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    Lowering of SUD Treatment Barriers Marks AAFP Advocacy Success

    AAFP Lauds X-waiver Elimination, Proposed Confidentiality Improvement

    Feb. 2, 2023, Scott Wilson — Among the numerous AAFP advocacy wins in the Consolidated Appropriations Act of 2023 was the elimination of an administrative hurdle — one the Academy had steadily opposed — that had been slowing primary care’s response to the opioid crisis.

    Following this ending of the X-waiver, a move that makes it easier for family physicians to prescribe buprenorphine when treating opioid use disorder, the DEA sent an advisory to all of that agency’s registered clinicians, clarifying the rule.

    “Medication for opioid use disorder helps those who are fighting to overcome opioid use disorder by sustaining recovery and preventing overdoses,” the Jan. 12 letter said. It went on to list three changes connected to the end of the X-waiver:

    • All prescriptions for buprenorphine require only a standard DEA registration number, not a Drug Addiction Treatment Act waiver registration number.
    • There is no longer a cap on the number of patients a prescriber may treat for opioid use disorder with buprenorphine.
    • The federal change does not supersede existing state laws or regulations.

    With that last point in mind, the Academy’s Center for State Policy can advise AAFP members on how to proceed.

    The law eliminating the X-waiver introduced new training requirements for prescribers that are scheduled to take effect June 21. The advisory noted that the DEA and the Substance Abuse and Mental Health Services Administration were working on follow-up guidance; the Academy is monitoring that process and providing input on ways to implement this requirement without adding to physicians’ administrative tasks or disrupting patient care.

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    Family Physician Perspective

    Blake Fagan, M.D., of Asheville, N.C. — chair of family medicine at the Mountain Area Health Education Center and director of the office-based opioid treatment services there — attended a White House event Jan. 24 marking the policy improvement.

    “Removing the X-waiver requirements is a huge win for our patients,” Fagan told AAFP News. “I believe opioid use disorder is a chronic disease. Family physicians are good at taking care of chronic diseases. All of us will now be able to prescribe buprenorphine for patients who disclose, and (in whom) we diagnose, an opioid use disorder.”

    “Now that the burdensome X-waiver requirement has been eliminated, we can treat our patients who have opioid use disorder in our clinics,” added Fagan, one of the authors who contributed to the AAFP’s Treating Opioid Use Disorder as a Chronic Condition: A Practice Manual for Family Physicians. “Buprenorphine can be written just like lisinopril or metformin. Patients love seeing their family physician who can refill their buprenorphine and lisinopril while evaluating their rash and/or providing vaccines.”

    More Burdens Likely to Lift

    The Academy also recently lauded a proposed rule that would update confidentiality protections for substance use disorder patients while decreasing administrative complexity for physicians, reflecting longtime Academy policy recommendations.

    “The AAFP applauds HHS, (its Office for Civil Rights) and SAMHSA for taking action to uphold patient privacy rights and streamline health data confidentiality requirements for physicians,” the Academy said in a Jan. 30 letter

    The rule would more closely align confidentiality rules for substance use disorder patient records in the Code of Federal Regulations with those of HIPAA, as the AAFP has called for. If enacted as proposed, it would reduce paperwork associated with overlapping and redundant regulations while upholding patients’ rights to seek SUD treatment without fear of discrimination or prosecution.

    The Academy cautioned, however, that elements of the rule related to EHRs require adequate runway for family medicine practices.

    “The AAFP remains concerned about the feasibility and functionality of EHRs and other platforms to improve data sharing while protecting patient privacy,” the letter said. “We urge HHS to provide physician practices with ample time to prepare for compliance and resources to streamline administrative changes for the few practices that are not already compliant with the existing HIPAA requirements.”

    The letter also flagged a section of the rule governing records disclosure “without patient consent to public health authorities, so long as the information is de-identified” — that is, stripped of direct patient identifiers so that such sharing doesn’t violate HIPAA.

    “While the AAFP supports this provision to better facilitate public health data reporting, we note that the current standard for de-identification is significantly burdensome and time consuming for many practices. The AAFP has concerns that this provision could result in unintentional breaches in patient confidentiality without improvements to existing health IT and reporting technology.”

    The letter urged HHS to “facilitate coordination between physicians and health IT entities to improve de-identification technology and make it more widely accessible for physician practices.”

    The Academy plans to comment as well on a new proposed rule from SAMHSA that would make permanent certain COVID-era flexibilities around telehealth prescribing of buprenorphine, take-home methadone doses and other prescribing priorities for opioid treatment programs.