Buprenorphine, one of three FDA-approved medications for the treatment for opioid use disorder (OUD), reduces the risk of overdose, illicit opioid use, and the transmission of infectious disease that can accompany injection drug use. Yet, federal requirements narrow the pool of eligible prescribers, and state policies often place stringent criteria on medication treatment that prevents people from initiating and remaining in care.
In response, some state agencies and policymakers have taken steps to facilitate access to “low-threshold” buprenorphine treatment, an approach that prioritizes prescribing medication as soon as a person is interested in treatment at low or no cost without placing additional conditions on the patient (e.g. counseling, abstinence). A newly published brief from The Pew Charitable Trusts, “Policies Should Promote Access to Buprenorphine for Opioid Use Disorder,” spells out the changes state and federal policymakers should make to facilitate low-threshold buprenorphine prescribing.
Delays in medication initiation increase risk for patient morbidity and mortality. For that reason, states should remove administrative burdens that prevent providers from prescribing buprenorphine to patients as soon as possible. For instance, Missouri’s Medicaid program removed prior authorization for buprenorphine coverage, which required providers to justify the need for the medication before prescribing it. States should also amend billing and reimbursement policies to allow providers to prescribe buprenorphine before completing intake assessments (lengthy patient medical histories). Missouri allots providers up to 30 days to complete intake assessments after prescribing buprenorphine.
Furthermore, states should issue clinical guidelines for unobserved initiation of buprenorphine, also called at-home induction. Patients may prefer to begin using this medication at home since the process can be time-consuming and include uncomfortable withdrawal symptoms, and studies show at-home initiation does not increase serious adverse medical events or interfere with successful treatment initiation or retention.
States should remove requirements that providers reduce a patient’s medication dosage over time or limit the maximum daily dose. Policies that support individualized prescribing, rather than predetermined changes to the buprenorphine dose, can lead to better treatment outcomes. For example, Missouri removed the requirement for providers to submit tapering plans for buprenorphine prescriptions when implementing its low-threshold treatment approach. In addition, Washington state permits providers to prescribe up to 32 milligrams of buprenorphine per day, while other states such as Tennessee cap the limit at 16 milligrams.
State agencies should also eliminate requirements that patients on buprenorphine receive counseling. Obligations to attend counseling sessions can be an impediment to staying in treatment, and outcomes don’t significantly differ for patients who don’t receive these services. While billing structures are often a barrier to offering buprenorphine on its own, states have multiple options to ensure this practice is financially feasible: for example, increasing reimbursement rates for prescribing buprenorphine like Missouri does, and separating counseling from medication in payment bundles, as Maryland did in its opioid treatment programs.
Third, states should prohibit publicly funded treatment programs from discharging patients for continued illicit drug use through the regulation of these programs’ licensure and certification. It is safer for patients to continue prescribed medications for OUD than suddenly stop treatment, which can increase the risk for overdose, and federal guidelines discourage the removal of patients from programs.
Low-threshold buprenorphine approaches can help reach populations of patients who may be uninsured and face housing insecurity, lack of transportation, and unemployment—all of which can interfere with their ability to start and remain in treatment. In response, states should use Medicaid or grant funding to address this multitude of needs for patients who seek additional services. For example, the Massachusetts Collaborative Care Model utilizes nurse care managers to help address patients’ nonmedical challenges, such as insurance or pharmacy problems. In addition, Kentucky used State Targeted Response to the Opioid Crisis grant funds to integrate peer support specialists into emergency departments as part of the state’s bridge clinic initiative.
Some state officials and providers are concerned that low-threshold buprenorphine could lead to diversion of the medication to people who would use it without a prescription. Although that is a risk with most prescription drugs, evidence suggests that diversion of buprenorphine may result from lack of access to treatment, and that people use the medication nonprescribed to self-treat or prevent withdrawal. This may indicate that low-threshold programs can reach people interested in treatment but who otherwise are unable to access it.
Finally, many states and rural jurisdictions do not have enough providers who can offer buprenorphine because of the federal requirements limiting who can prescribe it. Some states have offered supportive programs that link primary care providers to mentors and trainings on treating substance use disorders to help the providers become eligible to prescribe buprenorphine. The federal government could also remove prescription regulations altogether.
Low-threshold prescribing can expand access to buprenorphine. As states and localities continue to explore providing low-threshold treatment, policymakers should look to these innovations and initiatives to increase access to buprenorphine, a life-saving medication.
Beth Connolly is the director and Jenna Bluestein is a senior associate for The Pew Charitable Trusts’ substance use prevention and treatment initiative.