The repeal of the “X-waiver” in the Consolidated Appropriations Act of 2023 was widely celebrated as a long-overdue step toward expanding access to buprenorphine for opioid use disorder (OUD). By removing the requirement for supplemental training and a special DEA designation, policymakers hoped to normalize treatment and reduce barriers for clinicians.
Yet nearly two years after, buprenorphine prescribing remains inconsistent across the country. Only one in four Americans with OUD receives evidence-based medication treatment, an unacceptable gap in the midst of a public health crisis.
The inconsistency of residency training
Clinicians across specialties continue to report discomfort initiating buprenorphine, often viewing OUD treatment as the purview of addiction specialists rather than a routine part of primary or acute care. As a hospitalist, I see this hesitation regularly. As a researcher, I also see how unevenly residency programs have responded to the X-waiver repeal.
Some have embraced the opportunity to integrate medications for opioid use disorder (MOUD) training into their curricula. Others have made minimal changes, leaving new physicians without the skills or confidence to treat OUD in everyday practice.
We know this variability matters. Studies show that residency-integrated buprenorphine training reduces stigma, increases prescribing confidence, and helps physicians view OUD treatment as a core clinical responsibility. When training is present, clinicians prescribe. When it is absent, they don’t.
Regulatory gaps in medical education
The new DEA requirement, a one-time, eight-hour substance use training for clinicians seeking a new or renewed license, was intended to fill this gap. But the policy does not specify how much time must be dedicated to opioid-specific content, nor does it require documentation of completion.
Similarly, the Accreditation Council for Graduate Medical Education (ACGME) requires programs to teach pain management and recognition of addiction, but offers no guidance on which specialties must include MOUD training or how programs should structure it.
The result is predictable: wide disparities in how future physicians are prepared to care for patients with OUD.
A call to action for medical societies
As a medical community, we can do better.
Medical societies are uniquely positioned to lead the call for clearer, more actionable standards. By advocating for explicit MOUD training requirements across residency programs, and by supporting faculty with practical curricula, clinical tools, and mentorship models, we can help ensure that every graduating physician is equipped to treat OUD with the same competence they bring to managing other chronic conditions.
Buprenorphine saves lives. Training clinicians to prescribe it should not depend on geography, specialty, or the initiative of individual programs. It should be a universal expectation.
The X-waiver repeal removed a regulatory barrier. Now it’s time for our educational and professional systems to remove the structural ones. Medical societies, residency leaders, and practicing clinicians all have a role to play in making MOUD training a standard part of medical education, and in ensuring that patients with OUD receive the care they deserve.
S. Hillary Kim-Vences is a post-doctoral research fellow.
