Mr. R was already a long-term resident of a skilled-nursing facility when acute on chronic liver disease and a septic hip led to his hospitalization. He had been treated for pain with a low-dose fentanyl patch and oxycodone as needed, but his severe opioid use disorder was untreated. Following hepatic encephalopathy, clinicians increased his lactulose dosing and proposed buprenorphine-naloxone through a low-dose initiation protocol.

This combination was intended to treat the opioid use disorder while avoiding further cognitive complications associated with full opioid agonists. His pain and opioid use disorder were controlled on a sublingual dose of 16 milligrams of buprenorphine with 4 milligrams of naloxone, and his encephalopathy resolved. Despite that clinical improvement, the skilled-nursing facility refused to accept him back while he was receiving buprenorphine, citing the prescribing qualifications of the physician who had been managing his opioid analgesia.

The hospital team resisted returning him to the prior regimen, which had failed to control his opioid use disorder. Unable to secure a discharge destination that would allow him to continue treatment, Mr. R remained hospitalized for an additional month. The episode extended his hospital stay and placed the hospital team in direct conflict with the receiving facility, even though the medication had been effective and the proposed transfer required him to stop it.

Buprenorphine was a rational choice for Mr. R, according to the perspective. It is a partial mu-opioid agonist associated with reduced all-cause mortality in patients with opioid use disorder and is recommended when opioid use disorder occurs alongside chronic pain. Its ceiling effect on respiratory depression gives it a lower overdose risk than full opioid agonists.

For Mr. R, it also offered a way to limit the potential for hepatic encephalopathy associated with full agonists. Long-acting injectable buprenorphine has demonstrated analgesic efficacy, but the authors note a lack of sufficient studies in patients with cirrhosis and a relative contraindication in acute hepatic dysfunction, favoring the sublingual formulation in this case. The comparison with other treatments was also important.

Methadone was not favored because of its effects on body mass index and cardiovascular risk factors, while full opioid agonists require close monitoring in decompensated cirrhosis because they can produce supratherapeutic effects and worsen hepatic encephalopathy. Naltrexone was not considered because it lacks analgesic effectiveness and can be difficult to initiate in people currently taking opioid agonists. The authors note that short-acting fentanyl and oxycodone are not approved to treat opioid use disorder, although transient short-acting opioids may sometimes be used as adjuncts for acute pain in patients already receiving buprenorphine.

At the center of the refusal was a misunderstanding that had already been overtaken by federal policy. Under the Drug Addiction Treatment Act of 2000, buprenorphine previously could be prescribed only by clinicians with a special Drug Enforcement Administration registration identified by an X license. Those requirements were eliminated in January 2023, and any clinician with an active, unrestricted DEA registration can now prescribe buprenorphine as they can other controlled substances.

In addition, inpatient clinicians and facilities, including skilled-nursing facilities, were never required to hold an X license to dispense and administer buprenorphine. Nevertheless, the source perspective reports that clinicians and healthcare organizations continued to miss this change after it took effect. The prescribing data described in the perspective show that removing the waiver did not immediately translate into substantially broader treatment.

The number of clinicians prescribing buprenorphine rose only marginally in 2023, while the number of patients receiving the medication remained relatively unchanged. Attitudes also continue to shape access. Clinicians may acknowledge that opioid use disorder is common yet still believe they encounter too few affected patients to justify additional training.

The authors describe this as “intervention stigma,” a reluctance to treat opioid use disorder that has been reported across healthcare settings and is intensified by gaps in training and health literacy. Refusal by skilled-nursing facilities is part of a broader pattern documented in the perspective, with the authors stating that it is not uncommon. Such refusals can prolong hospitalizations, delay rehabilitation and contribute to worse health outcomes.

They also trap clinicians in an untenable choice: continue an effective, morbidity- and mortality-reducing medication and postpone discharge while seeking another facility, or revert to a less suitable regimen to secure placement. Multiple court settlements have established that refusing care because a patient receives medication for opioid use disorder can violate the Americans with Disabilities Act, which protects people with physical or mental disabilities, including substance use disorder, and applies to public and private hospitals and skilled-nursing facilities. The obstacles are not purely individual attitudes.

Staff shortages, inadequate training, medication-storage difficulties and low reimbursement can make facilities reluctant to accept patients receiving medication for opioid use disorder. The authors also point to the disproportionate Medicaid coverage of people with opioid use disorder: when facilities are reimbursed below the cost of care, financial and staffing pressures may discourage them from adopting medication treatment. State rules can add further barriers through dosage or prescription-duration caps, frequent or random drug testing and prior-authorization requirements.

Although the elimination of the federal X license was an important policy change, the perspective argues that this patchwork of clinical, financial and regulatory obstacles helps sustain discriminatory practices. Mr. R eventually returned to the skilled-nursing facility on buprenorphine after sustained clinician-to-clinician discussion, hospital advocacy and the facility’s willingness to learn about current clinical guidance and disability law. The outcome was possible because the hospital team assumed that the refusal reflected inadequate knowledge rather than an intention to punish or harm him.

That approach allowed the receiving physician to engage with the updated federal requirements while preserving clinically appropriate treatment. The perspective concludes that eliminating gaps in care requires interventions across the healthcare system, including targeted training, mentorship, policy reform and adequate support for facilities that provide medication for opioid use disorder. It nevertheless identifies hospital-based advocacy as an immediate tool for improving transitions of care.

Mr. R’s month-long delay demonstrates that a regulatory change alone cannot guarantee access when clinicians, administrators and institutions continue to operate under outdated assumptions. His eventual acceptance after education and negotiation shows both the cost of those assumptions and the potential for hospital teams to intervene constructively. The case does not establish how often such refusals occur or whether one conversation resolves them, but it provides a detailed account of how the post-X-waiver era can still leave patients facing discriminatory barriers to an established treatment.

Subject of Research: How barriers to buprenorphine access persist in skilled-nursing facilities after elimination of the federal X-waiver.

Article Title: Discriminatory Practice in Opioid Use Disorder: In a Post-X-Waiver Era, Barriers to Buprenorphine Persist

Article References: Freibert, H., Lofwall, M. R., & South, A.-M. (2026). Discriminatory Practice in Opioid Use Disorder: In a Post-X-Waiver Era, Barriers to Buprenorphine Persist. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10945-y

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10945-y

Keywords: buprenorphine, opioid use disorder, skilled-nursing facilities, medication treatment, X-waiver, healthcare discrimination, Americans with Disabilities Act, clinical stigma, health policy, hospital advocacy, Discriminatory, Practice