SHADAC Staff and External Authors

p 612-624-4802
e shadac@umn.edu

Brief: Strategies to Increase Access to Medications for Opioid Use Disorder during the COVID-19 Pandemic and Beyond

Impacts of the COVID-19 pandemic have been demonstrably far-ranging, including changes to substance use-related behaviors.¹ Evidence indicates that opioid use disorders (OUDs), overdoses, and overdose deaths grew as a result of COVID-19-related isolation and economic anxiety, and mortality data indicate that opioid overdose deaths, in particular, reached record levels in 2020.

SHADAC researchers Carrie Au-Yeung and Lynn Blewett, along with Hennepin Healthcare researcher Tyler Winkelman, authored a new Milbank Foundation policy brief that examines the federal and state policies changes put in place to improve access to medications for opioid use disorder (MOUD) during the COVID-19 pandemic, during which time MOUD became especially challenging to access because MOUD patients are typically required to have as many as six in-person clinic visits a week. The authors conclude with federal and state policy recommendations based on their analysis.

What is MOUD?
MOUD – sometimes referred to as medication-assisted treatment, or MAT – is the use of medications (methadone, buprenorphine, and naltrexone) to treat OUD, reduce opioid use, and lower the risk of overdose mortality. MOUD is frequently coupled with counseling and behavioral therapies and is the standard of care for OUD.

What policy solutions were put into place to make MOUD more accessible during COVID-19?
A number of policy solutions were put into place at the federal and state level in order to reduce the number of in-person clinic visits required for MOUD and to make MOUD more accessible in general. These solutions involved service delivery rules, prescribing rules, dispensing and refill rules, drug-testing requirements, counseling requirements, Medicaid prior authorization rules, and Medicaid coverage of telehealth.

For example, at the state level:

• Telehealth visits were allowed to replace in-person MOUD visits around prescriptions, assessments, and counseling.
• Some states loosened restrictions on dispensing and refill rules for MOUD and also allowed opioid treatment programs (OTPs) to deliver medications to quarantined or otherwise homebound patients.
• Some states gave more latitude to practitioners to use their own clinical judgment regarding toxicology screening and drug testing, and relaxed state-level counseling requirements or suspending them altogether.
• Individual states temporarily suspended certain Medicaid prior authorization requirements for MOUD, extended prior authorizations through the end of the COVID-19 emergency period, and/or expedited prior authorizations through documentation flexibility.
•  All 50 states and the District of Columbia (D.C.) modified Medicaid policies regarding telehealth to allow for more virtual visits: some upped payment rates for telehealth visits to match in-person visits, others extended policies to cover a wider array of providers, and others expanded “telehealth” to cover audio-only (telephonic) visits.

At the federal level, policy solutions included:

• In-person examination requirements for buprenorphine initiation were removed while for methadone, initiation must be in person, but subsequent visits can occur via telemedicine.
• In April 2021, the US Department of Health and Human Services altered prescribing rules to exempt eligible physicians and practitioners from federal training requirements to obtain a waiver to prescribe buprenorphine small numbers of patients (i.e., fewer than 30).
• Dispensing and refill rules, such as the standard take-home schedule for methadone, was relaxed by the Substance Abuse and Mental Health Services Administration (SAMHSA).
• The American Society for Addiction Medicine suggested pausing, limiting, or using alternative protocols for drug-testing requirements in certain areas to combat community spread of COVID-19.

Recommendation
The need to expand access to MOUD will not end with the COVID-19 emergency, as the number of individuals who need treatment far exceeds the capacity of MOUD providers and facilities. Some of the policy changes that have made MOUD more accessible during the pandemic have already been made permanent at the state level (e.g., expanding the definition of “telehealth” in Medicaid). The continuation of other changes, however, will require ongoing support from state and national policymakers.

The authors recommend continued efforts around three regulatory strategies in particular:

1. National and state policymakers should encourage the continuation of federal policies allowing buprenorphine initiation via telemedicine and the removal of state-level restrictions that go beyond federal requirements.
2. National and state policymakers should also promote the continuation of federal policies allowing OTPs to dispense more doses of methadone and the removal of any additional state-level methadone dispensing restrictions that exist.
3. Policymakers should work to prohibit Medicaid prior authorization requirements for MOUD and to make permanent any temporary suspensions of prior authorization requirements for these medications that were implemented during the COVID-19 emergency.

The authors note that, though there are other policy avenues for expanding access to MOUD, these three areas are particularly relevant for reducing logistical barriers to treatment. Moreover, evidence and testimony from providers and patients indicates that these mechanisms have been safe and effective during the COVID-19 pandemic and that continuing them beyond the pandemic period is warranted.

For more detail on policy changes to MOUD during the COVID crisis and recommendations for extending these policies beyond the pandemic, click on the image above to read the full brief.