Bilden Rebecca C, Roberts Mark S, Stein Bradley D, Jones Daniel B
University of Pittsburgh, Pittsburgh, PA, USA.
RAND Pittsburgh, Pittsburgh, PA, USA.
Subst Use Addctn J. 2025 Jul;46(3):503-509. doi: 10.1177/29767342241303583. Epub 2024 Dec 15.
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.
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.
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%).
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.
在美国，阿片类药物过量使用率持续上升，而治疗选择的可及性仍然有限。X豁免权允许临床医生在门诊环境中开具丁丙诺啡（一种用于阿片类药物使用障碍的药物，即MOUD），该豁免权于2022年12月被取消，以期增加丁丙诺啡的可及性。我们采用了一种准实验方法来评估取消X豁免权对宾夕法尼亚州丁丙诺啡处方开具的影响。
利用宾夕法尼亚州处方药监测计划2016年7月1日至2023年12月31日的数据，我们采用双重差分（DD）方法来评估在取消X豁免权之前和之后，宾夕法尼亚州各县中每县人口中X豁免提供者比例高于中位数的县与比例低于中位数的县之间丁丙诺啡处方开具的变化。我们还利用各县治疗前基线期（2016 - 2018年）的阿片类药物过量死亡率，测试受阿片类药物流行影响最严重、阿片类药物过量率最高的地区是否受X豁免权取消的影响更大。
31个县被归类为高于中位数，32个县低于中位数。我们没有观察到在宾夕法尼亚州高于和低于中位数的县之间，取消X豁免权对丁丙诺啡配给的影响存在显著差异（DD估计值：-0.6%，95%置信区间：-7.5% - 6.2%）。我们也没有发现取消X豁免权对受阿片类药物流行影响最严重的县的丁丙诺啡配给有显著影响（三重差分估计值1.6%，95%置信区间：-10.2% - 13.4%）。
我们没有发现证据表明取消X豁免权对宾夕法尼亚州豁免处方医生较少或致命过量率较高的县的丁丙诺啡配给有显著影响。增加丁丙诺啡使用的额外努力可能需要解决限制MOUD可及性的系统性障碍和污名问题。
