“Be present in all things and thankful in all things.”- Maya Angelou

- L.M. Montgomery (Anne of Avonlea)

Hello Fall!! This time of year is generally a time to show thanks, so I will focus this month’s message on what I am thankful for.

Fighting the Opioid Epidemic by Exemptions of X-Waivers

By: Jennifer A Tussey, PharmD, AAHIVP

This year, the US Department of Health and Human services announced new guidelines to expand access to medication-assisted treatment (MAT) for opioid use disorder (OUD). In Missouri, drug overdose deaths have been on the rise, recently hitting the largest ever death count in a 12-month period ending in March 2021 (per most recent CDC data). These new guidelines would allow physicians more access to prescribe buprenorphine outside of opioid treatment programs. These guidelines waive the previous requirements which involved physicians taking an 8 hour course and waiting 60-90 days to receive their waiver once submitting an application.

This move has been a push from health care providers, as it would assist in removing stigma and allowing more physicians to treat their patients and make an impact on the ongoing opioid epidemic. Under the new guidelines, physicians are able to get an exemption from the X-waiver, by filing a notice of intent, and are limited to treating 30 or less patients with MAT. If a physician is treating more than 30 patients, full training and an X-waiver is still required.

Physicians must still be licensed in their state and have a valid DEA registration and this exemption only applies to schedule III, IV, and V medications, such as buprenorphine and not CII medications, such as methadone. Mid-level practitioners are included in this exemption, but mut be supervised by or work in collaboration with a DEA registered physician. In Missouri, mid-level practitioners may only write a 30 day supply of buprenorphine and cannot include refills. Prescribers should place an “X” on the prescription and clearly identify that the prescription is being written for opioid use disorders.

A quick start guide from The Substance Abuse and Mental Health Services Administration (SAMHSA) is available here, which details facts and recommendations for practitioners.

MSHP would love to hear your questions, concerns or comments regarding this change and how MSHP can help you at Jennifer.tussey@bjc.org.

Open fractures are injuries frequently seen in emergency departments or trauma centers. Typically, the skin barrier has been compromised, exposing the sterile bone to environmental debris and soft tissue damage. Exposure to the ambient environment places these wounds at an increased risk of infection.¹ The Gustilo-Anderson classification system is utilized to grade the severity of open fractures, and to determine appropriate antibiotic prophylaxis (Table 1). The infection rates for grade I/II fractures range from 0 to 7% whereas the grade III fracture infection rate ranges from 5 to 50% without antibiotic prophylaxis.³ Ineffective prophylaxis may lead to complications such as nonunion of bones and osteomyelitis.² In fact, 19% of osteomyelitis cases are secondary to traumatic injury.­ As such, the use of antibiotic prophylaxis to decrease the rate of infective complications after open fractures has been considered standard of care for over 30 years.