Written by Elizabeth Cairns, Mobilize Recovery Special Projects and Michael Masiowski, MD, reviewed by Code Recover Clinician Advisors, August 2026

Dr. Nasir Naqvi talks about how the former "x-waiver" limited access to care, and now any prescriber with DEA clearance can prescribe buprenorphine.

The regulatory landscape for treating OUD changed significantly with the passage of the MAT Act in 2023. The X-Waiver, an additional DEA clearance which was formerly required to prescribe buprenorphine, was rescinded. Any prescriber with a standard DEA registration can now prescribe buprenorphine for OUD, removing a massive barrier to ED-initiated treatment and discharge prescriptions. There are also no longer federal limits on the number of patients with OUD a practitioner may treat with buprenorphine. (source)

Critics of MOUD cite concerns about abuse or diversion of the medications, but the evidence does not support treating these as barriers to care. Pharmacologically, buprenorphine has a "ceiling," where increased doses have no additional effect. The addition of naloxone (as in Suboxone) is intended to deter misuse by injection, since naloxone is poorly absorbed sublingually but active parenterally. Patients do not experience a high, but rather feel normal post-dosage.

Research indicates that diversion is largely driven by patients seeking to manage withdrawal or maintain abstinence rather than to get high. [Internal link to MOUD article] Buprenorphine's ceiling effect makes respiratory depression far less likely than with full agonists, and clinically meaningful respiratory suppression is rare when the medication is used as directed. That protection is reduced when buprenorphine is combined with benzodiazepines or other sedatives — a combination carrying an FDA boxed warning — but the FDA has been explicit that this is not a reason to withhold MOUD from patients taking benzodiazepines. (source) In geriatric patients, side effects can be more pronounced, so those patients should be monitored for sedation or respiratory depression.

For methadone, additional regulations apply. Under the federal "three-day rule" (21 CFR 1306.07(b)), a clinician can dispense up to a three-day supply of methadone to relieve acute withdrawal while arranging a transition to ongoing care — not for long-term treatment, which must occur through a licensed opioid treatment program. This allows the ED to bridge a patient for up to three days, giving the peer team time to secure a longer-term clinical placement. (source) Requirements vary depending on state, and prescribers should make themselves familiar with the rules that apply to their locality.

Despite the removal of the X-Waiver, prescribers must still comply with state-specific PDMP (Prescription Drug Monitoring Program) checks. Documentation should clearly state that the medication is being used for the treatment of Opioid Use Disorder and that the patient's PDMP was queried, to ensure clinical clarity and regulatory compliance.

The MATE Act training requirement

Since June 27, 2023, all practitioners with Schedules II–V on their DEA registration — with the exception of veterinarians — must complete eight hours of training on treating and managing patients with opioid or other substance use disorders. This is a one-time requirement, satisfied by attestation at your first registration or renewal after that date; it does not recur at subsequent renewals. (source)

Several groups are already considered to have met it: practitioners board-certified in addiction medicine or addiction psychiatry; those who graduated from professional school within five years of June 27, 2023 and completed at least eight hours of SUD coursework; and anyone who previously completed DATA-2000 waiver training. (source)

Importantly, the DEA and SAMHSA do not review, approve, or certify individual courses. Qualifying training must come from an ACCME- or CCEPR-accredited provider, an organization named in the MATE Act, or an entity approved by the Assistant Secretary for Mental Health and Substance Use — and practitioners are responsible for verifying accreditation themselves.

Where to get the training at no cost:

• PCSS-MOUD (funded by SAMHSA grant 1H79TI086770, administered by AAAP) — free eight-hour training meeting the DEA requirement
• AMA Ed Hub — free courses satisfying the full eight hours
• ASAM — four separate eight-hour trainings, each of which satisfies the requirement independently
• Boston Medical Center, Grayken Center for Addiction — free training with CME and nursing credits
• Yale's curated list of free MATE-qualifying CME across multiple providers

Additional organizations named in the MATE Act as qualifying training providers include the American Osteopathic Association, American Psychiatric Association, American Association of Nurse Practitioners, American Academy of Physician Associates, and the American Nurses Credentialing Center. A fuller list is maintained by SAMHSA.