As overdose deaths continue to rise, federal and state governments continue to grapple with the consequences of the ongoing opioid epidemic.
In May, the Centers for Disease Control and Prevention released provisional data showing that overdose deaths from all drugs, including opioids, continue to climb, with states reporting more than 100,000 deaths for the second straight year.
In response, states and the federal government have taken many steps to prevent opioid misuse and overdose, including distributing millions of doses of naloxone, enhancing access to treatment and targeting practices such as doctor shopping or over-prescribing. People with opioid use disorder, or OUD, unlike those with other substance use disorders, have the option to engage in medication assisted treatment, or MAT, which combines counseling with medications to relieve the withdrawal symptoms and psychological cravings associated with OUD. According to the National Institute on Drug Abuse, MAT decreases opioid use, opioid-related overdose deaths, criminal activity and infectious disease transmission.
The federal government has recently taken steps to increase the availability of one of these medications: buprenorphine. With the passage of the bipartisan Mainstreaming Addiction Treatment Act, Congress removed regulations requiring potential prescribers to register with the federal government. Buprenorphine, one of three medications approved by the Food and Drug Administration for the treatment for OUD, reduces the risk of overdose, illicit opioid use, and the transmission of infectious disease that can accompany injection drug use. With the registration requirement gone, health care providers with state and federal authority to prescribe narcotics can now prescribe buprenorphine.
Buprenorphine prescribing remains low, despite the drug’s overall effectiveness and safety as a treatment for OUD. From 2016 through 2019, 20% of Medicare patients with OUD filled prescriptions for buprenorphine, according to a recent study in the New England Journal of Medicine. Racial disparities also exist in prescribing of the drug, with white patients being 80% more likely to receive a prescription than Black patients and 25% more likely to receive a prescription than Latino patients.
Expanding Access to Buprenorphine
To fully take advantage of the federal changes, some states are reexamining their own statutes regulating buprenorphine prescribing.
Prior authorization, sometimes called prior approval, is a requirement in which physicians and other health care providers must obtain authorization from a health plan before they can deliver a specific service, such as a buprenorphine prescription. One study in the Journal of the American Medical Association reported that removal of prior authorization for buprenorphine was associated with increased medication use and improved health outcomes.
Several states have exempted buprenorphine from prior authorization requirements. Wisconsin prohibits its health services department from requiring prior authorization and other limitations on prescribing and dispensing of buprenorphine. New York requires that health insurers providing medical, major medical or similar comprehensive large-group coverage provide coverage for MAT and prohibits prior authorization for an initial or renewal prescription for all buprenorphine products. Arkansas prohibits prior authorization for a patient to obtain coverage of buprenorphine, naloxone, naltrexone and methadone for the treatment or detoxification of opioid and alcohol use disorders.
States are also reviewing their own registration and training requirements that exceed the federal regulations. The new federal law does not supersede laws in some states that require buprenorphine providers to register with the state or that impose training requirements on providers that are stricter than the previous federal requirements. Some states are expanding prescribing authority to nurse practitioners or physician assistants.
Oklahoma exempts providers of buprenorphine and other OUD medications from requirements to register as narcotic prescribers with the state Bureau of Narcotics and Dangerous Drugs Control. Arizona expanded the scope of practice of clinical nurse specialists to include the prescribing of medications for OUD. Delaware delegated to the state Behavioral Health Consortium the responsibility of issuing legislative and regulatory recommendations to increase access to buprenorphine prescribers.
States are also working to address delays in initiating buprenorphine resulting from state regulatory requirements. Research shows that delays in medication initiation increase risks for patient morbidity and mortality and that earlier induction into treatment can result in more positive health outcomes for patients. The Missouri Department of Mental Health developed the Medication First treatment approach to prioritize rapid, sustained, low-barrier access to MAT. The approach prohibits publicly funded substance use treatment programs from requiring counseling as a condition of receiving buprenorphine. Participating sites reported that use of MAT services nearly doubled, timeliness of MAT initiation improved, fewer psychosocial services were delivered, and treatment retention improved. The median cost per month was also 21% lower than in the previous year.
Another challenge facing states in expanding access to buprenorphine and other medications for substance use disorders is that Medicaid reimbursement rates often are lower than those of private insurers. Lower reimbursement rates for MAT services can create a disincentive for physicians to provide care for substance use disorder. Launched in 2017, Virginia’s Addiction and Recovery Treatment Services, or ARTS, initiative established enhanced treatment rates competitive with commercial payers. The number of providers billing Medicaid in Virginia for addiction and recovery treatment services increased to 2,081 from 729 after the program’s implementation. Moreover, the total number of people being treated for OUD increased 44%, and emergency department use by beneficiaries with OUD decreased.
Charlie Severance-Medaris is a project manager in NCSL’s Health Program.