State Proposed Strategies to Expand Access to Medications for Opioid Use Disorder

Abstract

Objective:

To identify state strategies to increase access to medications for opioid use disorder (MOUD) through Section 1115 Substance Use Disorder waivers.

Study Setting and Design:

We conducted a qualitative analysis of 27 waiver applications that were implemented between 2015 and 2020. We identified barriers and proposed strategies for expanding MOUD access and utilization.

Data Sources and Analytic Sample:

After excluding five states due to insufficient information, we analyzed 22 applications.

Principal Findings:

We identified six barriers and eight corresponding strategies. Barriers included care delays, limited MOUD facilities, lack of care transition support, limited MOUD access in residential treatment, insufficient care coordination, and prescriber shortages. Commonly proposed strategies were requiring access to MOUD in residential treatment, which was stipulated by the Centers for Medicare & Medicaid Services, addressing prescriber shortages through education and technical assistance, campaigns to address stigma, and increased reimbursement. Other strategies included changes to prior authorization requirements, efforts to increase the number of facilities that offer MOUD, and changes to improve care transitions.

Conclusions:

States proposed a variety of strategies to expand access to and use of MOUD. Future research could investigate how these approaches, implemented individually or in combination, are associated with outcome change and impact.

1 |. Introduction

The opioid crisis remains a pressing public health concern, with more than 77,000 deaths attributed to fatal drug overdoses in 2024 [1]. Medication for opioid use disorder (MOUD) includes three medications approved by the Federal Drug Administration: buprenorphine and naltrexone, which can be prescribed by clinicians, and methadone, which is, with a few exceptions, only available in federally licensed opioid treatment programs (OTPs). MOUD is considered a standard of care for opioid use disorder (OUD) treatment and is associated with reductions in opioid use, longer treatment retention, and reduced opioid-related mortality [2–4]. Despite clear evidence of its effectiveness, MOUD continues to be underutilized. For instance, less than 25% of individuals with OUD reported receiving any type of MOUD in 2021 [5].

There are numerous barriers that prevent MOUD availability and utilization. First, clinicians often lack the knowledge and expertise to initiate MOUD treatment [6, 7]. As a result, there aren’t enough clinicians who are willing to offer these medications [8–10]. Second, there is lingering stigma against MOUD from the public [11] and healthcare professionals [12–17] because of the historically predominant abstinence-only approach to substance use treatment [9]. As of 2020, most SUD residential treatment centers do not offer MOUD [18]. Third, 40% of individuals with OUD are enrolled in Medicaid [19], but Medicaid reimbursement rates for MOUD are often too low to cover the cost of care delivery [20]. Fourth, MOUD provision may require care coordination between medical and behavioral health care systems or between different types of care (e.g., emergency department, primary care), but such care coordination is often lacking [21, 22]. Fifth, clinicians have cited prior authorization requirements as an important administrative burden for prescribing buprenorphine [23]. Finally, individuals with OUD, particularly those living in rural areas, do not always have access to settings in which they can access MOUD [24]. For instance, distance to the nearest MOUD prescriber is significantly associated with the likelihood of receiving any MOUD [25].

One potential mechanism for expanding access to MOUD for Medicaid beneficiaries is through Section 1115 demonstration waivers for SUD treatment (henceforth, referred to as “SUD waivers”). The Centers for Medicare and Medicaid Services (CMS) introduced these waivers in 2015 to direct state development of a comprehensive approach to SUD treatment. States requesting waivers submit applications that describe their proposed strategies for meeting CMS’ six milestones [26], which include providing access to all American Society Addiction Medicine (ASAM) care levels, requiring residential facilities to offer MOUD on-site or facilitate off-site access, assessing provider capacity, and improving care coordination and care transitions between levels of care. In exchange for addressing these milestones, the waiver allows states to receive federal Medicaid funds for SUD treatment in Institutions for Mental Disease [27], defined as residential SUD and mental health treatment facilities with more than 16 beds, which are otherwise prohibited from receiving such funding for Medicaid enrollees ages 21–64.

Twenty-seven states received waivers between 2015 and 2020. In this study, we analyzed waiver applications to identify which barriers to MOUD access states sought to address, and whether they proposed similar or diverse strategies to address them.

2 |. Methods

2.1 |. Data and Sample

From CMS’ website, we sourced applications from all 27 states that applied for a SUD waiver between 2015 and 2020 [28]. Waiver applications contained information on each state’s current approach and future plans for improving access to SUD treatment, which included plans to expand MOUD access and use, as well as other SUD improvements that weren’t specifically related to MOUD (e.g., strategies for assessing workforce needs, improving coordination between levels of care, and a timeline for implementing changes). Applications may have included references to other relevant grants or programs that satisfied the waiver requirements (e.g., federal State Opioid Response [SOR] and State Targeted Response [STR] grant dollars). If links to this information were provided in the application, it was included in the dataset for analysis.

We assessed whether application documents contained sufficient details to be included in the study. An application was considered to have sufficient detail if it (i) explicitly indicated that a change was meant to improve access to MOUD (e.g., MOUD prior authorization removal) and (ii) provided information about how the change would be made (e.g., described a plan of action or identified a responsible party). Five applications were removed due to insufficient detail. The remaining applications from 22 states constituted the study sample. The Oregon Health & Science University institutional review board approved this protocol.

2.2 |. Analysis

This study followed the Consolidated Criteria for Reporting Qualitative Research [29]. We used an immersion-crystallization approach [30] where researchers immerse in data to identify (crystallize) findings. In the first immersion cycle, three qualitative analysts read and discussed four applications collectively. We discussed relevant information to include in the dataset because waiver applications also had information that was not specifically related to MOUD. We identified two topics as important to answer the research question: (1) descriptions of the barriers to MOUD access and (2) states’ proposed strategies to address these barriers and improve MOUD access and utilization. In a second immersion-crystallization cycle, each analyst independently read a subset of the remaining 18 state applications and summarized the barriers and proposed strategies. Barriers were not always explicitly stated in the applications, but implied, and analysts met to discuss these instances and reach consensus. All other application text was excluded from analysis. We also excluded references to adding methadone coverage because all states were federally required to cover this medication at the time of this writing. We continued to meet to identify and define the barriers to MOUD access and utilization using an inductive approach [31].

After proposed strategies and related barriers were identified and defined, we consulted the literature on barriers to MOUD access and utilization (e.g., lack of coverage, clinician stigma, fragmented care) to harmonize our terminology and definitions. To categorize the strategies, we adapted the Institute of Medicine’s framework for a systems approach to health care delivery, which distinguishes between four health care system levels: (i) patient; (ii) care team, which includes professional care providers (e.g., clinicians) and family members; (iii) organization (e.g., hospitals, primary care clinics); and (iv) political and economic environment (e.g., regulatory policies) that defines the conditions under which the other levels operate [32]. Adaptations were made to align with findings emerging from the applications, and include: removing the patient level, focusing the care team level on providers, and adding a level to align with strategies that support work between organizations to coordinate care and manage care transitions (inter-organization level). We then assigned each barrier and its proposed strategy to the appropriate level (environmental, inter-organizational, organizational, and provider). In the final cycle, when all proposed strategies were categorized by level and agreed upon, analysts presented this information in a matrix to organize the findings and make comparisons across states [33].

3 |. Results

We identified six barriers to MOUD access and utilization and eight proposed strategies to address these barriers (Table 1). States varied in how many barriers they proposed to address (range: 1–4) and the extent to which the barriers and strategies spanned multiple levels. For instance, 7 states mentioned the CMS-stipulated MOUD access requirement in residential care as their only strategy for improving MOUD access, and 13 states proposed more than one strategy. Most states proposed strategies at one level (12 of the 22 states).

TABLE 1 |.

Barriers and proposed strategies by states, across health system levels.

States	Total	AK	CA	DE	ID	IL	IN	KS	KY	LA	MI	MN	NE	NH	NM	NC	OH	PA	RI	VA	VT	WA	WI
Barrier: delays in care Strategy: streamlining prior authorization process	3						⚫								⚫					⚫
Barrier: lack of facilities that provide MOUD Strategy: expand facilities that provide MOUD	3				⚫			⚫							⚫
Barrier: lack of care transition support Strategy: supporting care transition efforts for MOUD patients	1																				⚫
Barrier: lack of MOUD access in residential treatment facilities Strategy: require MOUD access in residential treatment facilities	19	⚫		⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫	⚫			⚫	⚫
Barrier: insufficient clinic-level care coordination Strategy: bolstering clinic-level care coordination for MOUD	3	⚫																	⚫	⚫
Barrier: shortages of clinicians prescribing MOUD
Strategy 1: education and technical assistance for prescribing MOUD	6		⚫		⚫	⚫		⚫								⚫				⚫
Strategy 2: information campaigns to reduce clinician stigma toward MOUD	3									⚫			⚫				⚫
Strategy 3: increased reimbursement rates for providing MOUD services	3		⚫		⚫															⚫

Abbreviation: MOUD, medications for opioid use disorder.

Some states, such as New Mexico and Virginia, proposed multi-level changes and others focused on fewer levels. Below, we describe the barriers to MOUD and the strategies states proposed to address them.

3.1 |. Environmental Level—Barriers and Proposed Changes

We identified two environmental barriers that states proposed to address through SUD waivers: delays in care and lack of MOUD-providing facilities.

To address delays in care, three states (Indiana, New Mexico, Virginia) proposed streamlining prior authorization requirements related to MOUD. New Mexico and Virginia proposed removing prior authorization requirements for certain medications, while Indiana proposed working with managed care organizations (MCOs) to standardize prior authorization forms to minimize administrative burden. Three states (Idaho, Kansas, New Mexico) highlighted a lack of MOUD access in rural areas and proposed three strategies for addressing capacity. New Mexico proposed increasing MOUD capacity in these regions by increasing its OTPs and promoting telehealth, whereas Idaho and Kansas assigned responsibility to MCOs to increase the number of MOUD-providing facilities in their network.

3.2 |. Inter-Organizational Level—Barriers and Proposed Changes

Vermont was the only state that identified an inter-organizational barrier to MOUD access and utilization: lack of care transition support. Vermont proposed improving care continuity through enhanced discharge documentation and by building a centralized triage and scheduling call center. Vermont proposed requiring enhanced discharge documentation for MOUD-prescribing clinicians that would communicate information about prescribed medications and diagnoses with the primary care provider and/or external prescribing professional and proposed conducting an annual audit of these standards. The proposed centralized call center would give MOUD prescribers enhanced support for ensuring continuity during care transitions. The center would screen callers, have information on prescriber availability, and schedule assessments and appointments across all ASAM care levels. Individuals experiencing longer wait times would receive regular calls from the center to maintain engagement and facilitate treatment initiation. Additionally, the center would manage wait lists for services, assist individuals with obtaining transportation to appointments, and assist with care transitions between organizations.

3.3 |. Organizational Level—Barriers and Proposed Changes

States identified two organizational or clinic-level barriers: lack of MOUD access in residential treatment facilities and lack of care coordination within a clinical care team. The waiver required states to provide MOUD in residential facilities or facilitate off-site access. As such, 19 of the 22 states identified this barrier and described implementing or maintaining this requirement in their application. Some states included additional requirements for facilitating off-site MOUD access (e.g., specifying the maximum mileage from the residential facility and providing care coordination). A subset of states indicated an enforcement mechanism such as state audits.

Three states (Alaska, Rhode Island, Virginia) proposed promoting clinic-level care coordination to facilitate MOUD access and address fragmented care. Virginia proposed new coverage for MOUD care coordination benefits in office-based and OTP settings, and Alaska proposed requiring clinics to provide care coordination services, specifically focused on integrating SUD and medical care, to receive Medicaid reimbursement for MOUD. Lastly, Rhode Island proposed training to promote a peer specialist workforce that would provide MOUD care coordination in clinical settings.

3.4 |. Provider Level—Barriers and Proposed Changes

Six states (California, Idaho, Illinois, Kansas, North Carolina, Virginia) proposed addressing MOUD-prescribing clinician shortages through educational initiatives targeting clinicians and other clinical roles like case managers, peer specialists, and billing staff. Training programs varied in scope and scale. The proposed educational efforts included statewide technical assistance, clinician-to-clinician training models, and the establishment of an addiction medicine fellowship for clinicians and nurse practitioners.

Three states (Louisiana, Nebraska, Ohio) proposed implementing information campaigns to reduce clinician stigma toward MOUD. States that proposed this strategy reported a dominant culture of abstinence-focused care in their applications. These states proposed statewide outreach campaigns directed at combating stigma among residential treatment providers and dispelling myths associated with MOUD treatment. These campaigns proposed focusing on eliminating negative stereotyping related to MOUD provision, with Louisiana focusing on providing care to pregnant people with OUD.

Three states (California, Idaho, Virginia) proposed increasing reimbursement rates or a rate review to increase Medicaid MOUD prescribers. One state (Virginia) proposed Medicaid rate increases across OUD treatment services to align with or exceed commercial reimbursement rates. Rate increases ranged from 50% to 400%, depending on OUD treatment service, with reimbursement for MOUD services receiving the highest rate increase of 400%.

4 |. Discussion

In this study, we examined SUD waiver applications from 22 states to identify proposed strategies for expanding MOUD access and utilization. We identified the barriers these changes sought to address across health care system levels and showed how states’ proposed changes varied. Across the 22 applications, states were most likely to address two barriers: lack of MOUD access in residential care, (which CMS required in its 2017 guidelines), and MOUD prescriber shortages. Regarding the latter barrier, most states proposed education and information campaigns. Providing education and dispelling clinician stigma can combat the inadequate curriculum and faculty expertise generally found in United States medical schools, and ultimately cultivate a larger pool of prescribing clinicians [34]. This goal may be aided by increasing reimbursement rates for MOUD-related services, given that SUD treatment programs are less inclined to adopt MOUD when reimbursement rates are too low [35].

We did not observe many proposed changes to the Medicaid environment. Specifically, only five states proposed strategies at this level, focusing on removing or modifying prior authorization requirements and efforts to increase the number of facilities that provide MOUD. An important area for environmental-level changes could include managed care policies. Recent research on prior authorization for buprenorphine suggests that states give MCOs much leeway in designing prior authorization policies, and there is substantial variation in prior authorization policies among MCOs operating in the same state [34, 36].

Our study showed that states used a variety of strategies in their waiver to improve MOUD access [35]. Although Lindner et al.’s recent research suggested that waivers were not associated with improvements in MOUD treatment, they found evidence of MOUD increases among early waiver states, suggesting that some strategies may have been effective, and highlighting a need for future research to identify the specific strategies that were associated with improved treatment.

This study provides a snapshot of waiver strategies prior to the COVID-19 pandemic. Since then, important changes have occurred. Drug overdose deaths jumped from 70,630 in 2019 to almost 108,000 in 2022, likely fueled by the proliferation of fentanyl [37]. More recently, drug overdose deaths have started to decline. The reasons for this encouraging development are unclear. Recent policy efforts such as increasing naloxone distribution [38] and removing the X-waiver requirement for buprenorphine prescribing [39] may have played a role, although the impact of X-waiver removal has been modest [40, 41], and barriers described in this study are likely to persist. For instance, a study of the X-waiver removal found an increase in buprenorphine prescribers but not the number of patients receiving the medication, suggesting that strategies such as education campaigns or reimbursement rate increases remain relevant [41]. Subsequent research could investigate how waiver strategies changed in recent years, and whether new strategies address barriers to MOUD treatment.

4.1 |. Limitations

Our understanding of states’ efforts was limited to the information provided in their applications, and these declarations may not reflect policies that states implemented, especially if the first Trump administration (2017–2021) did not enforce 1115 application requirements maintained by previous administrations [42]. In at least one state, providers were allowed to opt in, meaning that changes were not necessarily implemented across all Medicaid providers, resulting in a smaller reach of change. Three states did not include information about the requirement for access to MOUD in residential facilities. These states were among some of the earlier states to apply for 1115 waivers, and this discrepancy may reflect a revision to application requirements or enforcement. We also do not know why states proposed some approaches and not others. For instance, some states may not have proposed to remove prior authorization requirements because they did not exist in their state. States may have engaged in other strategies that were not included in their materials. For example, between 2016 and 2020, many states received STR and SOR funds from the Substance Abuse and Mental Health Services Administration, established to address the opioid crisis in the United States by enabling states to implement effective intervention strategies, with a particular focus on expanding access to MOUD [43]. Some states had these grants prior to their SUD waiver. States used STR and SOR dollars to facilitate similar strategies like educational initiatives, use of peer specialists to engage and connect people to MOUD, expansion of hub-and-spoke models for improved MOUD access, and emergency department connections for individuals who have experienced an overdose, to bridge gaps in care [44]. The strategies proposed by states in their SUD waiver applications must be understood within the broader context of the work states are doing to expand MOUD access and utilization.

5 |. Conclusion

States that have not yet implemented SUD waivers may consider some of the strategies identified in this study to improve MOUD use and treatment outcomes among their Medicaid population. States can also pursue many of these strategies without a waiver such as removing prior authorization requirements or increasing reimbursement rates for buprenorphine prescribing. Future work is needed to determine which of these strategies are associated with outcome changes in medication use, overdoses and related fatalities, and utilization of hospital, outpatient, and residential SUD care, and should consider a mixed-methods design to better understand the impacts these strategies have on health outcomes.

Summary.

• What is known on this topic?

  • Medication for opioid use disorder (MOUD) is a standard of care for treating OUD.
  • Despite demonstrated effectiveness, MOUD is underutilized.
  • Barriers include lack of clinician training, stigma, lack of care coordination, MOUD restrictions in residential settings, low Medicaid reimbursement, prior authorization, and access issues in rural areas.
• What this study found?

  • States proposed using 1115 substance use disorder waivers to implement numerous strategies to increase MOUD access and utilization, which targeted different health care system levels: environmental, inter-organizational, organizational, and provider.
  • Commonly proposed strategies were requiring access to MOUD in residential treatment facilities (19 states) and addressing MOUD prescriber shortages (10 states).
  • Other strategies included changes to prior authorization requirements (3 states), efforts to increase the number of facilities offering MOUD (3 states), and changes to improve care transitions (1 state).

Data Availability Statement

The data that support the findings of this study are publicly available at https://www.medicaid.gov/.