Many states leaving policy options on the table in fight against opioid epidemic during COVID-19

A variety of legal and policy options exist for states to increase permanent access to life-saving medications to treat opioid use disorder during the pandemic, but most states have not changed their laws or adopted those policies, according to new data released today by the Temple University Center for Public Health Law Research.

The data, published as three comprehensive datasets to the Prescription Drug Abuse Policy System at PDAPS.org, examine the extent to which states have adopted law and policy mechanisms to expand access directly and through insurance coverage to medications likes buprenorphine or methadone, which are often used in combination with therapy to treat opioid use disorder.

Specifically, the data capture state Medicaid Waivers for substance use disorder treatment during the COVID-19 public health emergency, laws addressing mitigation measures in state correctional facilities relating to medications for opioid use disorder treatment (MOUD) during COVID-19, and laws that seek to increase access to MOUD by removing barriers like telehealth and prior authorization requirements during COVID-19.

"During the past few years, the United States has recorded record numbers of overdose deaths," said Elizabeth Platt, JD/MA, director of the Policy Research Technology Program and lead researcher on this project. "As our team has examined these laws, it's been startling to see just how minimally states have adopted permanent policies that could work to prevent those deaths or improve quality of life for so many Americans."

A few key findings from the datasets include:

• While many states have adopted the three types of Medicaid Waivers that allow states to make quick adjustments to their Medicaid plans, just 17 are using all three to make modifications specifically to address COVID-19.
• Since the onset of the pandemic, only 11 states have made changes to their laws to adapt to the need for continued treatment upon release from state correctional facilities, especially when there are states instituting early release orders for some populations.
• Only 13 states have made changes to their laws specifically meant to increase access to buprenorphine and methadone during COVID-19.

The data were produced in collaboration with researchers at Brown University, with funding from the National Institute on Drug Abuse through its Justice Community Opioid Innovation Network (JCOIN).

COVID-19 State Medicaid Waivers for Substance Use Disorder Treatment

Medicaid Waivers are one tool states may use during emergency situations to make quick adjustments to their requirements to provide greater access to care for patients. In the context of access to substance use disorder treatment, states have used Section 1115 Waivers, Section 1135 Waivers, and Section 1915(c) modifications to remove prior authorization barriers and increase the use of telehealth during the pandemic more broadly.

While all states have at least two of the three approved Waivers, but very few states are making modifications explicitly tailored to substance use disorder (SUD) treatment and COVID-19:

• Only 17 states have an approved Section 1115 Waiver to address COVID-19. Of the 17 states with an approved Section 1115 Waiver, only five have approved Section 1115 Waivers that explicitly address SUD treatment. Only California used a Section 1115 Waiver to suspend limits for SUD treatment services during COVID-19.
• While every state and the District of Columbia has an approved Section 1135 Waiver, none have one that explicitly addresses SUD treatment. Twelve states use Section 1135 Waivers to allow clinical facilities to provide services via telehealth, and 43 states use Section 1135 Waivers to suspend prior authorization in fee-for-service plans.
• Of the 51 states with an approved Section 1915(c) Appendix K modification, there are no states with a modification that explicitly addresses SUD treatment.

Individuals with opioid use disorder who are involved in the criminal justice system face unique barriers to treatment and care. With COVID-19 continuing to exacerbate the ongoing opioid crisis in the United States, this dataset examines whether state correctional facilities have explicitly established a medication for opioid use disorder treatment program, and what adjustments states have made to ensure access to continued treatment during the pandemic. Further, this dataset tracks state variance among different COVID-19 mitigation measures like early release and visitation restrictions.

Few state correctional facilities had established MOUD treatment policies prior to COVID-19, and even fewer have made changes to adapt to the need for continued treatment upon release, especially as states institute early release orders for some populations:

• Of the 18 states that had state correctional facilities with established MOUD treatment policies before COVID-19, 11 of those states made modifications to their policies during COVID-19.
• Of those 11 states that modified their policies, eight now have MOUD treatment policies aimed at ensuring the continuation of treatment for released populations.
• In the 11 states with modified policies, four of those states also have an order expediting the release of specific populations during COVID-19 (California, Colorado, Kentucky, Pennsylvania)—this means that only four states in the United States have established policies focused on ensuring the continuation of MOUD upon release.
• Further, the District of Columbia, Michigan, Montana, New Mexico, and Washington State have an order expediting the early release of specific populations during COVID-19 but have no MOUD treatment policy at all.

Early during the pandemic, the US Drug Enforcement Agency relaxed certain telehealth provisions, including allowing controlled substances to be prescribed via telehealth without the need for an initial in-person visit. Through early guidance documents, state agencies managing substance use disorder treatment encouraged measures that built upon this federal baseline, urging further relaxation in telehealth requirements, a removal of prior authorization requirements, an extension of prescription lengths for take-home doses, and naloxone co-prescribing.

Ultimately, very few states have taken MOUD-specific action during COVID-19:

• Just six states have removed the requirement for an in-person visit between a patient and a provider before starting MOUD treatment with buprenorphine.
• Iowa and New York are the only states to have permanently removed prior authorization requirements for Medicaid for MOUD treatment during COVID-19.
• Four states have extended the dosage for take-home MOUD prescriptions during COVID-19: Pennsylvania for buprenorphine, and Connecticut, Hawaii and Pennsylvania for methadone.