In April 2021, the Biden administration released revised practice guidelines for treating opioid use disorder (OUD) with buprenorphine. This update follows an earlier effort in the final weeks of the Trump administration to expand buprenorphine access, which was retracted due to legal concerns. These guidelines apply to providers who are state-licensed and registered by the Drug Enforcement Administration to prescribe controlled substances, including physicians, physician assistants, nurse practitioners, and others. Eligible providers can now treat up to 30 patients with OUD using buprenorphine without needing certifications that require specialized training. Given the epidemic of opioid addictions and related deaths over the last decade, especially during the COVID-19 pandemic, Biden administration health officials assert that ensuring medications for addiction treatment is essential.
Recent studies show significant racial inequities in access to buprenorphine. People who have access to this treatment are also less likely to be on Medicaid, unemployed, or incarcerated. This Medicaid Policy Cheat Sheet highlights implications of the updated practice guidelines on access to buprenorphine treatment, particularly among low-income, Black, and Latino communities.
A quick note on the use of buprenorphine for OUD treatment.
Buprenorphine is an FDA-approved medication that is safe and effective for treating OUD. Buprenorphine use has increased in recent years, partly due to Medicaid expansion and the enrollment of millions of previously uninsured adults. Unlike methadone, buprenorphine is the first medication that can be prescribed and administered in primary care settings and outside of opioid treatment programs, which are the only settings where methadone can be dispensed. Opioid treatment programs are federally regulated clinics and the only setting permitted to dispense methadone for OUD treatment. The Drug Addiction Treatment Act of 2000, or DATA 2000, an amendment of the Controlled Substances Act, spurred the changed regulations around buprenorphine prescriptions. According to public health experts and providers, buprenorphine prescriptions are preferable to other medications for addiction treatment, given buprenorphine’s effects have a lower threshold of intensity while being effective in treating OUD, and it’s easier to administer than methadone. After DATA 2000, however, barriers remained that limited the number of providers administering buprenorphine. Most notably, providers needed to undergo specific training to become waivered to prescribe and dispense the treatment. In contrast, there was never a requirement for provider training to prescribe opioids, which are a pathway to opioid addiction. Thus, the training requirement for treating opioid addiction was largely perceived as a double standard, given the probability and danger of overprescribing.
Who typically has access to medications like buprenorphine?
Individuals with private insurance tend to receive buprenorphine treatment more than people enrolled in Medicaid. There are also significant inequities in medication for addiction treatment access and availability by race, ethnicity, and geographic location. Counties in the U.S. that are predominantly white are three to four times more likely to have availability of buprenorphine, compared to majority Black and Latino counties, which are three times more likely to have facilities providing methadone. Moreover, Black Americans have an increased number of deaths from OUD. Structural racism, as manifested in disparities in health care resource allocation, and historically framing Black communities and other people of color as deserving of criminal punishment for addiction — rather than offering medical treatment — contribute to these disparities. Rural and low-income areas of the country also have a dearth of primary care providers, thus making buprenorphine more difficult to obtain.
What does this mean for Medicaid enrollees?
Medicaid is a major funder of substance use disorder (SUD) treatment programs. Specifically, Medicaid expansion helped increase overall medication for addiction treatment access for individuals with OUD, including methadone, naltrexone, and buprenorphine. With regard to buprenorphine, of note, studies show there is no significant difference between expansion and non-expansion states with respect to the number of buprenorphine prescriptions for Medicaid members nationally. In December 2020, however, the Centers for Medicare & Medicaid Services (CMS) released guidance that requires all state Medicaid programs to cover medications approved or licensed by the FDA, in addition to counseling services and behavioral therapies to treat OUD. While buprenorphine is now technically covered by all states’ Medicaid programs, prior to the Biden administration’s new guidelines, federal guidelines required providers to have prior authorization or a waiver to prescribe it.
What are the key takeaways from these guidelines?
Eligible providers will no longer need to undergo training before they can prescribe a treatment that is well-known to reduce overdose deaths, and that can be easily administered in various settings. Now, a wider range of health workers can offer this treatment, and more clinical settings can dispense it.
Why does this matter?
Increasing access to medications for addiction treatment, specifically buprenorphine, is critical for treating opioid addiction. Drug overdose deaths increased during the COVID-19 pandemic, especially for low-income, Black, and Latino communities. There also remains a harmful stigma associated with OUD and providers who treat people with SUD, especially given the long history of criminalizing these disorders in the U.S. Additionally, because buprenorphine can be difficult to obtain in low-income, segregated communities, individuals may have difficulty accessing these treatment options, or resort to illegal means to procure it. Without a primary care provider monitoring the use of these medications, individuals can experience slower recovery or relapse. The updated practice guidelines are a critical step toward systemic change, removing requirements on providers that can discourage them from becoming certified and authorized to prescribe buprenorphine to treat OUD.
Achieving equity in buprenorphine access, however, begins with more facilities and providers authorized to administer it in counties where a significant number of Black, Latino, and Medicaid-enrolled individuals reside. The Biden administration’s new guidelines offer promising new opportunities for increasing access to buprenorphine across the country, reducing the stigma associated with Black, Latino, and other people of color undergoing OUD treatment, and addressing longstanding inequities in access to buprenorphine for these communities.
What’s the bottom line?
These revised federal guidelines relax restrictions for providers to prescribe buprenorphine, presenting an opportunity for treatment to become more widely available, including in communities that have historically been unable to access it. Given there is a dearth of primary care providers and practices that administer the drug within low-income, rural, and Black and Latino communities, more health care providers can take advantage of these guidelines, thereby preventing unnecessary diversion of medications for addiction treatment. Additionally, CMS’ recent guidelines, which require all state Medicaid programs to cover FDA-approved medications to treat OUD, should augment access to treatment for Medicaid members. The opioid epidemic and racial and socioeconomic inequities are inextricably linked, and these recent policy developments are incremental steps toward critical change.