By Kamren Gilbard and Jane Koppelman
More than 500,000 people died from an opioid-related overdose in the U.S. between 1999 and 2020, a more than seven-fold increase, and an estimated 2.7 million people were diagnosed with opioid use disorder (OUD) in 2020.
Methadone and buprenorphine — medications approved by the Food and Drug Administration to treat OUD — are the most effective treatments, as they are proven to reduce overdose deaths and illicit drug use. However, access to these lifesaving treatments is limited, with only 22% of people with OUD receiving any form of medication in 2021. While methadone is only available at highly regulated clinics — known as opioid treatment programs — buprenorphine can be provided by physicians, nurse practitioners and physician assistants in a variety of settings, such as primary care clinics and physician’s offices. Despite this, prescription rates for buprenorphine are low. Forty percent of U.S. counties lacked a buprenorphine provider in 2018, the most recent year data is available.
Striking disparities in buprenorphine access and use exist across racial groups. While OUD rates are fairly comparable among Black, Hispanic and white populations, buprenorphine providers are notably less likely to be located in communities of color. One national study of Medicaid beneficiaries diagnosed with OUD found that Black, Hispanic and Native American patients were significantly less likely to receive buprenorphine than white patients. Meanwhile, opioid fatalities are rising at faster rates for Black and Native American people than for white people. Research suggests there are numerous factors at play beyond the absence of prescribers, including a lack of culturally responsive or respectful care and a bias among providers who withhold buprenorphine from patients of color.
The Mainstreaming Addiction Treatment Act, which President Joe Biden signed into law as part of a larger omnibus spending bill in December 2022, intends to increase the number of providers willing to prescribe buprenorphine. The law removes a cumbersome requirement for providers to apply for a special Drug Enforcement Administration waiver (known as the X waiver), before they can prescribe the medication to patients with OUD. It also removes buprenorphine-specific training requirements for those prescribing the medication. Still, this law does not supersede state laws placing registration and training requirements on buprenorphine providers. As of August 2020 — the most recent year state-by-state data was compiled — four states required prescribers to register with the state and six states required prescribers to complete additional clinical training beyond what the federal government required under the X waiver.
Other state-level rules create even more barriers to accessing buprenorphine. Some public and commercial state insurers require patients to receive preauthorization from their health care provider to obtain buprenorphine, which delays immediate access to medication. As of 2018, 16 states required patients to undergo counseling as a condition of receiving buprenorphine, despite research showing that medication alone — even without counseling — lowers OUD overdose death rates and improves treatment retention. Further, low Medicaid reimbursement rates at the state level can create prescribing disincentives for providers. Additionally, buprenorphine providers often lack the capacity to offer or coordinate wraparound services that patients with OUD may need, such as recovery housing or transportation.
State Progress in Expanding Buprenorphine Access
Due to rising opioid deaths and a significant racial gap in treatment for people with OUD, among other concerns, policymakers in many states are working to remove barriers to treatment and increase access to buprenorphine.
Offering provider support
Many states implemented the hub-and-spoke model, which is designed to support providers treating patients with OUD. In the model, originally developed by the Vermont Department of Health, hubs are a small number of specialty treatment providers staffed to care for patients with severe and sometimes complex OUD. These hubs provide clinical guidance and a trusted referral to a buprenorphine provider. A larger number of spokes — primary care providers, OB-GYNs, community health center staff and others that can prescribe buprenorphine — are designed to support people with less severe OUD or for people transitioning out of hub care. The model encourages primary care providers acting as “spokes” to accept patients who they may have previously felt had overly complex medical circumstances. As of 2021, 27 states and territories have used State Opioid Response Grants from the Substance Abuse and Mental Health Services Administration to implement hub-and-spoke models.
Raising provider reimbursement rates
States have leveraged Medicaid reimbursement rates to encourage more health care providers to prescribe buprenorphine for OUD. For example, Virginia’s Addiction and Recovery Treatment Services (ARTS) program significantly raised Medicaid reimbursement rates for substance use counseling and allows Medicaid to cover care coordination and peer support services for OUD patients. Combined with other Medicaid reforms, ARTS increased the number of providers able to offer buprenorphine, as well as the number of individuals receiving medication.
Granting immediate access to buprenorphine
Delaying the start of medication for OUD increases a person’s risk of overdose and death. In response, a number of states have placed limits on rules that interfere with a patient’s immediate access to buprenorphine — such as prior authorization, counseling and initial intake assessment requirements — and have adopted a low threshold strategy, which allows a provider to immediately prescribe buprenorphine the moment a patient wants treatment, at a cost the patient can afford and without the provider placing additional conditions on receiving the medication. Policymakers across the country have implemented elements of this approach. As of April 2020, 21 states and the District of Columbia had removed buprenorphine prior authorization requirements for public or commercial health plans.
Missouri fully embraced low-threshold treatment methods. The state’s Department of Mental Health developed the Medication First program in 2017 for publicly funded treatment programs, which removed rules that required patients to either go to counseling or wait for an assessment visit before getting a buprenorphine prescription.
Reducing racial access disparities
One strategy addressing racial disparities in buprenorphine access is to increase the level of culturally responsive care offered by providers. In Pennsylvania, Medicaid requires its managed care plans to achieve, or work toward, the National Committee for Quality Assurance’s Multicultural Health Care Distinction. Recipients awarded this designation established plans that disaggregate patient data by race, ethnicity and language; provide culturally and linguistically appropriate services; provide services in languages that patients use; collect race and ethnicity data of plan providers; and implement strategies to improve health disparities.
Through a variety of mechanisms, state policymakers can increase access to lifesaving medications for opioid use disorder. The strategies described above — which often involve maximizing Medicaid coverage, modifying state regulations, passing legislation or appropriating funds — are among the options that state legislators and executive branch officials can use to help more providers offer buprenorphine and allow patients quick access to evidence-based treatment.