State Policies Can Expand Access to Buprenorphine for Opioid Use Disorder

Overview

Medications for treating opioid use disorder (OUD) have been proven to reduce illicit drug use, overdose deaths, and disease transmission via injected drugs, yet access to this lifesaving treatment remains limited.¹ Two highly effective Food and Drug Administration-approved medications, buprenorphine and methadone, have different regulations and restrictions on their modes of distribution. Buprenorphine can be prescribed by physicians, nurse practitioners (NPs), and physician assistants (PAs) in a variety of settings, including primary care offices and clinics, while the federal government requires that methadone can be dispensed only in a small number of highly regulated specialty clinics known as opioid treatment programs (OTPs).²

The rate of fatal opioid overdoses in the United States increased more than eightfold between 1999 and 2020, claiming more than 560,000 lives, and approximately an additional 80,000 lives were lost in 2021.³ Yet in 2021, only 22% of people with OUD received any medications for their condition.⁴

When it comes to accessing lifesaving medications for OUD, states have considerably more leverage in amending rules or laws that can result in greater access to buprenorphine than in addressing methadone access, which the federal government tightly controls. To that end, in recent years there has been a flurry of state activity designed to increase the availability of buprenorphine. These efforts include creating incentives for more providers to prescribe the medication (as of 2020, only 5% of physicians in the U.S. had obtained the federal waiver needed to be able to do so) and making it easier for more patients to start and continue on it.⁵

In late 2022, Congress made it easier for providers to prescribe buprenorphine when it passed the Mainstreaming Addiction Treatment (MAT) Act, which removed a special prescriber registration requirement.⁶ But this special registration was not the only barrier to provider prescribing, and arguably not the most important one (it also doesn’t supersede state laws that impose their own registration requirements on buprenorphine prescribers).⁷ Other reported provider disincentives that states are seeking to change include low reimbursement rates, lack of experience in treating OUD, and lack of support in meeting a range of the health and social service needs of patients on buprenorphine. From patients’ perspective, even when they are able to find a buprenorphine prescriber, some state rules make it difficult to fill prescriptions and stay on the medication. For instance, public and private insurers in some states require approval before buprenorphine can be prescribed, delaying access to this lifesaving medication. And some states require counseling as a condition for patients to receive buprenorphine, despite research showing that medication alone—even without counseling—lowers OUD overdose death rates and improves retention in treatment.⁸

States are also being called on to redress significant access disparities to buprenorphine by race. Across the country, OUD rates are fairly comparable between Whites, Blacks, and Hispanics.⁹ However, research finds that buprenorphine providers are less likely to be located in communities of color, and that Black and Hispanic people are significantly less likely to receive buprenorphine than Whites. In addition, data shows that Black and Hispanic people who fatally overdosed were significantly less likely than Whites to have received any treatment for substance use disorder (SUD).¹⁰

With no signs of the opioid crisis abating, states have been testing strategies to increase access to buprenorphine in more health and behavioral health care settings and to a more diverse patient population. States are doing this through a combination of removing rules that are diminishing access to care, creating a variety of financial incentives to prescribing, and reorganizing health care delivery to better support the needs of buprenorphine prescribers. Such reforms are being led by governors’ offices, state legislators, and executive agency officials across state governments, with each using the various policy mechanisms at their disposal (executive orders, legislation, Medicaid waivers, regulatory reform) to create change.

Policies for change

This brief explores the most promising policy options that states can use to make buprenorphine more readily available.¹¹ It also outlines the mechanisms to enact each option, such as:

Governors’ directives: A governor-issued executive order, these are frequently used during a public health crisis or disaster. Directives often create task forces that oversee the development and execution of action plans and elevate important issues within agencies and the public.

Legislative action: Bills passed by state legislatures can mandate or encourage state agency action, remove barriers that exist in state laws or agency rules, and appropriate money to fund state agencies, providers, or community-based groups. Legislatures can also hold oversight hearings on executive branch activities.

State agency actions: State agencies oversee the regulation, licensure, authorization, and funding of a wide range of services and supports to address addiction and have several tools they can use to expand access to buprenorphine, including:

• Funding: Grants—including federal block grants—and state appropriations can support a range of reforms, including benefit expansion and expanding and diversifying the provider workforce.
• Community engagement: Invite community members to help brainstorm and develop strategies to address problems and expand care based on their own experiences in accessing care.
• Technical assistance (TA): Direct technical support to providers can ease administrative challenges.
• Advancing private insurance reform: State agency officials can take the lead on incentives and disincentives that help commercial health insurers discard barriers to accessing treatment and medications for opioid use disorder.
• Enforcing federal parity rules: State Medicaid directors and insurance commissioners can promote compliance with federal parity requirements and impose penalties on Medicaid and commercial health plans (except employer-sponsored health plans) that violate the Mental Health Parity and Addiction Equity Act.¹² (This law mandates that mental health and substance use benefit treatment limits cannot be more restrictive than medical or surgical benefits.¹³)

Medicaid: Medicaid is a joint federal/state health care entitlement program that serves primarily low-income and disabled Americans and is the largest source of funding for OUD-related services, covering nearly 40% of people with this condition.¹⁴ States have the option of doing more with Medicaid, and many are. For instance, they can expand eligibility for OUD services, increase the range of reimbursable benefits to treat OUD, and increase the relatively low number of Medicaid providers who prescribe buprenorphine through rate increases to providers.¹⁵ The box below describes the different actions Medicaid agencies can take to better serve people with OUD.

States that enact new policies to increase access to buprenorphine should also perform two key actions: collect data on OUD prevalence and treatment rates, and review and consider mitigating any long-standing structural barriers that will dilute efforts to reduce opioid addiction. States need to look at their OUD prevalence rates, use of medications, and treatment retention by age, race/ethnicity, sex, geography, and other important markers. This is the only way to determine which interventions are most needed and which populations (in which geographic areas) to target. States can collect data for services covered by Medicaid, federal block grants, opioid settlement funds (acquired through lawsuits with drug manufacturers and distributors), state discretionary grants, and commercial health insurers.

To understand the intractability of the opioid crisis, it’s critical to account for long-standing structural barriers that work against treatment and recovery efforts, such as laws related to housing, employment, and incarceration for drug use. For example, drug possession can often lead to incarceration. Of the nearly 2 million people in the nation’s prisons and jails, more than half have an SUD.²³ And the availability of medications for OUD in prisons and jails does not come close to meeting the need. Once released, many formerly incarcerated people face housing and employment policies that exclude those with criminal records. In addition, various jurisdictions of the country have rental housing policies that evict people for using substances or for having guests who use substances. Separately and combined, these policies create an instability that corrodes a person’s ability to seek treatment and maintain recovery. Although this brief does not address these issues, Pew has and will continue to develop materials to describe policy options that focus on legal system, housing, and employment policies that do not complicate OUD treatment and recovery efforts.²⁴

Policy Menu

States can select from many different policy approaches to improve service delivery, remove barriers to treatment access and retention, fund services, reduce racial inequities in care access and outcomes, and expand the treatment workforce. The following tables illustrate (1) policies targeting these specific issues, (2) mechanisms that can be used to enact them, and (3) examples of policies adopted in various states.

A. Reform treatment delivery systems

People with OUD often have a range of needs beyond care for their addiction, including treatment for co-occurring mental illness, general medical care, and access to social supports such as housing and employment. Some states are building delivery models that formalize the connections between these service systems and strengthen individual systems, all with the intent of improving patients’ prospects for recovery. Medicaid, as the largest payer of OUD care, has been a leader in implementing many of these system reforms.

1. The nurse care manager model helps primary care practices offer care management services to people with OUD.²⁵ Physicians prescribe buprenorphine to patients, but nurse care managers are their main point of contact, offering other medical care and connecting them to mental health and social service supports.

2. The hub and spoke model features specialty addiction clinics (often OTPs) as central “hubs” to treat patients with severe or complex opioid addictions.²⁷ Hubs are connected to “spokes”—primary care providers, OB/GYN offices, community health centers, and other settings that can prescribe buprenorphine for people with mild to moderate OUD. This model encourages providers to take on patients they may have previously felt had conditions that were too complex and refer them to the hub for more specialized care. As of 2021, the hub and spoke model has been implemented in 27 states throughout the country.²⁸

3. Medicaid opioid health homes (health home option) allow Medicaid to pay for comprehensive care management that includes care coordination, patient and family support, and social support services referrals.³¹ States receive an increased federal Medicaid matching rate of 90% during the first two years of the program.³² Normally, federal matching rates for fiscal 2024 range from 50% to 77%.³³Maine, Maryland, Michigan, Rhode Island, Vermont, and Wisconsin have adopted Medicaid opioid health homes.³⁴

4. Certified community behavioral health clinics (CCBHCs), a relatively new model developed by SAMHSA, offer coordinated comprehensive mental health and substance use care regardless of one’s ability to pay.³⁸ These clinics must get people into care quickly and offer core services including 24/7 crisis services; screening for mental health, addiction, and primary care needs; access to outpatient and family support services; and care coordination with medical and social services. The CMS has approved waivers for 10 states to implement a prospective payment system for CCBHCs at an enhanced rate that sets a uniform bundled payment for each patient encounter regardless of duration or intensity.³⁹ And in March 2023, SAMHSA released another round of $1 million planning grants to each of 15 states. These grants will let states develop a Medicaid prospective payment system and a CCBHC certification system, as well as help them apply for a four-year federal Medicaid CCBHC demonstration grant.⁴⁰ There are currently more than 500 CCBHCs operating in 46 states; Washington, D.C.; Puerto Rico; and Guam.⁴¹

5. Hospital emergency departments (EDs) can offer buprenorphine and coordinate to have primary care providers continue care.⁴⁴ EDs are often the only source of health care for many people with OUD and thus a critical location for delivering buprenorphine.⁴⁵ Yet despite evidence that this model improves health outcomes, few EDs offer these services, which require (among other efforts) intentional changes to ED staffing and strengthening of connections with community providers for follow-up care.⁴⁶

B. Remove barriers to buprenorphine access

In 2021, only 22% of people with OUD received any medications for their condition.⁵⁰ Societal stigma toward people who use drugs and reports of racial discrimination in medical settings are factors that contribute to this statistic.⁵¹ But state rules also play a role in slowing access to buprenorphine when patients seek it, despite research that shows that delays in starting medication increase the likelihood of death.⁵² Regulations in many states—such as required prior authorization from health insurers before a provider can prescribe, mandates for initial intake assessments before prescribing, and prohibitions on in-office initiation of medication—have been criticized as unnecessary and blocking patients from immediately receiving buprenorphine.⁵³ Additionally, Congress’ intent in passing the MAT Act was to allow states to eliminate obstacles to prescribing, such as those put in place by the “X waiver”—established by a 2000 law requiring providers to obtain separate registration and buprenorphine-specific training, and that capped the number of patients a provider can treat. But it’s noteworthy that the MAT Act does not mandate that states adopt these changes, thus the new law does not supersede any state rules that remain pertaining to these three domains.⁵⁴ These state rules can be removed without imperiling patient safety.⁵⁵

In addition to removing unnecessary regulations, states can actively promote models of care to offer immediate access to buprenorphine when a patient wants treatment (known as low-threshold treatment), without additional conditions.⁵⁶ States can launch these models in a variety of settings, including typical health care locations such as primary care offices, clinics, and hospitals, as well as alternative locations such as syringe services programs— which provide clean needles for people who inject drugs—homeless shelters, and fire departments.

Policy options to expedite buprenorphine treatment include:

1. Remove regulations that prevent immediate access

2. Help community-based organizations, harm reduction providers, and other low-barrier treatment providers initiate buprenorphine.

C. Promote treatment retention

The National Institute on Drug Abuse (NIDA) notes that with buprenorphine, many providers recommend staying on the medication for at least one year, and NIDA states that some patients with OUD may benefit from being on it indefinitely.⁶⁶ Yet treatment retention rates are found to be highly variable, with one recent study showing that only 20% of patients who start buprenorphine remain on it more than six months.⁶⁷ A number of rules at the state level can stand in the way of patients receiving ongoing access to medication—or to a sufficient dose of medication—while in treatment.⁶⁸ For instance, research finds that medication alone lowers OUD overdose death rates and improves treatment retention.⁶⁹ Expert bodies such as the National Academy of Sciences and the American Society of Addiction Medicine (ASAM) say that counseling should not be required as a condition of receiving these medications.⁷⁰ Yet a federal government report found that as of 2018, 16 states required counseling as a condition of receiving buprenorphine.⁷¹

Also, experts increasingly recognize that patients using medications for OUD who are also using other drugs can still benefit from these lifesaving medications. For example, ASAM recently updated its practice guidelines to state, “The use of cannabis, stimulants, alcohol, and/or other addictive drugs should not be a reason to withhold or suspend opioid use disorder treatment.”⁷² Yet programs in some states terminate OUD treatment when patients are using other substances.⁷³ Finally, some state Medicaid programs limit the time a patient can remain on buprenorphine, running counter to evidence-based guidance that some patients may need long-term treatment.⁷⁴ And many state Medicaid agencies impose maximum daily dosage limits on buprenorphine, despite expert guidance that dosages should be flexible to meet a patient’s needs.⁷⁵

Policy options to promote treatment retention include:

D. Create sustainable financing

Financing for state SUD treatment systems comes from a mix of Medicaid, Medicare, private insurance, federal block grants, and other discretionary funds and state allotments. Medicaid is by far the largest—and, as an entitlement program, the most stable—source of funding. In 2019, Medicaid spent an estimated $23 billion in federal and state dollars on opioid-related services alone, with the federal contribution representing more than half.⁸⁰ Federal discretionary grant funding for OUD from a variety of agencies came in at just under $10 billion in 2019, with the largest amount from SAMHSA in the form of the Substance Use Prevention and Treatment Services block grant and from SOR grants (funded at $2 billion and $1.4 billion, respectively, in fiscal 2023).⁸¹ State allotments from opioid legal settlements and judgments are a recent addition and estimated to provide more than $50 billion to states and localities over a period of years.⁸² Because grant funding is not as reliable as entitlement funding, some states are trying to sustain treatment systems for the long term by leveraging Medicaid to pay for direct treatment services and using grants to supplement what Medicaid typically does not pay for, such as infrastructure costs for building upgrades, mobile units, electronic administrative systems, and workforce training. There are numerous ways to do this, including using Medicaid to: (1) cover a wider range of prevention, treatment, harm reduction, and recovery support services, (2) reimburse a wider range of providers, including peer recovery specialists, and (3) reimburse for telehealth services to increase access to—and retention in—treatment. In addition, as Medicaid reimbursements have been traditionally lower than that of Medicare and commercial insurance, some states are raising Medicaid reimbursement for OUD-related services to ensure an adequate provider network.⁸³

Policy options to create sustainable funding include:

E. Reduce racial inequities in buprenorphine access and provide culturally responsive and accessible care to all

Although OUD rates are fairly comparable between Whites, Blacks, and Hispanics, research finds that buprenorphine providers are less likely to be located in communities of color, that Black and Hispanic people are significantly less likely to receive buprenorphine than Whites, and that Black and Hispanic people who fatally overdosed were significantly less likely than Whites to have previously received SUD treatment.⁹³ Experts investigating these trends among Black people suggest numerous factors at play, including fear of reaching out for care given the greater likelihood of arrest for using illicit drugs, lack of culturally responsive or respectful care, and medical racism among providers toward Black people that has a negative effect on seeking care.⁹⁴

Meanwhile, the Tribal Nations/Indigenous peoples population has the highest OUD rate among all racial/ ethnic populations in the U.S.—more than twice the rate of White people.⁹⁵ National data on treatment access and utilization is difficult to ascertain for Tribal Nations/Indigenous peoples, although some research suggests that this population is less likely than other racial/ethnic groups to be offered buprenorphine or methadone for maintenance to support recovery.⁹⁶ Drug overdose fatalities—largely driven by opioids—are higher, and rising faster, among Black and Tribal Nation/Indigenous populations than among White and Hispanic people.⁹⁷ Some research focused on OUD rates among Tribal Nations points to long-standing underlying social factors including racism, trauma associated with the legacy of genocide and colonization, and chronic federal underfunding of the Indian Health Service, which results in poor access to treatment.⁹⁸ Efforts to improve access to quality treatment for Tribal Nations span a broader set of funding streams that include the Indian Health Service and targeted federal grant programs from SAMHSA and the Centers for Disease Control and Prevention.⁹⁹ And experts exploring treatment programs for this population emphasize that effective strategies integrate Indigenous cultural and spiritual healing practices.¹⁰⁰

In addition, there are documented disparities in SUD treatment access for people with physical and/or cognitive disabilities. People with disabilities are more likely to have a co-occurring SUD and less likely to use treatment than their nondisabled peers.¹⁰¹ Despite the 1990 Americans with Disabilities Act, which mandated that public and private health care providers (including SUD treatment providers) make reasonable accommodations to serve people with disabilities, research finds that access barriers exist within many SUD treatment facilities.¹⁰² The following are options for increasing the number of buprenorphine providers in communities of color, reducing racial disparities in access to care, and working to ensure that providers in every community are educated to provide care that is respectful and responsive to the range of cultures represented in their patient pool. For more information on how providers can make these accommodations and how states can help them, SAMHSA has published a comprehensive document titled “Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities.”¹⁰³

1. Encourage existing providers to offer buprenorphine to low-income communities and reduce racial disparities

• 1.2 Increase buprenorphine availability in FQHCs: FQHCs provide care to low-income people in more than 14,000 locations nationally; 62% of FQHC patients are members of racial/ethnic minority groups. ¹⁰⁴ Yet in 2019, 36% of FQHCs did not offer medications for opioid use disorder.¹⁰⁵

• 1.3 Develop CCBHC infrastructure to reduce racial disparities in treatment (See Section A4 for policy levers and state example)
• 1.4. Raise Medicaid reimbursement rates (See Section D1 for policy levers and state example)
• 1.5. Engage nontraditional providers (See Section B2 for policy levers and state example)

2. Require all Medicaid providers to offer culturally and linguistically effective care

3. Implement value-based purchasing bonuses in Medicaid that reward reducing racial disparities in treatment access and retention

4. Diversify the provider workforce

• 4.1 Recruit students of color into the behavioral health professions

• 4.2 Create financial incentives to recruit and retain a diverse workforce

For more policy levers and state examples, see “State Strategies to Increase Diversity in the Behavioral Health Workforce” by the National Academy for State Health Policy.¹¹¹

F. Expand the provider workforce

Workforce shortages of SUD treatment providers—including psychiatrists, primary care providers, and counselors specializing in SUD treatment—have been widely reported across the states, fueled in part by low reimbursement rates and staff burnout.¹¹² Along with the need to encourage more physicians, NPs, and PAs to prescribe buprenorphine, it’s important to ensure that there is an adequate workforce to offer a package of services for patients on this medication, including behavioral health counseling and links to housing, transportation, and other needed social services to support recovery. And increasingly, peer recovery specialists—paid employees who themselves are in recovery and provide social, emotional, and practical support to people in treatment—are an important component of many care teams. Some studies show promising results in peers’ ability to connect and help retain people in treatment.¹¹³ Although credentialing requirements vary by state, peers typically have some level of formal training. Finally, along the lines of ensuring an adequate behavioral health workforce to address SUD, some states restrict the types of behavioral health counselors who can bill for SUD counseling or restrict the provision of SUD counseling to licensed specialty clinics, both of which create hurdles to primary care facilities that want to integrate counseling into their programming. In addition to the options listed below, states should review their licensing and reimbursement policies with an eye toward removing obstacles to primary care sites providing SUD counseling.¹¹⁴

Policy options to increase the SUD-related workforce include:

1. Allowing licensed providers to work across state lines. When the federal government declared a public health emergency for the COVID-19 pandemic, many states temporarily relaxed licensing laws and allowed providers to offer telehealth services across state lines.¹¹⁵ But these allowances have been uneven across types of providers, and recently, a number of states have revoked their temporary reciprocity laws as the pandemic has eased.¹¹⁵ In addition, state licensing boards for various behavioral health professions can join interstate compacts that allow practice across state lines.

2. Reimbursing for telehealth visits at the same rate as in-person visits.

• Policy lever: see D4
• State example: see D4

3. Creating competitive reimbursement for buprenorphine prescribers and other SUD treatment providers.

• Policy lever: see D1
• State example: see D1

4. Training and reimbursing for peers in medication treatment programs

5. Identifying and reforming rules related to specialty SUD providers that impede offering behavioral health counseling in primary care settings

Conclusion

The policy options and levers noted above describe efforts states are taking to make buprenorphine—a lifesaving medication for people with OUD—available in as many locations as possible. Dozens of state governments have champions leading these reforms across governors’ offices, state legislatures, and executive agencies, each using the policy levers at their disposal as vehicles for change. State policymakers can use these options—guided by data informing treatment needs—to continue closing the treatment gap.

Endnotes

1. H.S. Connery, “Medication-Assisted Treatment of Opioid Use Disorder: Review of the Evidence and Future Directions,” Harvard Review of Psychiatry 23, no. 2 (2015): 63-75, https://journals.lww.com/hrpjournal/Fulltext/2015/03000/Medication_Assisted_Treatment_of_Opioid_Use.2.aspx.
2. The Pew Charitable Trusts, “Medications for Opioid Use Disorder Improve Patient Outcomes,” (2020), https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2020/12/medications-for-opioid-use-disorder-improve-patient-outcomes.
3. Centers for Disease Control and Prevention, “Overdose Death Rates Involving Opioids, by Type, United States, 1999-2020,” https://www.cdc.gov/drugoverdose/data/OD-death-data.html; Centers for Disease Control and Prevention, “Data Driven Action: CDC’s Commitment to Strengthen Overdose Surveillance and Prevention Efforts,” https://www.cdc.gov/drugoverdose/featured-topics/overdose-data-to-action.html#:~:text=The%20rate%20of%20drug%20overdose,22%25%20between%202020%20and%202021.&text=In%202021%2C%20over%2080%2C000%20drug,involved%20more%20than%20one%20drug.
4. Substance Abuse and Mental Health Services Administration, “Key Substance Use and Mental Health Indicators in the United States: Results From the 2021 National Survey on Drug Use and Health” (2022), https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report.
5. Martin et al., “Get Waivered Remote: Nationwide, Remote DEA-X Waiver Course in Response to COVID-19,” Digital Health (2021), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8529309/.
6. S. Doyle and V. Baaklini, “President Signs Bipartisan Measure to Improve Addiction Treatment” (2022), The Pew Charitable Trusts, https://www.pewtrusts.org/en/research-and-analysis/articles/2022/12/30/president-signs-bipartisan-measure-to-improve-addiction-treatment.
7. Health Affairs, “Removing the X-Waiver Is One Small Step Toward Increasing Treatment of Opioid Use Disorder, but Great Leaps Are Needed,”  https://www.healthaffairs.org/content/forefront/removing-x-waiver-one-small-step-toward-increasing-treatment-opioid-use-disorder-but.
8. National Library of Medicine, “Medications for Opioid Use Disorder Save Lives” (2019), https://www.ncbi.nlm.nih.gov/books/NBK541390/#sec_004.
9. Substance Abuse and Mental Health Services Administration, “Key Substance Use and Mental Health Indicators in the United States: Results From the 2021 National Survey on Drug Use and Health.”
10. W.C. Goedel et al., “Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States,” JAMA Network Open 3, no. 4 (2020): e203711, https://www.ncbi.nlm.nih.gov/pubmed/32320038; T. Nguyen et al., “Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic,” JAMA Network Open 5, no. 6 (2022): e2214765, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9161014/; M. Kariisa et al., “Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics— 25 States and the District of Columbia, 2019-2020” (Centers for Disease Control and Prevention, 2022), https://www.cdc.gov/mmwr/volumes/71/wr/mm7129e2.htm?s_cid=mm7129e2_w.
11. The Pew Charitable Trusts, “Policies Should Promote Access to Buprenorphine for Opioid Use Disorder” (2021), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/05/policies-should-promote-access-to-buprenorphine-for-opioid-use-disorder.
12. K. Pestaina, “Mental Health Parity at a Crossroads” (2022), https://www.kff.org/mental-health/issue-brief/mental-health-parity-at-a-crossroads/.
13. The Kennedy Forum, “Mental Health Parity: Where Do We Stand as 2021 Comes to a Close?” (2021), https://www.thekennedyforum.org/blog/mental-health-parity-where-do-we-stand-as-2021-comes-to-a-close/.
14. K. Orgera and J. Tolbert, “The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment” (KFF, 2019), https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/.
15. The Medicaid and CHIP Payment and Access Commission (MACPAC), “Access to Substance Use Disorder Treatment in Medicaid” (2018), https://www.macpac.gov/wp-content/uploads/2018/06/Access-to-Substance-Use-Disorder-Treatment-in-Medicaid.pdf.
16. J.S. Crowley and M. O’Malley, “Medicaid’s Rehabilitation Services Option: Overview and Current Policy Issues,” (2007), https://www.kff.org/wp-content/uploads/2013/01/7682.pdf.
17. Centers for Medicare and Medicaid Services, “Medicaid Program: Optional State Plan Case Management Services,” https://downloads.cms.gov/cmsgov/archived-downloads/MedicaidGenInfo/downloads/CMS2237IFC.pdf.
18. Centers for Medicare and Medicaid Services, “Health Home Information Resource Center,” https://www.medicaid.gov/resources-for-states/medicaid-state-technical-assistance/health-home-information-resource-center/index.html.
19. Centers for Medicare and Medicaid Services, “State-by-State Health Home State Plan Amendment Matrix” (2022), https://www.medicaid.gov/state-resource-center/medicaid-state-technical-assistance/health-home-information-resource-center/downloads/state-hh-spa-at-a-glance-matrix-09-2022.pdf.
20. Medicaid and CHIP Payment and Access Commission, “Waivers,” https://www.macpac.gov/medicaid-101/waivers/.
21. Centers for Medicare and Medicaid Services, “Contract Review,” https://www.medicaid.gov/medicaid/managed-care/guidance/contract-review/index.html; Centers for Medicare and Medicaid Services, “Shared Savings Program,” https://www.cms.gov/medicare/payment/fee-for-service-providers/shared-savings-program-ssp-acos/about.
22. KFF, “States That Reported Accountable Care Organizations in Place,” https://www.kff.org/medicaid/state-indicator/states-that-reported-accountable-care-organizations-in-place/view/print/?currentTimeframe=0&print=true&sortModel=%7B%22colId%22:%22SFY%202019%22,%22sort%22:%22asc%22%7D.
23. J. Kang-Brown et al., “People in Jail and Prison in 2020,” Vera Institute of Justice, https://www.vera.org/publications/people-in-jail-and-prison-in-2020; J. Bronson et al., “Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009” (U.S Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2017), https://bjs.ojp.gov/content/pub/pdf/dudaspji0709.pdf.
24. The Pew Charitable Trusts, “Opioid Use Disorder Treatment in Jails and Prisons” (2020), https://www.pewtrusts.org/en/research-andanalysis/issue-briefs/2020/04/opioid-use-disorder-treatment-in-jails-and-prisons.
25. Boston Medical Center, “Nurse Care Manager Model of Office Based Addiction Treatment: Clinical Guidelines” (2018), https://pcssnow.org/wp-content/uploads/2021/05/BMC-OBAT-Policy-and-Procedure-Manual-2018-1.pdf.
26. Medicaid Innovation Accelerator Program, “Collaborative Models for Medication Assisted Treatment: Key Elements of the Massachusetts Collaborative Care Model” (Centers for Medicare and Medicaid Services, 2019), https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/reducing-substance-use-disorders/mat-key-elements-ma.pdf.
27. State of Vermont Blueprint for Health, “Hub and Spoke,” accessed April 5, 2023, https://blueprintforhealth.vermont.gov/about-blueprint/hub-and-spoke.
28. Substance Abuse and Mental Health Services Administration, “2021 Report to Congress on the State Opioid Response Grants (SOR)” (2021), https://www.samhsa.gov/sites/default/files/2021-state-opioid-response-grants-report.pdf; Primary Care Collaborative, “Vermont Hub and Spokes Health Homes,” https://www.pcpcc.org/initiative/vermont-hub-and-spokes-health-homes?language=en.
29. R.A. Rawson, “Vermont Hub-and-Spoke Model of Care for Opioid Use Disorders: An Evaluation” (Vermont Center on Behavior and Health, 2017), https://www.healthvermont.gov/sites/default/files/documents/pdf/ADAP_Hub_and_Spoke_Evaluation_2017_1.pdf.
30. Substance Abuse and Mental Health Services Administration, “2021 Report to Congress on the State Opioid Response Grants (SOR)” (2021), https://www.samhsa.gov/sites/default/files/2021-state-opioid-response-grants-report.pdf; Primary Care Collaborative, “Vermont Public Hub and Spokes Health Homes.”
31. Centers for Medicare and Medicaid Services, “Health Home Information Resource Center.”
32. Centers for Medicare and Medicaid Services, “Health Homes,” https://www.medicaid.gov/medicaid/ltss/health-homes/index.html.
33. KFF, “Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier,” https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
34. Centers for Medicare and Medicaid Services, “State-by-State Health Home State Plan Amendment Matrix.”
35. E. Morin, “Emergency Rule Bolsters Maine Opioid Treatment,” April 11, 2017, Maine Public Radio, https://www.mainepublic.org/politics/2017-04-11/emergency-rule-bolsters-maine-opioid-treatment; State of Maine Department of Health and Human Services, “Health Homes,” https://www.maine.gov/dhhs/oms/providers/value-based-purchasing/health-homes.
36. Maine Department of Health and Human Services, “MaineCare Benefits Manual,” https://www.maine.gov/sos/cec/rules/10/ch101.htm.
37. Maine Department of Health and Human Services, “MaineCare Opioid Health Home Organizations” (2022), https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/OHH-Provider%20List%206.30.2022_0.pdf.
38. Substance Abuse and Mental Health Services Administration, “Certified Community Behavioral Health Clinics Demonstration Program Report to Congress 2017,” https://www.samhsa.gov/sites/default/files/ccbh_clinicdemonstrationprogram_081018.pdf.
39. U.S. Department of Health and Human Services, “Biden-Harris Administration Announces Millions of Dollars in New Funds for States to Tackle Mental Health Crisis,” https://www.hhs.gov/about/news/2022/10/18/biden-harris-administration-announces-millions-dollarsnew-funds-states-tackle-mental-health-crisis.html.
40. Substance Abuse and Mental Health Services Administration, “HHS Awards CCBHC Planning Grants to 15 States to Help Address Ongoing Mental Health Crisis,” (March 16, 2023), https://www.samhsa.gov/newsroom/press-announcements/20230316/hhs-awards-ccbhc-planning-grants-15-states-address-ongoing-mental-health-crisis.
41. National Council for Mental Wellbeing, “2022 CCBHC Impact Report: Expanding Access to Comprehensive, Integrated Mental Health and Substance Use Care,” (2022), https://www.thenationalcouncil.org/resources/2022-ccbhc-impact-report/.
42. Substance Abuse and Mental Health Services Administration, “HHS Awards CCBHC Planning Grants to 15 States to Help Address Ongoing Mental Health Crisis,” (March 16, 2023), https://www.samhsa.gov/newsroom/press-announcements/20230316/hhs-awards-ccbhc-planning-grants-15-states-address-ongoing-mental-health-crisis.
43. West Virginia Legislature, “2022 Regular Session Introduced Senate Bill 247,” https://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=SB247%20INTR.htm&yr=2022&sesstype=RS&i=247.
44. Substance Abuse and Mental Health Services Administration, “Use of Medication Assisted Treatment in Emergency Departments” (2021), https://store.samhsa.gov/sites/default/files/pep21-pl-guide-5.pdf.
45. M.M. Ali, “Opioid-Related Emergency Department Visits and Access to Health Care—An Opportunity for Treatment Engagement,” Journal of Studies on Alcohol and Drugs 81, no. 6 (2020): 760-61, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7754835/pdf/jsad.2020.81.760.pdf.
46. Substance Abuse and Mental Health Services Administration, “Use of Medication Assisted Treatment in Emergency Departments,” (2021), https://store.samhsa.gov/sites/default/files/pep21-pl-guide-5.pdf.
47. Rhode Island Department of Health and Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals, “Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder” (2017), https://health.ri.gov/publications/guides/LevelsOfCareForTreatingOverdoseAndOpioidUseDisorder.pdf.
48. CA Bridge, “Our Work,” https://cabridge.org/solution/our-work/.
49. California Department of Health Care Services Opioid Response, “CA Bridge Program,” https://californiamat.org/matproject/california-bridge-program/; CA Bridge, “Bridge Navigator Program,” https://californiaopioidresponse.org/matproject/california-bridge-program/.
50. Substance Abuse and Mental Health Services Administration, “Key Substance Use and Mental Health Indicators in the United States: Results From the 2021 National Survey on Drug Use and Health” (2022), https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report.
51. O.T. Hall et al., “Experiences of Racial Discrimination in the Medical Setting and Associations With Medical Mistrust and Expectations of Care Among Black Patients Seeking Addiction Treatment,” Journal of Substance Abuse Treatment 133 (2022): 108551, https://www.sciencedirect.com/science/article/pii/S0740547221002774; P.A. Lagisetty et al., “Buprenorphine Treatment Divide by Race/Ethnicity and Payment,” JAMA Psychiatry 76, no. 9 (2019): 979-81, https://doi.org/10.1001/jamapsychiatry.2019.0876.
52. S.C. Sigmon et al., “Bridging Waitlist Delays With Interim Buprenorphine Treatment: Initial Feasibility,” Addictive Behaviors 51 (2015): 13642, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558243/.
53. The Pew Charitable Trusts, “States Can Reduce Barriers to Prescribing Buprenorphine for Opioid Use Disorder” (2021), https://www.pewtrusts.org/en/research-and-analysis/articles/2021/05/24/states-can-reduce-barriers-to-prescribing-buprenorphine-for-opioid-use-disorder; Medicaid and CHIP Payment and Access Commission, “Report to Congress: Utilization Management of Medication-Assisted Treatment in Medicaid,” (2019), https://www.macpac.gov/wp-content/uploads/2019/10/Report-to-Congress-Utilization-Management-of-Medication-Assisted-Treatment-in-Medicaid.pdf.
54. Substance Abuse and Mental Health Services Administration, “Removal of Data Waiver (X Waiver) Requirement,” (April 25, 2023), “Waiver Elimination (MAT Act),” (October 10, 2023),.
55. A.E. Woodruff et al., “Dismantling Buprenorphine Policy Can Provide More Comprehensive Addiction Treatment,” NAM Perspect 2019 (2019), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8406568/; M. Auriacombe et al., “French Field Experience With Buprenorphine,” The American Journal on Addictions 13 Suppl 1 (2004): S17-28, https://pubmed.ncbi.nlm.nih.gov/15204673/; C.L. Rowe et al., “Evaluating Buprenorphine Prescribing and Opioid-Related Health Outcomes Following the Expansion the Buprenorphine Waiver Program,” Journal of Substance Abuse Treatment 132 (2022): 108452, https://www.sciencedirect.com/science/article/pii/S0740547221001781.
56. The Pew Charitable Trusts, “Policies Should Promote Access.”
57. American Society of Addiction Medicine, “A Patient’s Guide to Starting Buprenorphine at Home,” https://www.asam.org/docs/default-source/education-docs/unobserved-home-induction-patient-guide.pdf?sfvrsn=16224bc2_0.
58. Group or Blanket Accident and Health Insurance Policies, Standard Provisions, 3221, New York State Senate (2023), https://www.nysenate.gov/legislation/laws/ISC/3221.
59. E. Weber, “Spotlight on Legislation Limiting the Use of Prior Authorization for Substance Use Disorder Services and Medications,” Legal Action Center, (2020), https://www.lac.org/resource/spotlight-on-legislation-limiting-the-use-of-prior-authorization-for-substance-use-disorder-services-and-medications.
60. American Society of Addiction Medicine, “National Practice Guideline 2020 Focused Update,” https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline.
61. R.P. Winograd et al., “Implementation and Evaluation of Missouri’s Medication First Treatment Approach for Opioid Use Disorder in Publicly-Funded Substance Use Treatment Programs,” Journal of Substance Abuse Treatment 108 (2020): 55-64 https://www.ncbi.nlm.nih.gov/pubmed/31277891.
62. Congress.gov, “Mainstreaming Addiction Treatment Act of 2021,” https://www.congress.gov/bill/117th-congress/senate-bill/445.
63. Prevent Overdose Rhode Island, “Get Help,” https://preventoverdoseri.org/get-help/.
64. Centers for Disease Control and Prevention, “Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP)”, SHO 23-001 - https://www.medicaid.gov/sites/default/files/2023-01/sho23001_0.pdf.
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66. National Institute on Drug Abuse, “Medications to Treat Opioid Use Disorder,” (2018), https://nida.nih.gov/sites/default/files/21349-medications-to-treat-opioid-use-disorder.pdf.
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68. The Pew Charitable Trusts, “Policies Should Promote Access.”
69. National Library of Medicine, “Medications for Opioid Use Disorder Save Lives” (2019), https://www.ncbi.nlm.nih.gov/books/NBK541390/#sec_004.
70. Ibid.; American Society of Addiction Medicine, “The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder—2020 Focused Update” (2020), https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline.
71. Medicaid and CHIP Payment and Access Commission, “Report to Congress: Utilization Management of Medication-Assisted Treatment in Medicaid” (2019), https://www.macpac.gov/wp-content/uploads/2019/10/Report-to-Congress-Utilization-Management-of-Medication-Assisted-Treatment-in-Medicaid.pdf.
72. K. Crotty, K.I. Freedman, and K.M. Kampman, “Executive Summary of the Focused Update of the ASAM National Practice Guideline for the Treatment of Opioid Use Disorder” (American Society of Addiction Medicine, 2020), https://www.asam.org/docs/default-source/quality-science/jam-exec-summary.pdf?sfvrsn=a40a52c2_2.
73. The Pew Charitable Trusts, “Policies Should Promote Access to Buprenorphine for Opioid Use Disorder” (2021), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/05/policies-should-promote-access-to-buprenorphine-for-opioid-use-disorder.
74. Medicaid and CHIP Payment and Access Commission, “Report to Congress: Utilization Management of Medication-Assisted Treatment in Medicaid,” (2019), https://www.macpac.gov/wp-content/uploads/2019/10/Report-to-Congress-Utilization-Management-of-Medication-Assisted-Treatment-in-Medicaid.pdf.
75. Ibid.
76. Nomodeaths, “Medication First Approach,” https://www.nomodeaths.org/medication-first-implementation.
77. North Carolina Department of Health and Human Services, “Treatment of Opioid Use Disorder With Buprenorphine and Buprenorphine/Naloxone” (2019), https://files.nc.gov/ncdhhs/BuprenorphineGuidance.pdf.
78. Tennessee Department of Mental Health and Substance Abuse Services, “Tennessee Nonresidential Buprenorphine Treatment Guidelines ”(2021), https://www.tn.gov/content/dam/tn/mentalhealth/documents/2018_Buprenorphine_Treatment_Guidelines.pdf.
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88. State of Arizona House of Representatives, 55^th Legislature, H.B. 2454 (2021), https://legiscan.com/AZ/text/HB2454/id/2391998.
89. New Jersey Department of Human Services, “NJ Human Services Awards Contracts to Opioid Treatment Providers to Expand Access to Mobile Treatment Programs,” (2022), https://www.nj.gov/humanservices/news/pressreleases/2022/approved/20220614.html; John Brooks Recovery Center, “John Brooks Recovery Center Receives Grant for Mobile Access to Medications for Substance Use Disorder,” (2022), https://jbrcnj.org/john-brooks-recovery-center-receives-grant-for-mobile-access-to-medications-for-substance-use-disorder/.
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93. Substance Abuse and Mental Health Services Administration, “The Opioid Crisis and the Black/African American Population: An Urgent Issue” (2020), https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-05-02-001_508%20Final.pdf; O.T. Hall et al., “Experiences of Racial Discrimination in the Medical Setting and Associations With Medical Mistrust and Expectations of Care Among Black Patients Seeking Addiction Treatment,” Journal of Substance Abuse Treatment 133 (2022): 108551, https://www.sciencedirect.com/science/article/pii/S0740547221002774.
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102. Substance Abuse and Mental Health Services Administration, “Substance Use Disorder Treatment.”
103. National Association of Community Health Centers, “Community Health Center Chartbook” (2021), https://www.nachc.org/wp-content/uploads/2021/04/Chartbook-Final-2021.pdf.
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117. TennCare, “Buprenorphine Enhanced Medication Assisted Recovery and Treatment (BESMART) Program,” https://www.tn.gov/tenncare/tenncare-s-opioid-strategy/office-based-buprenorphine-treatment.html.
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