) is seeking comment on this very issue in the Calendar Year 2020 Physician Fee Schedule Proposed Rule. ACEP is strongly supporting this potential proposal.

We are optimistic there will changes in the future, and we can break down the barriers to treating patients with opioid use disorder.

Until next week, this is Jeffrey saying, enjoy reading regs with your eggs!

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