Assessing the Initial Impact of X-Waiver Elimination on Buprenorphine Prescribing for Opioid Use Disorder

Background: To expand access to buprenorphine treatment for opioid use disorder (OUD), the X-waiver requirement was removed in January 2023. This study examined changes in OUD diagnosis and buprenorphine prescribing before and after waiver elimination. Methods: We conducted a retrospective analysis using TriNetX electronic health record data (EHR) on adults with OUD during the waiver-required (2021-2022) and elimination (2023-2024) periods. Logistic regression estimated the likelihood of new OUD diagnoses and buprenorphine initiation, adjusting for demographic and clinical characteristics. Results: Among 1 041 754 adults with an OUD diagnosis (516 508 in the waiver-required and 525 246 in the waiver-elimination periods), 295 675 participants (146 904 in the waiver-required and 148 771 in the waiver-elimination periods) had a new OUD diagnosis recorded. Among those with a new OUD diagnosis, buprenorphine was prescribed to 27 665 (18.8%) participants in the waiver-required and 29 223 (19.6%) participants in the waiver-elimination periods. Those in the waiver-elimination period, compared to those in the waiver-required period, were 2% less likely to receive a new OUD diagnosis (adjusted odds ratio [aOR] = 0.98, 95% confidence interval [CI]: 0.97, 0.98) and 14% more likely to have buprenorphine initiated (aOR = 1.14, 95% CI: 1.12, 1.16). Conclusion: In this retrospective analysis of a large EHR dataset, we found that following the elimination of the X-waiver, the incidence of new OUD diagnoses declined by 2%, while subsequent buprenorphine initiation increased by 14%. These findings highlight the impact of regulatory changes on buprenorphine prescribing and underscore the need for continued efforts to reduce barriers to this life-saving treatment for OUD.