Since 1999, more than 932,000 people have died of a drug overdose in the United States. Opioids were involved in roughly three-quarters of those deaths.
Opioids are a class of drugs that includes the illegal drug heroin; synthetic medications such as fentanyl; and pain relievers available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine and many others that are sometimes diverted and sold and used illegally.
Beginning as a surge in deaths due to prescription opioids in the early 2000s, the opioid epidemic gradually became more deadly as heroin—a more potent opioid than prescription varieties—became more widely available on the drug market. Today the synthetic opioid fentanyl (which is 50 times stronger than heroin and 100 times stronger than morphine) is involved in 82% of opioid overdoses.
Overall, the number of drug overdose deaths increased by nearly 30% from 2019 to 2020 and has quintupled since 1999. While opioids are primarily responsible for this increase, overdoses due to other drugs such as cocaine, which is now involved in 1 in 5 overdose deaths, and methamphetamine are also on the rise. Complicating the picture for policymakers and public health officials, at least half of overdoses now involve the use of two or more drugs, also known as polysubstance use.
Outside of drug overdose deaths, many Americans continue to die from tobacco and alcohol use. Each year, more than 480,000 premature deaths occur due to cigarette smoking, and 140,000 deaths occur due to excessive alcohol use. Collectively, deaths from drug use, tobacco, alcohol and suicide—frequently termed “deaths of despair”—are rising in the U.S. and driving down life expectancy.
These statistics are certainly alarming, but states have access to effective strategies to prevent drug misuse and treat people currently experiencing a substance use disorder.
People with opioid use disorder or alcohol use disorder have the option to receive medication assisted treatment, or MAT, which has been shown to relieve cravings and withdrawal symptoms. Research has shown that use of medications for substance use disorders, combined with therapy or counseling, can help sustain recovery. According to the National Institute on Drug Abuse, MAT decreases opioid use, opioid-related overdose deaths, criminal activity and infectious disease transmission. This form of treatment is also sometimes referred to as MOUD, or medications for opioid use disorder.
There are three primary medications associated with MAT for opioid use disorder: methadone, buprenorphine and naltrexone. Methadone and buprenorphine can help control withdrawal symptoms and cravings for other opioids without providing a euphoric effect for the patient. Naltrexone blocks the euphoric effects of opioid and alcohol use. MAT can help prevent relapse and facilitate longer periods of abstinence when used with integrated treatment plans that take other health considerations into account.
To fully take advantage of the benefits of MAT, many states are reexamining their statutes regulating the prescription of the drugs used in this form of treatment. By examining and reducing barriers to MAT, states can improve access and help move people with opioid use disorder further along the continuum of care into long-term recovery.
Insurance Coverage and Prior Authorization
Many privately insured adults with substance use disorders in the U.S. do not have coverage specifically for treatment. States have begun requiring that private insurers cover MAT-related services.
In Georgia, health insurers that cover mental health or substance use disorders must also cover the treatment of mental health or substance use disorders in accordance with the Mental Health Parity and Addiction Equity Act and maintain a streamlined process for handling consumer complaints regarding parity compliance. New Mexico prohibits insurers from limiting coverage for mental health or substance use disorder in ways that are more restrictive than for coverage of other health care services.
Prior authorization, sometimes called prior approval, is a requirement that physicians and other health care providers obtain authorization from a commercial or public health plan before they can deliver a specific service, such as a prescription for an MAT-related drug. One study in the Journal of the American Medical Association reported that removal of prior authorization for MAT was associated with increased medication use and improved health outcomes.
Delaware prohibits health insurance carriers from imposing prior authorization on buprenorphine and naltrexone. Maine requires commercial plans to cover at least one MAT medication without prior approval for pregnant women. Maryland specifies that individual and group plans may not require prior authorization for buprenorphine, methadone and naltrexone for treatment of opioid use disorder. Missouri requires health plans to cover MAT medications, including long-acting formulations, without prior authorization when dispensed through an opioid treatment program. Montana stipulates that health plans may not impose prior authorization on an “oral therapy prescription used to treat opioid use disorder.”
States have also removed prior authorization requirements from their Medicaid programs. Medicaid is the single largest payer of opioid use disorder treatment, covering 38% of all nonelderly adults with OUD. Federal legislation enacted in 2018 required state Medicaid programs to cover MAT.
Arkansas requires that at least one formulation each of methadone, buprenorphine and naltrexone be available as a preferred drug and that this formulation be available without prior authorization. In Colorado, Medicaid-managed care plans may not require prior authorization for any FDA-approved medications for substance use disorder covered by the plan. Medicaid plans in Delaware must cover a 72-hour emergency supply of medications for the treatment of drug and alcohol dependencies without prior authorization.
Expanding Treatment Capacity
In addition to financial barriers to treatment, including lack of insurance coverage, and logistical barriers such as prior authorization, a lack of providers also can hinder access to treatment. In response, states are working to identify gaps in community access and expand provider capacity and authority to deliver MAT.
One strategy, telemedicine, or the remote delivery of health care using telecommunications technology, can increase access to MAT in underserved and rural areas by providing services from afar. With the onset of COVID-19, state and federal lawmakers loosened the rules affecting the use of telemedicine. Many states are now making permanent the flexibilities they implemented during the pandemic. The federal Drug Enforcement Agency is likewise proposing a new rule that would allow for 30-day prescriptions of buprenorphine without an in-person consultation—a practice currently prohibited by federal law.
New Hampshire allows providers to prescribe MAT medications through telehealth as long as the provider conducts an in-person examination at least once annually. Vermont has extended provisions allowing providers to renew existing buprenorphine prescriptions through telehealth without an in-person office visit. Arkansas ensures Medicaid reimbursement for telehealth after the public health emergency. Other states, including Delaware and Florida, joined interstate compacts allowing behavioral health professionals in other states to provide telehealth services.
Other state actions include supporting the development of local infrastructure to close gaps in the continuum of care. Colorado established grants to support behavioral health care and expand youth-oriented and family-oriented behavioral health services. Utah required its Department of Health to expand local behavioral health services through a grant program, and to explore ways to reimburse certain behavioral health services through the state Medicaid program.
In December 2022, Congress passed the Consolidated Appropriations Act of 2023, which included provisions for the Mainstreaming Addiction Treatment Act. It also removed a federal barrier to prescribing medication for opioid use disorder known as the “x-waiver,” a requirement for buprenorphine prescribers to register with the federal government. With this removal, physicians can more easily prescribe buprenorphine, increase access to treatment and reduce stigma surrounding opioid use.
This resource is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services as part of an award totaling $813,543, with 100% funded by HRSA/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. government.