Obtaining a DEA-X Waiver Exemption

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In contrast to methadone for maintenance treatment, buprenorphine enables ED physicians to begin OUD medication-assisted therapy immediately in the emergency department upon presentation. Two routes for its clinical deployment are via administration and prescription: 

Administration

Under emergency circumstances, an emergency physician reserves the right to exercise the nonrenewable, non-extendable “three-day rule,” an exemption to the federal mandate requiring a separate DEA-X Waiver to employ narcotic drugs in treating acute opioid withdrawal. In this event, DEA-X Waiver protocol legally allows a provider to administer up to 72 hours of buprenorphine treatment at his or her professional discretion. However, treatment is capped at one day’s limit at a time, thereby requiring multiple visits to continue care within the same ED. This averts the potential for abuse or adverse consequences during the detoxification process. Furthermore, the patient must be referred to longer-term care following treatment.

Prescription

Implementing buprenorphine maintenance therapy requires that physicians obtain a DEA-X Waiver. To do so, practitioners must first register for and then successfully complete a SAMHSA-approved eight-hour training course. Current statistics indicate that only 1% of all emergency medicine physicians have this waiver to prescribe buprenorphine, implying missed opportunities to successfully treat OUD immediately in the ER. 

Both mechanisms require a continuity of care that incorporates long-term management within primary care or specialty care environments. 

DEA-X Waiver Protocol Following Training

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Application
Under the Drug Addiction Treatment Act of 2000 (DATA 2000), physicians who have completed the mandatory eight-hour training course are now eligible to obtain a DEA-X waiver to administer and/or prescribe buprenorphine medication-assisted therapy to treat opioid use disorder. DEA-X waiver protocol requires physicians to first notify the SAMHSA Center for Substance Abuse Treatment (CSAT) of their
intent via the Online Request for a New Waiver form. To verify waiver eligibility, physicians are to provide their DEA number, state medical license number, and training certificate details. Additional credentials and certifications will be assessed for qualification (i.e. the capacity to refer patients to counseling and/or alternative interventions). Physicians must also consent to the annual limit of thirty patients that may be treated with buprenorphine during the first year. Following application submission, official training certificates must be faxed to 301-576-5237, or emailed to csatbupinfo@dsgonline.com, to support the application under review.

Review
Processing may take up to 45 days following receipt. If approved, SAMHSA will send an email confirming the waiver and including the practitioner’s prescribing identification number. If no response is received after 45 days post-submission, please contact CSAT’s Buprenorphine Information Center at 866- BUP-CSAT (866-287-2728) or send an email to infobuprenorphine@samhsa.hhs.gov.

Exemptions
Special permission is granted to providers seeking to provide treatment immediately while an application is under review. For consideration, physicians must have a valid medical license, Drug Enforcement Administration (DEA) registration, or have completed the mandatory eight-hour training. Applicants
should check “New Notification, with the intent to immediately facilitate treatment of an individual (one) patient” on the notification form before contacting CSAT’s Buprenorphine Information Center at 866- BUP-CSAT (866-287-2728) to confirm receipt and to provide notification of the intent to begin treatment. Provisions limit immediate treatment to strictly one patient per form. If multiple forms are required, each must have a different submission date to be considered.