Oakland, CA, Thursday, January 21, 2021

Game-Changing: HHS Moves to Exempt Physicians From X-waiver Requirements

HSS moved to exempts physicians from the X-waiver requirement, with no limitations on prescribing buprenorphine for opioid use disorder treatment for emergency physicians and other hospital-based physicians, pending a 60-day review from the Biden administration. This newly proposed exemption marks incredible progress for accessible substance use disorder treatment but does not negate the need for in-depth medication for addiction treatment (MAT) training. It also does not yet include NPs and PAs, who are still required to apply for the X-waiver.

However, because this is a practice guideline and not yet a law it is subject to review and update by HHS. ACEP recommends waiting for publication in the federal registry before putting it into practice. In the meantime, we encourage clinicians to reach out to their pharmacy for readiness to change practice (e.g., writing in the note to pharmacy section, in the place of the X-wavier DEA #, write X for opioid use disorder).


The new guidance outlines that physicians are generally exempt from the X-waiver requirement, including the following details:

– The exemption only applies to physicians who treat patients located in the states in which they are authorized to practice medicine.

– Physicians utilizing this exemption will be limited to treating no more than 30 patients with buprenorphine for opioid use disorder at any one time (note: the 30 patient cap does not apply to hospital-based physicians, such as Emergency Department physicians).

– The exemption applies only to the prescription of drugs or formulations covered under the X-waiver of the CSA, such as buprenorphine, and does not apply to the prescription, dispensation, or use of methadone for the treatment of OUD.

– Physicians utilizing this exemption shall place an “X” on the prescription and clearly identify that the prescription is for opioid use disorders.

– An interagency working group will be established to monitor the implementation and results of these practice guidelines, as well as the impact on diversion.

– Prescribers, including physicians and other practitioners, may continue to seek an X-waiver per current protocols. These prescribers will not be subject to the specific prescribing limitations of physicians using this exclusion.

– This exemption does not apply to non-physician practitioners. These health care practitioners still require an X-waiver.

– In California resident physicians are given a post-graduate training license rather than an official license, so it’s unclear how this applies to residents.


Here are some specific ways this impacts providers – both the ability of hospital-based providers to prescribe but also in the ability of outpatient providers to prescribe – and actions to take:

  1. Contact your hospital outpatient pharmacy or primary outpatient pharmacy partner to discuss implementation.
  2. Reach out to the ED and hospital-based physicians with the steps to prescribe based on guidance from HHS and plans developed with outpatient pharmacies.
  3. Reach out to primary care networks to discuss the continuation of buprenorphine prescriptions as a part of the regular primary practice. We must work actively to increase the network of available prescribers.
  4. Sign on to this letter to extend the exemption to ALL clinicians eligible to prescribe life-saving treatment so that NPs and PAs are included in this advancement to care.

We celebrate this step forward as we collectively work towards better access to SUD treatment in health care. But there is much more to be done. In the short term, we need to widely distribute clear regulations for pharmacists to ensure patients receive continuous care (we expect more details within the next few months). For the long term, we must increase MAT training throughout healthcare systems. Without legal barriers, nothing should stand in the way of treatment – share our Blueprint for Hospital OUD Treatment to help more providers prepare for MAT implementation. 

We will update you with more important details as they come (sign up for our newsletter). Thank you for being part of this movement to reduce the harms associated with drugs. 

California Bridge is a program of the Public Health Institute. Our goal is that people with substance use disorder receive 24/7 high-quality care in every California health system.  Funding for Bridge is provided through the Substance Abuse and Mental Health Services Administration (SAMHSA) State Targeted Response to the Opioid Crisis Grant to the California Department of Health Care Services (DHCS).