Xing out the X-waiver: Updates for nurses who prescribe buprenorphine

May 2023

More than 60 percent of nurses who prescribe buprenorphine planned to request an increase in the number of patients they can treat under the Drug Enforcement Agency waiver according to the results of an APNA survey presented during the 2022 APNA Annual Conference. But with the X-waiver no longer required by the DEA to prescribe buprenorphine, practitioners with current DEA registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorder in their practice if permitted by applicable state law. What change will this decision on prescribing buprenorphine – which curbs opioid cravings, reduces drug use, and prevents death among those who use opioids – make?

Laura Leahy, DrNP, APRN, PMH-CNS/FNP, CARN-AP, FAANP, the APNA Addictions Council Co-Chair, and board certified in psychiatry & addictions, shares her thoughts on the ending of the X-waiver and the benefits of the change.

Are there any potential challenges with the expanded pool of prescribers?

While the expanded pool of prescribers should improve access to treatment for opioid use disorder, the potential challenges lie in prescribers who may not understand the nuances of buprenorphine regarding induction to treatment, formulations available for treatment of [opioid use disorder], as well as the necessity of engaging patients who struggle with OUD in psychosocial therapies.

What are the benefits to the change in the requirements for prescribing medications for persons with a substance use disorder diagnosis?
Increased access to potential providers is the first benefit that comes to mind; however, perceived stigma both among health care professionals and those seeking treatment remains an obstacle. Assisting providers/prescribers to view not just OUD but all substance use disorders as the chronic relapsing disorders of the brain that they are, and to treat patients as they would any patient with a chronic medical illness is the challenge that will ultimately provide the most benefit to patients.

What concerns should those who prescribe buprenorphine have when prescribing buprenorphine?

Prescribing is a privilege! And the ability to prescribe buprenorphine to patients with OUD should be treated in the same manner as the practitioner prescribes other medications. There are inherent side effects, risks, and benefits. One concern with buprenorphine is the risk of diversion, thus perpetuating the opioid crisis and reducing the chance of the patient sustaining long-term recovery. Providers should take care in evaluating their patients with OUD and share in the decision-making regarding the treatment. Buprenorphine is not the only medication available to treat OUD; though the “convenience” of being able to prescribe this treatment has the potential to benefit many in their recovery journey.

Do you believe the change in prescription requirements will help in stemming the growing tide of overdose deaths in the U.S.?

The change in prescription requirements has removed decades-old barriers to prescribing this MOUD with the hope of reducing opioid overdose deaths. Unfortunately, the majority of opioid overdose deaths in recent years have involved fentanyl. Fentanyl presents many potential complications when attempting to institute an induction with buprenorphine. If precipitated withdrawal occurs, the patient may deem that buprenorphine is not a viable option as a tool in their recovery and may actually perpetuate return to use, placing patients at even higher risk for overdose/death.

Note: Leahy participated as a lead mentor and APNA representative on a new resource approved by SAMHSA, “Practice-Based Guidelines: Buprenorphine in the Age of Fentanyl.” Leahy will soon record a quick overview of the guidelines which will be available in the APNA eLearning Center for FREE.

What additional supports do you recommend for persons who are prescribed buprenorphine?

As a psychiatric & addictions advanced practice nurse, I don’t believe we can dismiss the mental health issues which co-occur in those with substance use disorders. Whether the individual is prescribed buprenorphine, methadone, or the extended-release naltrexone injection, it is essential that psychosocial interventions and therapies be an integral part of the recovery treatment plan. Peer-facilitated support groups such as [Narcotics Anonymous], individual, group, and family therapy, vocational rehabilitation, and counseling among others should be incorporated into the treatment as well as identifying and developing healthier coping skills and outlets to replace the substance of abuse.

Why should psychiatric-mental health nurses continue to pursue education in this area?

Not only should PMH nurses but ALL prescribers of MOUD (formerly MAT) should continue to engage in education regarding substance use disorders, harm reduction, eliminating stigma, and the prescribing of medications used as part of the recovery plan for patients. Education is essential! We have observed the changes in opioids over the years, moving from abuse of prescription opioids and heroin to the fentanyl epidemic which now permeates our society. These changes require knowledge to adapt the treatment, especially MOUD, to ensure the patient is comfortable and the MOUD adequately addresses the cravings which often drive individuals to return to use.

Ongoing revision of treatment guidelines and evidence of best outcomes is critical to not only the treatment of SUDs but psychiatric disorders and ALL health conditions. Couching SUDs as health conditions and working with your patients to improve their overall health is the ultimate goal; continuing education is a means to accomplish that goal!

>>> Coming soon from APNA for ALL nurses, including those who prescribe buprenorphine: FREE training on effective treatments for opioid use disorder.
Be the first to know when the training is available: Sign up to receive emails from APNA.

>>> Learn even more about providing care without the X-waiver when you register for the APNA 37th Annual Conference and attend sessions including “Goodbye X-Waiver: Good News for PMHNPs and for the Treatment of People with Opioid Use Disorder”; “Updated Buprenorphine Prescribing Training Requirements for APRNs”; and “Buprenorphine Induction in the Era of Fentanyl: Avoiding Precipitated Withdrawal Symptoms.”

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About APNA: The American Psychiatric Nurses Association is a national professional membership organization committed to the practice of psychiatric-mental health nursing and wellness promotion, prevention of mental health problems, and the care and treatment of persons with psychiatric disorders. APNA’s membership is inclusive of all psychiatric-mental health registered nurses including associate degree, baccalaureate, advanced practice (comprised of clinical nurse specialists and psychiatric nurse practitioners), and nurse scientists and academicians (PhD). APNA serves as a resource for psychiatric-mental health nurses to engage in networking, education, and the dissemination of evidence. The American Psychiatric Nurses Association is accredited as a provider of continuing nursing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.