So Why Ban the X Waiver?

Getting the X waiver is a small but worthwhile hassle. It takes about eight hours and a couple hundred bucks, and you have to do a small amount of electronic paperwork. ACEP and many other groups offer these courses. Do this now! I did it last year, and I haven’t regretted it for a nanosecond. I have started a small number of patients on Suboxone. I may have already saved one or more lives by doing so. During that time, I have had zero successful thoracotomies. If we are keeping track of otherwise healthy lives saved, buprenorphine is clearly winning—if not already, then certainly in the long run.

But I also freely admit that getting that waiver was indeed a “small” hassle. And even that small hassle appears to be preventing physicians who want to get waivered from doing so. For any armchair behavioral economists out there, this is a prime example of what Nobel Prize–winning economist Richard Thaler has termed “sludge.” Sludge is “excessive or unjustified frictions that make it more difficult for consumers, employees, employers, students, patients, clients, small businesses, and many others to get what they want or to do as they wish.” Sludge is what keeps you from signing up for things you actually want, like that tax shelter for your medical expenses or child care. Everyone hates sludge. But emergency physicians are particularly averse to it. The X waiver requirement would not pass what economist Cass Sunstein calls a “sludge audit,” an exercise designed to determine whether any barriers preventing a particular action are reasonable and worthwhile. (Mr. Sunstein and I published an opinion this month in The Boston Globe calling for removing the X waiver requirement on this basis).

For that reason, I join many experts in calling for the X waiver requirement itself to be erased from the law books. This summer, the American College of Medical Toxicology made this stance its official policy. ACEP endorsed the position and now has its own statement to the same effect. Bipartisan legislation in both chambers of Congress has been proposed. Let’s urge our lawmakers to move forward on this.

While the fate of the X waiver is unknown, it’s unlikely to go away immediately. In the meantime, I encourage you to take any and all steps to help our opioid use disorder patients. Go and get your X waiver! Also: Ban the X waiver!