More Reforms Needed to Boost Buprenorphine Uptake

Between 2018 and 2023, the U.S. saw a 57% increase in overdose deaths, and despite some recent declines, fatal overdoses still numbered more than 80,000 in 2024. During that time, the federal government changed some key policies designed to make buprenorphine—a U.S. Food and Drug Administration-approved medication for opioid use disorder (OUD)—more available to people seeking treatment. This included allowing any clinician registered with the Drug Enforcement Administration to prescribe buprenorphine by eliminating a requirement for a special license, known as the X-waiver. Public health experts had increasingly come to see the X-waiver as an unnecessary barrier to care and championed its elimination.

Two new research studies by a Rutgers University-led team and supported by The Pew Charitable Trusts examined the effect of the X-waiver elimination and other changes to the OUD treatment landscape during a time of shifting Medicaid policy and the COVID-19 pandemic. One study showed that from 2018 to 2024, state-level disparities contributed to modest gains in buprenorphine prescriptions nationwide. The other, looking at data from 2021 to 2024, found more clinicians prescribing buprenorphine, but limited increases in the number of patients receiving the medication from their primary care or behavioral health physician.

Importantly, both studies offer potential approaches to overcome continued challenges in prescribing this essential medication.

The impact of Medicaid

The researchers found that Medicaid—the public health insurance program primarily for low-income Americans—was the leading source of payment for buprenorphine, and the main driver of patients receiving more of the medication.

States that expanded Medicaid eligibility to their residents between 2018 and 2024 had the highest buprenorphine uptake. Those states saw a 27.3% increase in buprenorphine prescribing, driven by Medicaid paying for 137.4% more of those prescriptions over the study period.

States that expanded Medicaid before 2018 had more modest prescribing gains of 11.6%. States that did not expand Medicaid saw a 2.1% overall decline in prescribing, with many fewer Medicaid prescriptions than in the expansion states and a widening gap in all-payer prescriptions.

The disparity by Medicaid expansion status widened over the study period. By 2024, medication uptake in nonexpansion states was more than 35% below that of both early and recent expansion states.

The trends—and possible explanations

The permanent removal of the X-waiver in January 2023 brought limited gains for patients, the researchers found. The number of patients receiving buprenorphine each month grew from May 2021 through December 2022 but stagnated and even decreased in the months immediately following the X-waiver elimination. This came even as the number of unique buprenorphine prescribers grew steadily, particularly among nurse practitioners and physician assistants between May 2021 and December 2024.  

There are several possible reasons why buprenorphine uptake did not increase after the removal of the X-waiver. Although Medicaid coverage drives access, the study period came as Medicaid eligibility reviews, known as redeterminations, started being done again after being suspended during the COVID-19 pandemic.

During the pandemic, Medicaid enrollment was extended continuously without beneficiaries having to reapply, and telehealth capabilities were expanded, allowing more patients to initiate and continue addiction treatment without having to physically go to a doctor’s office. As eligibility redeterminations resumed, this and other shifts to prior practices could have had a profound impact on buprenorphine prescribing and access.

The researchers also identified state-level barriers that continue to impede uptake. For example, some states restrict buprenorphine prescribing by nonphysicians, require prior authorization for addiction treatment, or do not allow telehealth prescriptions to be filled at pharmacies. The study authors state that these issues likely contributed to a low number of buprenorphine prescriptions in several states, including Texas, Tennessee, Alabama, Georgia, and Florida.

Next steps

Identifying the obstacles that limit buprenorphine uptake allowed the Rutgers-led researchers to highlight potential solutions.

For instance, expanding Medicaid, along with implementing automated eligibility review processes with less administrative burden on potential beneficiaries, could make for sustained Medicaid enrollment and more consistent access to buprenorphine. And policymakers should also consider removing state-level impediments such as prior authorization, prescriber restrictions, and limitations on telehealth.

And as always, a focus on reducing stigma by educating communities on substance use disorders and mental health, in addition to greater peer support, continue to be necessary everywhere and would especially benefit areas of the country with large treatment gaps.

Alexandra Duncan works on Pew’s substance use prevention and treatment initiative.