OUD: Zooming to an X-waiver: A silver lining of the COVID-19 Pandemic

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OUD: Zooming to an X-waiver:

A silver lining of the COVID-19 Pandemic

By: Joelle Brown, MS4

A disheveled man sits crumpled on the cement steps, dirt-stained jeans pooling around his ankles. Oblivious to the cold wind that nips his bare skin, his chin slowly dips to his chest and his eyes close in a drugged stupor. 


This scene is all-to-common to the doorsteps of cities, suburban towns and rural villages throughout America that have been ravaged by the ongoing opioid epidemic. In many ways, the COVID-19 pandemic has exacerbated this crisis through lockdowns, increased isolation, and limited access to healthcare resources and safe drug supplies, to name few factors.1 Yet even the COVID-19 pandemic is not without a silver lining. Quarantine measures have normalized virtual education initiatives and by doing so, increased opportunities for healthcare providers and students to learn more about evidence-based treatments for opioid use disorder (OUD), specifically through online X-waiver training. 


Medication-assisted therapy (MAT) has been established as the gold standard for treatment of OUD. In the seminal clinical trial for emergency department (ED) treatment of opioid dependence, D’Onofrio et al demonstrated that, compared to psychosocial interventions alone, buprenorphine/naloxone (Suboxone) treatment initiated in the ED resulted in significantly increased engagement with addiction treatment and decreased self-reported opioid use for up to two months after the initial ED visit.2,3 Other studies have shown that patients who suffer from a nonfatal opioid overdose have an increased mortality risk, particularly within the first month post-overdose.4 Therefore, it is critically important that patients presenting to the emergency department with OUD are treated with appropriate medical therapy to increase the likelihood of their survival and possible recovery. 


Yet despite evidence of both the efficacy and necessity of MAT for OUD, it is still not common practice in many emergency departments. Though all licensed clinicians can dispense doses of buprenorphine in the ED, the Drug Addiction Treatment Act of 2000 requires any outpatient prescriptions to be issued only by providers that have completed special training and obtained a waiver (aka, the X-waiver).5  In a survey conducted in 4 academic emergency departments across the US between April 2018 – Jan 2019, Hawk et al. discovered that only 9 out of 268 respondents had obtained X-waiver training. Many participants reported a lack of formal training on treatment of OUD, lack of time and institutional resources, and lack of departmental protocols as key factors for their reluctance to integrate MAT into their practice.5 In another survey done at a separate academic emergency department, the majority of respondents likewise felt unprepared to discuss MAT with their patients, and many cited length of the waiver training course as a key barrier in their efforts to become more educated on the topic.6 


The COVID-19 pandemic has indirectly created an opportunity t9o address this obstacle. Mass cancellation of in-person events have normalized virtual educational conferences, making it easier for people to attend who might otherwise have been discouraged by travel time or costs. In May 2020 a group of physicians applied the virtual educational model to X-waiver training, organizing a one-day Zoom webinar open and free to clinicians in all levels of training, including students and non-physicians. Pre-conference surveys showed a majority of participants decided to take the course due to the convenience of the Zoom format, citing time and logistical challenges as the biggest reasons for why they had not completed the course earlier. A total of 799 attendees completed the course.7 The American College of Emergency Physicians has since adopted this model for Zoom-based X-waiver training by partnering with Providers Clinical Support System (PCSS) to offer free virtual X-waiver training courses throughout the fall of 2020 and early 2021 for any interested clinicians or trainees.9 


It remains to be seen whether increased availability of X-waiver training will result in more emergency clinicians discussing MAT and engaging patients in therapy. Accessibility of X-waiver training is only the most common barrier discussed in the literature; other issues that need to be addressed include linkage of care between EDs and primary care/addiction medicine services, perception of OUD treatment as part of the emergency medicine scope of practice, development of clear protocols for MAT, and support from hospital leadership and ancillary services.5,6,8 Despite these challenges, however, the expansion of virtual X-waiver classes has increased awareness and education about America’s other deadly epidemic. Hopefully, this will result in more compassion and advocacy for people on doorsteps throughout the country who suffer from it.  


  1. Jenkins W, Bolinkski R, Bresett J, et al. Covid-19 during the opioid epidemic – exacerbation of stigma and vulnerabilities. J. of Rural Health. 2020(00):1-3. doi:10.1111/jrh.12442

  2. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474.  

  3. D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention. J Gen Intern Med. 2017(32):660-666. doi:10.1007/s11606-017-3993-2.

  4. Weiner SG, Baker O, Bernson D, Schuur J. One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Ann Emerg Med. 2020;75(1):13-17. doi: 10.1016/j.annemergmed.2019.04.020.

  5. Hawk KF, D’Onofrio G, Chawarski MC, et al. Barriers and facilitators to clinician readiness to provide emergency department-initiated buprenorphine. JAMA Netw Open. 2020;3(5):e204561. doi: 10.1001/jamanetworkopen.2020.4561.  

  6. Im D, Chary A, Condella A, et al. Emergency department clinicians’ attitudes toward opioid use disorder and emergency department-initiated buprenorphine treatment: a mixed-methods study. West J Emerg Med. 2020;21(2)261-271. doi: 10.5811/westjem.2019.11.44382.

  7. Shayer D, Raber J.P., Raja A, Martin A. 189 Get waivered remote: a nationwide, remote, and interactive educational conference designed in response to COVID-19. AnnEmergMed. 2020;76(4):S73. doi: 10.1016/j.annemergmed.2020.09.201. 

  8. Martin A, Bulter K, Chavez T, et al. Beyond buprenorphine: models of follow-up care for patients with opioid use disorder in the ED. West J Emerg Med. 2020;21(6)257-263. doi:10.5811/westjem.2020.7.46079. 

  9. American College of Emergency Physicians ED X-Waiver Training Corps. Available at: https://www.acep.org/ed-x-waiver/. 

John Purakal