Who can manage Suboxone (buprenorphine) for patients in a given state?

Who Can Manage Suboxone (Buprenorphine) for Patients

As of the evidence provided, physicians with a Drug Addiction Treatment Act (DATA) waiver—obtained after completing an 8-hour training course—can prescribe buprenorphine to treat opioid use disorder, with initial patient caps of 30 in year 1, expandable to 100 in year 2, and up to 275 with additional qualifications. 1

Federal Requirements for Prescribing

Waivered Physicians

• Physicians must obtain a federal waiver (X-waiver) from SAMHSA after completing an 8-hour training course on proper buprenorphine prescribing 1
• Waivered physicians can treat up to 30 patients with buprenorphine in the first year 1
• After year 1, physicians may increase their patient cap to 100 patients 1
• Qualified physicians with sufficient training and experience can treat up to 275 patients 1
• Primary care physicians are more likely to prescribe buprenorphine compared to psychiatrists 2

Non-Waivered Physicians (Emergency/Acute Settings Only)

• Any DEA-licensed physician without a waiver can administer (but NOT prescribe) buprenorphine in emergency departments for up to 72 hours while arranging referral 1, 3
• Specific restrictions include:
  • Not more than one day's medication may be administered at one time 1
  • Treatment cannot exceed 72 hours 1
  • The 72-hour period cannot be renewed or extended 1
  • Must arrange for patient referral to treatment 1

Advanced Practice Clinicians

Nurse Practitioners and Physician Assistants

• Federal law permits NPs and PAs to obtain waivers to prescribe buprenorphine, but this is subject to state-specific regulations 1, 4
• State laws create additional barriers beyond federal requirements:
  • One state prohibits all APCs from prescribing buprenorphine entirely 4
  • Five states require PA supervision by a federally waivered physician 4
  • Three states require NP supervision by a federally waivered physician 4
• The 2016 federal budget proposal supported pilot projects for NPs and PAs to prescribe buprenorphine where permitted by state law 1

State-Specific Considerations

State regulations vary significantly and may impose additional requirements beyond federal law, including:

• Supervision requirements for advanced practice clinicians that differ from general scope of practice laws 4
• Some states have created laws explicitly regulating buprenorphine prescribing by APCs outside of licensed SUD facilities 4
• State policies regarding Medicaid funding and specific guidance for office-based buprenorphine use influence the number of waivered physicians 5

Common Pitfall

Do not assume that state scope of practice laws are the only regulations governing buprenorphine prescribing—several states have enacted separate laws specifically for buprenorphine that require additional supervision or impose outright bans on APC prescribing 4

Practical Barriers to Access

Despite federal authorization, significant barriers limit buprenorphine access:

• Less than 4% of prescribers had obtained waivers as of 2016 (just over 37,000 physicians) 1
• Many waivered physicians do not actively treat patients 1
• 43% of US counties had no buprenorphine-waivered physicians in 2011 5
• Cited barriers include lack of institutional support, insufficient mental health/psychosocial support, time constraints, lack of specialty backup, and resistance from practice partners 1
• Solo practice physicians are more likely to prescribe compared to group practice settings 2

Methadone Comparison

Methadone for opioid use disorder can only be dispensed through federally licensed opioid treatment programs, not in office-based settings 1

• Like buprenorphine, methadone can be administered (not prescribed) for up to 72 hours in emergency settings without program enrollment 1