In Case You Haven't Heard…

Why is there such passion about the x‐waiver — the requirement that prescribers have a special Drug Enforcement Administration registration to treat opioid use disorder (OUD) patients with buprenorphine? It's partly turf — those with the waiver, and those with expertise, don't want to lose their market share. And it's partly concern that patients would die — as happened when methadone was put into primary care — although buprenorphine's safety profile is much better (as long as it's not combined with alcohol or benzodiazepines). The harm‐reduction extremists, who want free distribution of buprenorphine (and, in many cases, methadone), and public policy academics, as well as medical centers focused on integrating addiction treatment into primary care, are united in wanting to get rid of the x‐waiver. “Medication first” is not only a valid approach — that is the indicated approach for buprenorphine — but it is not the same as “medication only.” Nobody is against medication first as long as it results in access to comprehensive treatment. None of these debates are new. But it is possible to create solutions for patients with OUDs without sacrificing their access to comprehensive care. They deserve it. If they want it, it should be there for them, because so many of them want to get completely well. Not all patients need counseling, but all patients deserve access to it.