According to an article in Politico, the White House held a ceremony on January 24, 2023 to sign the Mainstreaming Addiction Treatment (MAT) Act. This Act eliminated the special training requirement for doctors and other health practitioners who wanted to prescribe medication-assisted treatment to the opioid-addicted. While making medication-assisted treatment more broadly available could be a positive move, does it take into account the care that the opioid-addicted really need ?

According to an article in Politico, the White House held a ceremony on January 24, 2023 to sign the Mainstreaming Addiction Treatment (MAT) Act. This Act eliminated the special training requirement for doctors and other health practitioners who want to prescribe medication-assisted treatment to the opioid-addicted.

The signing of this Act was praised by the director of the Overdose Prevention Initiative and Senator Maggie Hassan (D-N.H.), among others. Sen. Hassan said, “For too long, federal barriers, which are rooted in stigma, have impacted access to lifesaving opioid use disorder treatment.”

Maggie Hassan

Sen. Maggie Hassan (D-N.H.)

The Politico article stated “Getting an X waiver was a time-consuming process that both discouraged doctors from prescribing the drug and created an unhelpful stigma around the medication, advocates say.”

Brian Hurley of the American Society of Addiction Medicine was quoted on the website MedpageToday as saying: “Removal of the X waiver opens up the capability of prescribing to a much broader group of clinicians.”

What was the relief that was provided to these medical practitioners as a result of waiving this requirement? They no longer had to complete an eight-hour online course before beginning to treat addicted individuals by prescribing Suboxone (buprenorphine + naloxone), Subutex (buprenorphine alone) or similar formulas. This course could even be obtained at no charge from some sources.

It could be debated whether an eight-hour online course constitutes an onerous burden or not. The benefit of this course would have to be weighed against the barrier it creates for a practitioner who wants to begin offering medication-assisted treatment (MAT).

About the X Waiver

Prior to the signing of this bill, any health practitioner who already had a DEA license to prescribe controlled substances could complete this eight-hour course and then open their practice to people with OUD—opioid use disorder.

Who now benefits from the elimination of the X Waiver requirement?

Of course, doctors, plus the following: “…the exemption will be available to physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives.”

These individuals (as long as they have that DEA license) can now treat as many as 30 patients who are addicted to opioids.

Is This the Best Care for Those Who Are Addicted? 

As with most issues in life, there are two sides to this one. Helping a person get off illicit opioids is a good thing, especially with the presence of deadly fentanyl in street drug supplies. With access to medication-assisted treatment, some people are able to bring their lives more under their control and avoid illicit drugs, drug dealers and criminal activities.

However, when we loosen requirements for treatment of the opioid-addicted, we must take into account what is needed to enable them to recover from their addictions. Real recovery requires more than a prescription for buprenorphine or methadone.

The National Institute on Drug Abuse describes what is really needed to support recovery in their document, Principles of Drug Addiction Treatment.

Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture…

Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence. 

This document also finds a place for medication as a person stabilizes their life.

The Big Question: Who is Actually Qualified to Help the Opioid-Addicted Recover?

The elimination of the X Waiver does not turn doctors, PAs, NPs, midwives and others into addiction specialists.  Now, instead of receiving at least eight hours of some kind of education into prescribing for the addicted, these individuals will receive none.

Nora Volkow

Dr. Nora Volkow of NIDA

A bigger question might be this: How many of these professionals, no matter how earnest, will be able to provide individual, family or group counseling, or assistance with psychological, social, vocational or legal problems?

As Nora Volkow of NIDA notes: “But addiction is more than just compulsive drug taking—it can also produce far-reaching health and social consequences.” Making MAT more broadly available may relieve the compulsive drug taking that got a person in trouble but it does not automatically remedy the far-reaching health and social consequences. How is this likely to work out in the long run?

The loss of this minimal training requirement will mean that we may and probably will have tens of thousands more practitioners prescribing these drugs without any training in the treatment of the addicted. While addiction medicine is itself a specialty, at least with the X waiver, these practitioners had some small indoctrination into the basics of treating those who are addicted—a challenging and complex task indeed.