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During the COVID-19 pandemic, there was slower growth in the number of new waivers authorizing clinicians to provide buprenorphine treatment for opioid use disorder. However, treatment capacity grew at a stable rate as a result of already authorized clinicians obtaining waivers for larger patient panels. Advanced practice nurses accounted for the largest portion of capacity growth during the pandemic.

Opioid overdose deaths have soared during the COVID-19 pandemic, with more than 80,000 opioid-related deaths in the US in 2021 alone. Increasing access to buprenorphine treatment is a key component of policies to mitigate the opioid epidemic. To prescribe buprenorphine in an office-based setting, clinicians must obtain an “X waiver” that exempts them from the requirement that opioid agonist and partial-agonist medications used to treat opioid use disorder (methadone and buprenorphine) be administered by a licensed treatment program. During the pandemic, efforts to mitigate difficulties accessing buprenorphine treatment included emergency authorization of telehealth for buprenorphine prescribing, offering mail-based services and home delivery, and suspending mandatory urine drug testing; these emergency provisions will expire without legislative or regulatory changes. In addition, Drug Enforcement Administration (DEA) guidelines issued in April 2021 relaxed the requirement that clinicians complete training before applying for a waiver to treat thirty or fewer patients. As seen in exhibit 1, despite these efforts, growth in the percentage of clinicians with waivers slowed during the pandemic, particularly for physicians.

Opioid treatment capacity has fallen short of need for decades. The Drug Addiction Treatment Act of 2000 expanded access to buprenorphine by establishing the X-waiver program. To address continuing shortages of buprenorphine prescribers, federal legislation passed in 2016 and 2018 authorized advanced practice nurses (APNs) and physician assistants (PAs) to obtain waivers. During their first year with a waiver, clinicians are allowed to treat up to thirty patients concurrently; they can apply to treat 100 patients after the first year and can increase their panel from 100 to 275 patients if they hold board certification in addiction medicine or addiction psychiatry or if they practice in settings with twenty-four-hour coverage and case management services.

In this article we describe changes in the size, composition, and potential treatment capacity of the X-waivered workforce before and during the COVID-19 pandemic. This detailed information can help identify opportunities to expand treatment access.