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. Author manuscript; available in PMC: 2026 Jan 6.
Published in final edited form as: Am J Prev Med. 2025 Aug 12;69(5):108055. doi: 10.1016/j.amepre.2025.108055

Buprenorphine Dispensation After X-Waiver Elimination by Clinician Specialty

Elizabeth M Stone 1,2, Fangzhou Xie 1,3, Jennifer Miles 1,2, Hillary Samples 1,4, Mark Olfson 5, Stephen Crystal 1,6
PMCID: PMC12766698  NIHMSID: NIHMS2124519  PMID: 40812485

Abstract

Introduction:

Elimination of the X-waiver, which required clinicians to complete additional registration to prescribe buprenorphine for opioid use disorder, removed one barrier to treatment. This study examined the association of the X-waiver elimination with buprenorphine dispensations by clinician specialty.

Methods:

Using IQVIA Longitudinal Prescription data, patients with 15 or more days of dispensed buprenorphine supply each month from May 2021 to December 2024 were identified. Interrupted time series analyses (conducted in 2025) examined changes in monthly counts of clinicians associated with dispensations and patients, overall and stratified by clinician specialty.

Results:

During the study period, 189,771 clinicians dispensed buprenorphine to 2,699,441 patients. X-waiver elimination was associated with significant increases in the number of clinicians associated with dispensed buprenorphine prescriptions overall (change in level= 1,626 clinicians; 95% CI=577, 2,674; p<0.01; change in slope: 15 clinicians per month, 95% CI=13, 18, p<0.001) and across all specialties. X-waiver elimination was associated with a decrease in the number of patients with buprenorphine dispensations in January 2023 overall (change in level= −24,104 patients; 95% CI= −40,010, −8,198; p<0.01) and from all clinician groups except behavioral health physicians. Decreasing monthly rates of patients with buprenorphine dispensed by behavioral health physicians slowed after X-waiver elimination; monthly rates of buprenorphine patients with dispensations from primary care providers increased after (versus before) the policy change.

Conclusions:

Although the number of clinicians associated with dispensed buprenorphine prescriptions after X-waiver elimination increased across all clinician types, patient-level gains associated with X-waiver elimination were limited.

INTRODUCTION

People with opioid use disorder (OUD) face barriers to accessing medications, contributing to a national treatment gap.1-3 Recent policy changes have attempted to increase access to these potentially life-saving treatments, including elimination of the X-waiver, which had been required to prescribe buprenorphine for OUD since the Drug Abuse Treatment Act of 2000.4,5 The 2023 Consolidation Appropriations Act eliminated the X-waiver, allowing clinicians with Drug Enforcement Administration registration to prescribe buprenorphine without additional registration requirements.6,7

Two studies have examined initial associations between X-waiver elimination and access to buprenorphine in national prescription data through December 2023. One study found that X-waiver elimination was associated with increases in buprenorphine-prescribing clinicians but no changes in patients initiating buprenorphine.8 However, a second study reported a decrease in monthly patients receiving buprenorphine after the elimination of the X-waiver.9 Both analyses considered buprenorphine dispensations across all clinicians.

Consideration of buprenorphine prescribing with regard to trends across clinician specialties may improve the understanding of the relationship between X-waiver elimination and treatment outcomes.10 Using national all-payer prescription data, this study examined monthly changes in the number of clinicians associated with buprenorphine dispensations and patients with dispensed buprenorphine between May 2021 (after the prior X-waiver guidance change11) and December 2024, overall and across primary care physicians (PCPs), behavioral health physicians (BHPs), other physicians, and nonphysician advanced practice practitioners (APPs).

METHODS

IQVIA Longitudinal Prescription data include nearly 4 billion prescription claims per year across all payer types and covers >90% of U.S. retail pharmacies. This prescription-level data set includes National Drug Code, dispensing date, days supplied, National Provider Identifier and American Medical Association self-designated practice specialty of the clinician for each dispensation, and an anonymized patient identifier to link dispensations to individuals over time.

Analyses were limited to buprenorphine dispensations among adults aged ≥18 years from May 2021 through December 2024. Buprenorphine dispensations for OUD were identified using National Drug Code numbers (Appendix Table 1, available online), excluding formulations for pain management. Four clinician categories included PCP, BHP (e.g., addiction psychiatrist), other physician, and APP (e.g., nurse practitioner) (Appendix Table 2, available online). Prescriptions with missing clinician specialty were excluded (2.2%). For each month, unique patients with ≥15 days of dispensed buprenorphine supply and unique clinicians associated with those dispensations were counted. Individuals with <15 days’ supply were excluded because consistent use of buprenorphine is associated with better treatment and recovery.12,13

Interrupted time series analyses were conducted to assess immediate changes in dispensed buprenorphine at the time of X-waiver elimination in January 2023 (change in level) and the monthly change in trends during the postelimination period compared with that in the preelimination period of the X-waiver (change in slope). For each outcome, overall and stratified analyses by clinician group were conducted. Sensitivity analyses assessed changes among patients with new buprenorphine dispensations (i.e., no dispensations in the prior 180 days). Analyses were conducted in R (Version 4.4.2), and all models used Newey-West SEs with 1 lag.14 This study was approved by the Rutgers IRB and followed the STROBE reporting guidelines.15

RESULTS

Over the 44-month study period, buprenorphine was dispensed from 189,771 clinicians to 2,699,441 patients. Clinicians associated with buprenorphine dispensations increased from 35,338 in May 2021 to 62,017 in December 2024 (Figure 1). In May 2021, PCPs (35%; n=12,517) were the largest buprenorphine-dispensing group. By December 2024, APPs were the largest group of buprenorphine-dispensing clinicians (41%; n=25,184). The number of patients with buprenorphine dispensations each month increased from May 2021 to December 2022, although this trend did not continue into 2023 and 2024 (Figure 2). Reflecting clinician trends, in May 2021, the largest group of patients had dispensations associated with PCPs (36%; n=281,370). By December 2024, nearly half of all patients had dispensations associated with APPs (49%; n=460,879).

Figure 1.

Figure 1.

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Monthly number of clinicians associated with buprenorphine dispensations by clinician specialty, May 2021 to December 2024.

Note: Presented are monthly counts of clinicians associated with buprenorphine dispensations to patients with at least 15 days’ supply of dispensed buprenorphine per month and interrupted time series analysis regression lines from May 2021 to December 2024, overall and by each of 4 clinician specialties: primary care physicians, behavioral health physicians, other physicians, and advanced practice practitioners. The vertical line at January 2023 denotes the elimination of the X-waiver.

Figure 2.

Figure 2.

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Monthly number of patients with buprenorphine dispensations by clinician specialty, May 2021 to December 2024.

Note: Presented are monthly counts of patients with at least 15 days’ supply of dispensed buprenorphine per month and interrupted time series analysis regression lines from May 2021 to December 2024 overall and by each of the 4 clinician specialties: primary care physicians, behavioral health physicians, other physicians, and advanced practice practitioners. The vertical line at January 2023 denotes the elimination of the X-waiver.

X-waiver elimination was associated with increases in clinicians associated with buprenorphine dispensations at the policy change (change in level=1,626 clinicians; 95% CI=577, 2,674, p<0.01) and in monthly trends after X-waiver elimination (change in slope=15 clinicians per month; 95% CI=13, 18; p<0.001) (Table 1). The largest increases at X-waiver elimination were among PCPs and APPs. Smaller statistically significant increases were observed in the change in slope of BHPs and the level and slope of other physicians.

Table 1.

Change in Buprenorphine Dispensations Associated With X-Waiver Elimination, May 2021 to December 2024

Interrupted time series analyses n 95% CI
Monthly number of clinicians associated with buprenorphine dispensations
Overall
 Change in level at January 2023 1,625.80** 577.41, 2,674.19
 Change in slope before versus after X-waiver elimination 15.48*** 13.04, 17.91
Primary care physicians
 Change in level at January 2023 845.50** 378.98,1,312.02
 Change in slope before versus after X-waiver elimination 5.81*** 4.74, 6.89
Behavioral health physicians
 Change in level at January 2023 25.52 −68.55, 119.60
 Change in slope before versus after X-waiver elimination 1.26*** 1.00, 1.51
Other physicians
 Change in level at January 2023 269.07** 83.99, 454.15
 Change in slope before versus after X-waiver elimination 1.45*** 1.01, 1.89
Advanced practice practitioners
 Change in level at January 2023 485.71** 138.46, 832.96
 Change in slope before versus after X-waiver elimination 6.96*** 6.13, 7.79
Monthly number of patients with buprenorphine dispensations
Overall
 Change in level at January 2023 −24,104.25** −40,010.25, −8,198.24
 Change in slope before versus after X-waiver elimination 47.08 −1.21, 95.38
Primary care physicians
 Change in level at January 2023 −8,509.90** −13,525.61, −3,494.19
 Change in slope before versus after X-waiver elimination 18.34* 2.84, 33.84
Behavioral health physicians
 Change in level at January 2023 −1,396.05 −3,681.65, 889.56
 Change in slope before versus after X-waiver elimination 16.74*** 8.89, 24.58
Other physicians
 Change in level at January 2023 −2,915.76* −5,269.08, −562.44
 Change in slope before versus after X-waiver elimination 3.05 −3.44, 9.54
Advanced practice practitioners
 Change in level at January 2023 −11,837.80* −21,312.34, −2,363.26
 Change in slope before versus after X-waiver elimination 11.22 −16.79, 39.23
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Note: *p<0.05, **p<0.01, and ***p<0.001.

X-waiver elimination was associated with a significant decrease in patients with buprenorphine dispensations at the time of the policy change overall (change in level= −24,104 patients; 95% CI= −40,010, −8,198; p<0.01) and among patients with dispensations from all clinician groups except BHPs. Although there were statistically significant increases in slope after (versus preceding) the policy change for patients with dispensations from PCPs and BHPs, the slope in the postelimination period remained negative for the BHP group,

In sensitivity analyses, X-waiver elimination was associated with increases in change in monthly clinicians associated with new buprenorphine dispensations overall and across all specialties and a change in level among dispensations from other physicians in January 2023 (Appendix Table 3, available online). In contrast to the main results, X-waiver elimination was not associated with any change in the levels of patients with dispensations at the time of the policy change for any group; increases in the monthly rates of patients with new buprenorphine dispensations from PCPs and BHPs were observed.

DISCUSSION

Using a national database of buprenorphine dispensations, X-waiver elimination was associated with an increase in clinicians associated with dispensations across all specialties, driven primarily by PCPs and APPs. In contrast, X-waiver elimination was associated with decreases in the number of patients with buprenorphine dispensations at the time of the policy change from all clinicians except BHPs. Although monthly rates of patients receiving dispensations from PCPs and BHPs after (versus preceding) X-waiver elimination increased, the observed rates after the policy change remained negative among BHPs and relatively flat among PCPs.

This study adds to the growing evidence that elimination of the X-waiver was insufficient to meaningfully increase buprenorphine access for people with OUD despite increasing numbers of prescribing clinicians.8,9 Critically, the removal of the X-waiver overlapped with the unwinding of the coronavirus disease 2019 (COVID-19)–era pause in Medicaid eligibility redeterminations, which may have contributed to disruptions in access to buprenorphine and stagnation in the number of patients with buprenorphine prescriptions observed in 2023 and 2024.16,17 Additional policies reducing patient barriers (e.g., cost sharing), increasing patient demand (e.g., peer support), and reducing stigmatization of medication for OUD may be needed to connect more patients to medication.18-20

Limitations

Although IQVIA data cover >90% of retail pharmacies, it does not capture buprenorphine administration in other settings and only includes information on dispensations, which may not accurately reflect changes in treatment practices if prescriptions go unfilled. IQVIA data contain limited patient information; analyses could not be limited to people with OUD because the data do not include diagnoses. To address this concern, buprenorphine formulations used for pain management were excluded. Although changes in dispensation by clinician specialty and among new dispensations were examined, variation may exist in X-waiver effects by state, region, or patient characteristics. Other policy changes, including expansion of telehealth visits during the COVID-19 pandemic and Medicaid unwinding at the end of the federal emergency period, may also impact buprenorphine dispensations.16,17,21,22

CONCLUSIONS

Although the number of clinicians associated with buprenorphine dispensations after X-waiver elimination increased across all clinician types, patient-level increases were limited. Additional policy changes addressing patient-side barriers may be needed to meaningfully improve access to buprenorphine for people with OUD.

Supplementary Material

Appendix

Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j.amepre.2025.108055.

ACKNOWLEDGMENTS

Disclaimer: Funders had no role in study design; collection, analysis, or interpretation of data; writing of the report; or the decision to submit the report for publication.

Access to IQVIA Longitudinal Prescription data was provided to the study team through a project supported by the Preparedness and Treatment Equity Coalition and The Pew Charitable Trusts; the authors thank IQVIA for graciously providing Longitudinal Prescription data for this project.

Funding:

Effort of coinvestigators JM, HS, and SC are supported through National Institute of Drug Abuse awards K99DA057372 (JM), K01DA049950 (HS), R01DA057568 (SC) and R01DA047347 (SC).

Declaration of interest:

HS has received consulting fees from The Pew Charitable Trusts unrelated to this work. No other financial disclosures were reported.

Footnotes

CREDIT AUTHOR STATEMENT

Elizabeth M. Stone: Conceptualization, Data curation, Formal analysis, Methodology, Validation, Writing – original draft. Fangzhou Xie: Data curation, Formal analysis, Investigation, Software, Visualization, Writing – review & editing. Jennifer Miles: Conceptualization, Resources, Validation, Writing – review & editing. Hillary Samples: Supervision, Writing – review & editing. Mark Olfson: Supervision, Writing – review & editing. Stephen Crystal: Conceptualization, Resources, Supervision, Writing – review & editing.

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Associated Data

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Supplementary Materials

Appendix
NIHMS2124519-supplement-Appendix.pdf (244KB, pdf)

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