Examining the Impact of Eliminating the X Waiver on Buprenorphine Dispensation in 63 Counties in Pennsylvania

Background

Opioid overdose rates continue to rise in the United States while access to treatment options remains limited. The X waiver, which allowed clinicians to prescribe buprenorphine, a medication for opioid use disorder (MOUD), in an outpatient setting, was eliminated in December 2022 with hopes of increasing buprenorphine access. We used a quasi-experimental approach to evaluate how eliminating the X waiver affected buprenorphine prescribing in Pennsylvania.

Methods

Drawing on Pennsylvania Prescription Drug Monitoring Program data from July 1, 2016, to December 31, 2023, we used a difference-in-differences (DD) approach to assess changes in buprenorphine prescribing between Pennsylvania counties with the proportion of X-waivered providers per county population above the median versus counties with the proportion below the median, before and after the elimination of the X waiver. We also tested whether areas most affected by the opioid epidemic with the highest rates of opioid overdose were more impacted by the X-waiver elimination, using opioid overdose death rates from a pretreatment baseline period (2016-2018) for each county.

Results

Thirty-one counties were categorized as above the median and 32 as below the median. We did not observe a significant difference in the effects of eliminating the X waiver on buprenorphine dispensation (DD estimate: -0.6%, 95% CI: -7.5%-6.2%) between above versus below-the-median counties in Pennsylvania. We also did not find a significant effect of the X-waiver elimination on buprenorphine dispensation in counties most affected by the opioid epidemic (difference-in-difference-in-differences estimate 1.6%, 95% CI: -10.2%-13.4%).

Conclusions

We found no evidence that eliminating the X waiver had a significant impact on buprenorphine dispensing in Pennsylvania in counties with fewer waivered prescribers or higher fatal overdose rates. Additional efforts to increase buprenorphine use will likely need to address systemic barriers and stigma limiting MOUD access.