In the final days of the Trump administration, the Department of Health and Human Services (HHS) modified federal regulations to allow more physicians to prescribe buprenorphine and other medication-assisted treatment for opioid use disorder (OUD).1 But days into his new term, President Biden pressed pause on this plan.2

Under revised practice guidelines, physicians using this exemption would have been limited to treating no more than 30 patients with buprenorphine for OUD at any one time, although the cap would not have applied to hospital-based physicians, such as those who work in the ED. The move earned praise from industry groups. Even as a presidential candidate, Biden supported “removing undue restrictions on prescribing medications for substance use disorder.”3 But now, officials in the Biden White House are unsure the move by Trump’s HHS was legal.

At the heart of the issue is the X-waiver. Physicians who want to prescribe buprenorphine or other medication-assisted treatment outside opioid treatment programs have to take a course, apply to the DEA for an X-waiver, and wait weeks before receiving agency approval. “The X-waiver was an outdated and cumbersome barrier to treatment, and it exacerbated stigma for those struggling with opioid use disorder. Now, more than ever, we need compassion and action in treating patients with addiction,” Mark Rosenberg, DO, MBA, FACEP, president of the American College of Emergency Physicians (ACEP), said in a statement on Jan. 14, shortly after the Trump HHS announcement.4

ACEP has long called for an elimination to the X-waiver requirement. In 2020, ACEP rolled out a new accreditation program aimed at nudging EDs across the United States to up their game when it comes to both the treatment of pain and the way they manage patients who present with OUD. (Read more about the Pain and Addiction Care in the ED, or PACED, program in the November 2020 issue of ED Management.5)

The American Medical Association (AMA) classified the X-waiver process as part of a “burdensome regulatory regime” that discourages physicians from prescribing medication-assisted treatment. “Ensuring physician-led teams for treating patients with opioid use disorder is critical to ending the opioid epidemic. Removing the waiver requirement can also help lessen the stigma associated with this treatment and the persistent health disparities in treating substance use disorders,” Patrice Harris, MD, MA, chair of the AMA opioid task force, said in a statement, also on Jan. 14.6

More coverage on this issue will appear in future issues of ED Management and in articles on


  1. Department of Health and Human Services. Announcement of practice guidelines for the administration of buprenorphine for treating opioid use disorder.
  2. Diamond D, Bernstein L. Biden moving to nix Trump plan on opioid-treatment prescriptions. The Washington Post. Jan. 25, 2021.
  3. The Biden plan to end the opioid crisis
  4. American College of Emergency Physicians. ACEP applauds removal of X-waiver, expanding medication-assisted treatment for opioid use disorder. Jan. 14, 2021.
  5. Brooks D. Accreditation program elevates pain and addiction care in the ED. ED Management. November 2020.
  6. American Medical Association. AMA statement on HHS decision to remove barriers for opioid treatment. Jan. 14, 2021.