Research to law: A qualitative study of Massachusetts’ 2018 Care Act expanding emergency department initiation of medication for opioid use disorder

Abstract

Background:

Initiating medication for opioid use disorder (MOUD) during emergency department (ED) visits is an important innovation to engage individuals in addiction treatment. In 2018, Massachusetts passed the CARE Act, becoming the first state to legislate that hospitals with EDs must be able to offer MOUD. We performed a qualitative study to explore factors influencing policy enactment.

Methods:

Semi-structured interviews were conducted in 2019 with ten key stakeholders involved in the policymaking process representing state government, hospitals, physician professional societies, and recovery/behavioral health organizations. Data were analyzed in 2020–2021 using a hybrid inductive-deductive approach.

Results:

The first key theme stakeholders expressed was the importance of research and public health consensus; they described consensus building within existing coalitions regarding the pressing need for action, and supporting expansion of treatment with this evidence-based strategy. Second, stakeholders discussed overcoming financing and feasibility concerns by passing budget-neutral legislation and ensuring flexibility for diverse hospital types. Lastly, stakeholders looked towards implementation, describing the implementation guide development process and ensuring capacity for continuing treatment existed throughout the state.

Conclusions:

This study suggests that research supporting the effectiveness of ED MOUD induction drove the passage of this state legislation. Long-term collaboration between diverse stakeholders towards a common goal of increasing access to evidence-based treatment to address the opioid epidemic was also perceived as facilitating the law’s passage. Policymakers and advocates in other states may look towards Massachusetts’s legislative process as a model for implementing similar legislation as part of their strategies to address the drug overdose crisis.

1. Introduction

The incidence of drug overdose deaths over the last decade has been rising with over 90,000 drug overdose deaths in 2020 (Ahmad et al., 2021). Evidence-based guidelines recommend that individuals with opioid use disorder (OUD) – both youth and adults – should receive treatment that includes pharmacotherapy, the most effective treatment for OUD (Committee on Substance Use and Prevention, 2016; D’Onofrio et al., 2015; Mattick et al., 2009; Volkow et al., 2014). Medication for opioid use disorder (MOUD) with the opioid agonists buprenorphine and methadone, or the antagonist naltrexone, have been demonstrated to be life-saving (National Academies of Sciences Engineering and Medicine, 2019). Unfortunately, most individuals with OUD do not receive treatment with MOUD, which has spurred the development of innovative programs designed to expand access to treatment.

Initiation of MOUD in patients during emergency department (ED) visits is an important innovation and touchpoint to engage individuals in formal addiction treatment. A 2015 randomized clinical trial conducted by Yale researchers first demonstrated the efficacy of initiating treatment with buprenorphine for adults with OUD in the ED (D’Onofrio et al., 2015). Since this seminal paper, programs and protocols for treating adults have been developed and scaled-up in real-world settings. Treatment for OUD in the ED has been demonstrated to increase access, improve retention in treatment, decrease opioid use, and overall is cost-effective (Busch et al., 2017; Houry et al., 2018; Samuels et al., 2018). Although youth are less likely than adults to receive MOUD after an overdose (Alinsky, Zima, et al., 2020), these ED induction studies have been largely confined to adults (U.S. National Library of Medicine, n.d.).

In 2018, Massachusetts became the first state to legislate that all hospitals with EDs must be able to offer MOUD and addiction treatment through the passage of Chapter 208 of the Acts of 2018, known as the CARE Act: An Act for Prevention and Access to Appropriate Care and Treatment of Addiction (Acts of 2018, Chapter 208: AN ACT FOR PREVENTION AND ACCESS TO APPROPRIATE TREATMENT OF ADDICTION, 2018; MA House Bill No. 4742, 2018; Massachusetts Health & Hospital Association, 2019). Section 50 of this legislation stated the following: “An acute-care hospital…that provides emergency services in an emergency department… shall maintain… protocols and capacity to possess, dispense, administer and prescribe opioid agonist treatment… and offer such treatment to patients who present… for care and treatment of an opioid-related overdose” (Acts of 2018, Chapter 208: AN ACT FOR PREVENTION AND ACCESS TO APPROPRIATE TREATMENT OF ADDICTION, 2018).

Mandating that an entire state scale-up treatment for OUD is a novel strategy in combating the drug overdose crisis. This landmark legislation has the potential to serve as a model for other states to replicate as part of their own strategies to address the drug overdose crisis. Thus, it is crucial to understand the factors that led to the passage of this unique legislation in Massachusetts in order to support enactment and subsequent implementation in other states, and consider what modifications might be needed to ensure the law works for people of all ages, including adolescents and young adults.

To gain insight into the key factors driving the policymaking process for this groundbreaking legislation, the study team performed a qualitative study with three objectives. First, to characterize the origination and drafting of the 2018 CARE Act and specifically Section 50 of the law that required hospitals to maintain capacity to provide MOUD. Second, to examine key factors in the policymaking process including the role of research, personal stories, economics, and public health considerations, as well as what compromises were made and how stakeholders engaged in either support or opposition of the legislation. Lastly, to explore plans for implementation including impressions of how the legislation would be enforced, how protocols would be implemented, expected challenges, and consideration for the needs of youth.

2. Methods

2.1. Sample, recruitment, and instrument

The study team identified key stakeholders who had a professional role in the policymaking process for the Massachusetts law whose names and roles were identified in legislative documents, news stories, and hospital implementation guides. The study team then asked interviewees to identify other relevant stakeholders from different organizations (snowball sampling). Potential interviewees were contacted by email with a letter explaining the study’s goals and purposes; follow up emails were sent two weeks apart for non-responders. Additional interviews were conducted until data saturation was reached with strong consistency in themes being raised across interviewees, as well as no new stakeholders being identified through snowball sampling.

One study team member completed semi-structured interviews via telephone between August and November 2019. The interview guide (Table S1) was developed based upon a literature review of policy implementation and our specific research questions, and included questions focusing on conceptualization of the law; the comparative roles that research, personal stories, economic impact, and public health impact played during the policymaking process; controversies and compromises; youth-specific considerations; and thoughts about implementation. Oral consent was obtained at the beginning of each interview through a consent process approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, which deemed the project as not human subjects research (IRB No: 00009637). The interviews were digitally recorded and transcribed.

2.2. Analysis

Analysis was conducted using NVivo Version 12 using a hybrid inductive-deductive approach. An initial codebook was developed based on the research questions, the prior literature on policy implementation, implementation science frameworks characterizing policy as an outer context or bridging factor, specifically the Consolidated Framework for Implementation Research (CFIR) and the Exploration, Preparation, Implementation, and Sustainment Framework (EPIS), and preliminary themes identified in the summary memos created after each interview. As implementation science frameworks have not been focused primarily on policy implementation, the study team viewed this combined approach as more useful than application of a single framework. The codebook was then refined through an iterative process of pilot coding of a subset of two interview transcripts by two coders and review by the full study team; discrepancies in coding this subset were discussed by the team, then used to modify the codebook until there was agreement between the study team. The final codebook was applied by one coder to the full set of transcripts; any questions in coding were discussed with and resolved by consensus among the study team. Analysis was performed between February 2020 and August 2021. The final results were emailed to all interviewed stakeholders for member checking in August 2021, and no significant changes needed to be made based upon feedback.

3. Results

The study team contacted nineteen individuals for interviews, which constituted the majority of individuals found to have played a key role in the policymaking process. Of these, one person declined to participate, three were removed from the list when data saturation (defined as consistency in themes being discussed and no new key themes emerging from the interviews) was reached, and five did not respond to recruitment requests. Interviews were completed with ten stakeholders from the following groups: government, physicians and associated organizations, hospitals and associated organizations, and recovery and behavioral health organizations (Table 1). Interviews lasted between 21 and 43 min (median: 38 min).

Table 1.

Characteristics of stakeholders.

Key stakeholder groups	Number of stakeholders interviewed
Legislative branch staff	1
Hospital leadership, hospital associations/organizations leadership	3
Physicians in leadership roles, physician professional society leadership	4
Organizations and advocacy groups focused on behavioral health services and recovery	2

In regards to the policymaking process, three domains of key themes emerged from our analysis of stakeholder interviews:

3.1. The role of research in public health consensus (Table 2)

Table 2.

Stakeholders perceptions regarding the role of research in public health consensus.

Key themes and sub-themes	Summary	Illustrative quotes
Key theme: Pressing need for action
Urgent public health need mentioned by 9 of 10 stakeholders	Stakeholders commented upon the general sense among the community that more needed to be done urgently to address the opioid epidemic given the rise of fentanyl and increasing opioid overdose deaths.	We thought that it was going to be evidence-based treatment and harm reduction that really addressed the current fentanyl-driven crisis in Massachusetts.
Key theme: Role of research versus personal stories
Research was crucial Mentioned by 8 of 10 stakeholders	Stakeholders cited the strong role of research in supporting this legislation as an evidence-based public health intervention.	In terms of getting access to [medication for opioid use disorder], research is critical, I mean it’s the whole ballgame.
Pioneer study Mentioned by 7 of 10 stakeholders	Stakeholders noted that the original randomized controlled trial regarding Emergency Department buprenorphine induction by D’Onofrio et al. from Yale in JAMA (D’Onofrio et al., 2015) provided the initial evidence base for this intervention. This was followed by multiple subsequent demonstrations of its success in the literature and successful models in practice.	There was a JAMA study from Yale and that was really helpful because it had folks who didn’t get treatment and folks who did get treatment [in the ED] and followed them afterwards… who kept with their treatment program, who didn’t keep with their treatment program. So that like really was a good study to help us to say this helps people stick with it if they get it right here when they were kind of ready.
Unequivocal evidence Mentioned by 8 of 10 stakeholders	Stakeholders agreed that the evidence was unequivocal that ED inductions save lives. Additions were made to the legislation that hospitals needed to specifically be able to provide opioid agonist treatment, the type of medication the evidence supports as effective.	The fact that there’s clear research and data that makes MAT evidence-based was critical…if you’re objective and you’re really concerned about the people coming into your hospital and your ED and you look at the research, it’s clear.
Divergent sub-themes Personal stories Mentioned by 3 of 10 stakeholders	Most stakeholders mentioned that personal stories are always powerful and helpful, and certainly this legislation was no exception. While the majority of stakeholders thought that research played a larger role than personal stories, several stakeholders thought that the personal stories were more impactful than research/evidence for this particular legislation.	What ended up carrying the day is that vision of a parent… dragging in the patient with substance use disorder reluctantly and almost involuntarily and saying, “We’re going to get you help tonight at three o’clock in the morning,” and if they don’t get that, they’re never going to come back.
Stigma discouraging personal stories Mentioned by 2 of 10 stakeholders	Some stakeholders described the lack of individuals testifying with personal stories due to stigma that exists against addiction and MAT.	One of the issues is because there is still the stigma around it, you don’t hear as many stories. You’re not going to hear too often from a businessperson…. You might hear it from an advocate, but an advocate has nothing to lose.
Key Theme: Multiple stakeholders coming together
Collaboration Mentioned by 7 of 10 stakeholders	Throughout the policymaking process, there was cooperation between the multiple branches of government and among many diverse stakeholders including hospitals, physician groups, behavioral health providers, and patients and families.	I think overall the legislation was like a big collaboration…. Even though it was the governor’s bill we were able to put pieces that we thought were good in it, the hospital association got things that they were helping with, you know, the doctors, outside providers, there’s just– it was a big collaboration and it was a success.
Lack of opposition Mentioned by 8 of 10 stakeholders	There was really no opposition to the aspect of the legislation that expanded buprenorphine treatment in the ED, it was only a matter of working out the logistics to make it work for all involved stakeholders.	My recollection is that it was not a lot of controversy around this, it just was kind of a thing like, “Yeah, this is something we have to do.”
Governmental cooperation Mentioned by 10 of 10 stakeholders	The governor of Massachusetts had a strong track record of addressing the opioid epidemic, and key advocates for the legislation within both the executive and legislative branches helped carry it through the policymaking process.	There’s been a clear commitment on the part of state government both in the executive branch and in the legislature for many years to put in place laws and policy and funding to combat the epidemic and I think that’s no small thing.
Positive personal recollection Mentioned by 6 of 10 stakeholders	Stakeholders in general voiced very positive recollections of the cooperative process, and felt proud of the overall accomplishment and the positive impact this legislation would have.	I like it when the outcome is good and evidence-based and I believe that this one is…. I believe that this is the right thing in this situation, it’s a terrible tragic situation but I actually do think that the way that this turned out, it’s pushing us to do what we need to do to help address it so it’s good.

3.1.1. Pressing need for action

The first key theme identified was the pressing need for action for this public health crisis. Nine of the ten stakeholders noted the sense among the community that action was urgently needed to address the opioid epidemic and rapidly rising overdose deaths (‘We’re in epidemic mode and we need to do something’), and that the legislation was thus developed as a way to expand addiction treatment.

3.1.2. Role of research versus personal stories

Another key theme was the crucial role of research in spurring and supporting the legislation, with eight of the ten stakeholders agreeing that research was critical, and played a larger role than personal stories: ‘Ironically in most policy fights and legislation fights, the role of personal stories usually trump research and science only because that’s how most people think…. but anything to do with [MOUD], the science and the research I think is critical.’ Eight of ten stakeholders agreed the success of the legislation was due to the unequivocal research supporting the efficacy of ED medication inductions as life-saving: ‘If you’re objective and you’re really concerned about the people coming into your hospital and your ED and you look at the research, it’s clear.’ Divergent themes mentioned by a small subset of stakeholders included sentiments that personal stories about affected patients were still important, but that stigma played a role in discouraging personal stories.

3.1.3. Multiple stakeholders coming together

The last key theme in this domain was that multiple groups of diverse stakeholders came together, with the long-term relationships between the scientific community and government leading to effective incorporation of scientific evidence in the policymaking process. Ultimately these collaborations lead to nearly universal consensus about the legislation with a remarkable lack of opposition: ‘Something that should be transformative passed I would say without a lot of controversy.’ After the initial legislation was drafted by staff in the governor’s office and revised by legislative office staff, there was extensive collaboration across government branches and between diverse stakeholder groups to move the legislation forward, and stakeholders voiced pride and positive recollections about this process and its accomplishment.

3.2. Overcoming financing and feasibility concerns (Table 3)

Table 3.

Stakeholders perceptions regarding overcoming financing and feasibility concerns.

Key themes and sub-themes	Summary	Illustrative quotes
Key theme: Cost to the state
Politicians care about cost mentioned by 4 of 10 stakeholders	Stakeholders reflected that the cost of any legislation is always a huge consideration.	First thing that the government and the insurance industry think is, “What’s it going to cost?” And if you come to them and say, “This will improve patient care,” the first thing they say is, ‘What’s it going to cost?’ And if it costs 10 cents more than they’re already spending, they’re not interested, because, quite frankly, they’re already unable to pay for the cost of medical care in the United States…. And if you tell them it will save money, they’re all ears because that’s a two-for.
Need for budget neutrality Mentioned by 4 of 10 stakeholders	Stakeholders agreed that the legislation had to be crafted with economics and the state budget in mind. There was consideration at some point that the legislation would include money from the state budget to give resources to hospitals, but this was taken out so it could be budget neutral.	There was just no way that this was going to pass if the state had to increase its budget for it.
Key theme: Cost to stakeholder groups
Lack of pushback from stakeholders Mentioned by 7 of 10 stakeholders	The public health rationale and large consensus pushing for the legislation outweighed potential financial barriers for stakeholder groups. Groups that might otherwise have been opposed to the legislation were willing to compromise on the finances because there was such strong support for this legislation. Adjustments were made to the legislation that included specific billing codes to ensure reimbursement went smoothly for these expanded services.	I think that the groups that might be inclined to oppose something like that might be insurers because… now it’s mandated, they have to cover the cost of it… The insurers knew that this was not a bus they wanted to get in front of, the Governor was proposing it, the legislature was on board with it, the hospitals were on board with it that to argue that it was going to cost more money for employers wasn’t going to be a compelling argument.
Key theme: Hospital financial considerations
Willingness to compromise Mentioned by 8 of 10 stakeholders	As economic and logistical barriers arose during consideration of the legislation, compromises were made regarding feasibility to allow different models of implementation.	It didn’t come down to the fact of any party principally opposing the concept because of economics… instead it was, “We support this in concept. However, we as a small rural emergency department need to urge language that provides enough flexibility that this is economically feasible for our small community hospital along with larger academic teaching hospitals.”
Flexibility for hospitals Mentioned by 7 of 10 stakeholders	The legislation was adjusted to make implementation a requirement for hospitals rather than putting the burden all upon the EDs, so that different types of hospitals could be flexible in how and where to provide the medication, such as actually in the ED versus an associated bridge clinic, making it feasible for all types of hospitals.	Different hospitals have different patient needs, different resources, and so the idea was to kind of provide several different ways that hospitals could implement. So for instance some hospitals will provide a patient with a suboxone kit when they’re discharged, others will provide a prescription. It just kind of depends on their resources.
Divergent sub-theme Why all hospitals? Mentioned by 1 of 10 stakeholders	Some concern was noted about why this needed to be mandated for all hospitals throughout the state, but this was addressed by recognizing the pervasive nature of opioid overdose across the state and that patients do not have the luxury of choosing which hospital they go to for treatment for an opioid overdose, and thus all hospitals must be able to help these patients.	Why do we need every single hospital with an emergency department being able to do this? And the pushback that [our organization] gave them was… patients come in after an overdose or patients come in because their family members dragged them in… if they don’t get the help they need during that one solitary emergency department visit, their entire experience with the health care system is going to be reflected in that, and they’re never going to come back…. The patient who comes in with opioid use disorder… and is blown off by a small emergency department, isn’t going to make the trip into [the major city] to get the help they need.

3.2.1. Cost to the state

Four of the ten stakeholders felt strongly that a crucial aspect of this legislation’s success was that it was budget-neutral. Stakeholders discussed that the cost of legislation to the state budget is a major factor in most political debates, and that this legislation was no exception. ‘There’s no increase really to the state budget to allow for more resources for this…. Initially we were pushing for some sort of a state fund to help pay for this…. That eventually got taken out just in order to get it to pass.’

3.2.2. Cost to stakeholder groups

Seven of ten interviewees noted that despite the potential resultant cost and burden of implementation of this legislation for particular stakeholder groups such as insurers and physicians, ultimately there was a lack of pushback from those groups given the strong support for the legislation from the governor’s office as well as the multi-sector collaboration: ‘Insurers knew that this was not a bus they wanted to get in front of.’ As part of these discussions, language was added to the legislation that included verified billing codes to ensure services would be reimbursed and considered in contract negotiations.

3.2.3. Hospital financial considerations

Lastly, a key theme emerged regarding hospital financial considerations, given the impact that this un-funded legislative mandate could have on them. Stakeholders reported that hospitals were willing to compromise and support the legislation once revisions were made to allow for flexibility for different types of hospitals, so that both large academic centers and small rural hospitals would be able to develop a feasible model: ‘The bill said that the hospital has to have the capacity to provide [MOUD] to appropriate patients, it doesn’t say who’s going to do it, and that was important.’ One stakeholder mentioned early discussions questioning why this was needed across all hospitals in the state, but that concern was alleviated by recognizing that a wide safety net needed to be cast throughout the state in order to help all patients who might be presenting with an overdose.

3.3. Looking towards implementation (Table 4)

Table 4.

Stakeholders perceptions regarding policy implementation.

Key themes and sub-themes	Summary	Illustrative quotes
Key theme: Planning for implementation
Hospital implementation guide mentioned by 6 of 10 stakeholders	The hospital association organized a large group of stakeholders who came together after the legislation passed to create an implementation guide that hospitals could tailor to their own unique needs.	Everyone was pleased to see the Mass Hospital Association bring together a lot of stakeholders so that they could begin to think about what these protocols would look like and so that different stakeholders in the process could begin to share best practices and begin to talk about what protocols might look like for different types of hospitals or different types of emergency departments…. There was a lot of detail and granularity that was addressed through that process.
Key theme: Concerns about implementation
Necessity of aftercare providers Mentioned by 9 of 10 stakeholders	The largest concern cited among stakeholders was that large-scale ED inductions would not work if there were not a network of providers to which individuals could be referred for ongoing aftercare. Because this concern was recognized during the policymaking process, it was able to be addressed concurrently by the state through investment in expanding capacity across the healthcare system for MAT prescribing.	What’s going to determine the long-term success of that provision is whether or not the treatment options are available in the community for hospitals to refer patients to. So it’s great if you can induce somebody in the ED but if that person … can’t access ongoing treatment fairly quickly then the likelihood of the success, the long-term success of that person that should be in recovery is going to be challenged if there is not the bridge to community treatment.
ED workflow Mentioned by 3 of 10 stakeholders	Stakeholders raised concerns about the time constraints of doing this work in the ED.	What’s the rate-limiting step? Well, you know, it’s how busy is the ER and how much space do you have?
Key theme: Unclear enforcement strategy
Lack of clarity regarding enforcement Mentioned by 9 of 10 stakeholders	The legislation did not stipulate how hospital compliance would be enforced. Stakeholders had different ideas about how this might happen, whether through the Health Department, or spurred by news stories that could come about regarding adverse outcomes for patients who were not able to access treatment.	There’s lots of talk about enforcement, but there has never been a really great definition of how it will be enforced and just importantly how the data will be gathered around patients not getting access to medications for opioid use disorder in the ED, and so that’s still pretty vague.
It’s the right thing to do Mentioned by 2 of 10 stakeholders	Stakeholders noted that they thought most hospitals and physicians would comply with the law because it was the right thing to do to help patients.	Even though I have not heard explicitly about enforcement efforts, I certainly have heard from physicians their desire to work in good faith to make sure that it is implemented, and I think that’s largely in part because it’s the right thing to do, but also because they appreciate that this is now Massachusetts law that they need to follow and respect.
Key theme: Minimal consideration of youth
Youth not considered initially Mentioned by 7 of 10 stakeholders	Stakeholders reported that the specific needs of youth (adolescents and young adults) were not considered during the legislative process.	I don’t remember anything in there specifically about minors or adolescents.
Planning for youth in implementation Mentioned by 2 of 10 stakeholders	Stakeholders noted that the hospital association implementation guide was going to be updated to include information about how to address the needs of adolescents and young adults since it was not part of the initial legislation or implementation strategy.	I’m updating the guidelines that we did right now, and … the most substantive part of that update is around adolescence because… definitely not in our guidelines did we consider them, and I don’t believe it was specifically considered in the legislation.

3.3.1. Planning for implementation

Stakeholders discussed that a key factor in preparing to carry out the law was a workgroup convened by the Massachusetts Health & Hospital Association, in conjunction with the Massachusetts College of Emergency Physicians, which developed guidelines and recommendations that hospitals could follow to stay in compliance with the law (Massachusetts Health & Hospital Association, 2019): ‘We wanted to make sure that there was a pathway for every hospital to implement regardless of their geography or their staffing ability or their resources or… the volume of patients in need of the services.’

3.3.2. Concerns about implementation

Another key theme evolved regarding concerns about implementation, including the necessity of aftercare providers for continuing medication started in the ED (‘For a hospital to induce somebody on [MOUD] is one thing but then to make sure that person can access treatment… to me that’s going to be the biggest challenge of implementation’), and potential logistical and time constraints for busy EDs (‘If you try to do too much in the emergency room, you just backlog and it affects everyone’).

3.3.3. Unclear enforcement strategy

The majority of stakeholders (nine of ten) reported a lack of clarity regarding how this law would be enforced: ‘Hmm. I don’t really know about enforcement.’ While the legislation granted authority to the Massachusetts Department of Public Health to promulgate regulations for the implementation and enforcement of this legislation, they had yet to do so by the time hospitals needed to start making changes to follow the law. Two stakeholders noted that despite the lack of an enforcement plan, hospitals were moving forward because it was the right thing to do to help patients.

3.3.4. Minimal considerations of youth

Lastly, most (seven of ten) stakeholders noted that the legislation did not take into consideration the specific needs of adolescents and young adults (‘I don’t think that we really specifically focused on adolescents’), but two stakeholders noted youth were now being considered in implementation plans (‘I’m updating the guidelines that we did right now, and… the most substantive part of that update is around adolescence’).

4. Discussion

Our key themes were consistent with prior literature on policy dissemination and implementation, which has shown that long-term investment in coalitions, consensus building, and engagement of relevant stakeholders are key facilitators to enactment of evidence-based policy (Mcginty et al., 2019). Our study provides insights into how these facilitators supported passage of legislation requiring statewide availability for MOUD initiation in the ED in Massachusetts. This case is a unique example of translation of evidence into policy despite the fact that the target population, people with OUD, is heavily stigmatized (Barry et al., 2014; Botticelli & Koh, 2016; Madden et al., 2021; National Academies of Sciences Engineering and Medicine, 2019; Olsen & Sharfstein, 2014).

The perceived strong role that research played in the origination of the legislation and throughout the policymaking process is an important finding. Research can be slow to disseminate into policymaking, though there is a call for better alignment of science with policy (Ansari et al., 2020; Loncarevic et al., 2021; Oliver, Innvar, et al., 2014). Our nation’s historical “war on drugs” approach to substance use policy is based on long-held archaic views positioning drug use as a moral failing; this policy approach has been rooted in systemic stigma and racism (Mcginty et al., 2019; National Academies of Sciences Engineering and Medicine, 2019). Stigma against individuals who use drugs is highly prevalent, and this extends to stigma regarding the treatment with MOUD (Barry et al., 2014; Botticelli & Koh, 2016; Madden et al., 2021; National Academies of Sciences Engineering and Medicine, 2019; Olsen & Sharfstein, 2014). Science was able to win over stigma in this legislation, and our results suggest that may be due in part to the community’s recognition of the urgent public health need to address the overdose crisis. Perhaps Massachusetts, a state with a strong track record of innovative legislation from a governor committed to public health and long-term coalition engagement, was a fertile context for this kind of legislation. Amidst this environment, relevant stakeholders were able to reach goal consensus and negotiate through perceived barriers to enact legislation they all believed could save many lives (Mcginty et al., 2019). This policymaking experience grounded in scientific research demonstrates that although evidence-based policymaking is challenging, collaborations between the scientific community and the political world have the potential to be highly successful when based upon long-term stakeholder collaborations and clear evidence that readily lends itself to consensus building (Crowley et al., 2021; Glasgow et al., 2012; Loncarevic et al., 2021; Mcginty et al., 2019; Oliver, Lorenc, & Innvær, 2014; Sallis, 2019). This experience may not be transferable to states that have not prioritized addressing the opioid epidemic with a strong track record of stakeholder collaboration and legislation.

Study results highlight the economic pressures ubiquitous in politics. Consistent with prior literature (Brownson et al., 2006, 2009; Purtle et al., 2020; Sallis, 2019), the budgetary effect of the legislation was perceived by stakeholders to be a major factor in the policymaking process. Although most stakeholders were not aware of much discussion regarding the economic implications of the legislation, the stakeholders that were part of those conversations highlighted the necessity of having a budget-neutral proposal. They noted that it would have been much harder to pass legislation that added to the state budget, thus because the legislation was kept budget-neutral for the state, ultimately the economic implications did not become a contentious debate. While stakeholders hypothesized that this made it easier for the legislation to pass, the consequence of this is that hospitals were left with the burden of carrying out an unfunded mandate. This may translate into more difficult implementation of the law, especially as hospitals now struggle with the financial hit of the COVID-19 pandemic. However, within only a few short years of ED MOUD inductions, multiple cost-effectiveness evaluations have demonstrated that this practice can be cost-saving (Busch et al., 2017; D’Onofrio et al., 2018; Hawk & D’Onofrio, 2018; Samuels et al., 2018). This cost-effectiveness evidence presents an opportunity for strategic economic considerations in future legislation (Brownson et al., 2009) that could result in favorable financial positions for the state, insurers, and hospital systems. Recognizing important policymaking influences such as economics can improve the development of evidence-based policy (Glasgow et al., 2012; Oliver, Innvar, et al., 2014; Oliver, Lorenc, & Innvær, 2014; Purtle et al., 2020; Sallis, 2019).

Finally, study results demonstrated the idea that translating research into policy does not stop with law enactment. Consideration and planning for rulemaking and implementation are arguably as important as the law-making process itself (Oliver, Innvar, et al., 2014). Stakeholders recognized that simply passing the policy was not enough to solve the overdose crisis, and that concerted and organized efforts must be made to ensure a successful system for implementation; where the law fell short in addressing needs of youth, stakeholders recognized the need and began to make modifications in implementation plans for this group. In order for all patients to be able to access treatment as mandated, stakeholders said there must be a continued push for capacity building throughout the commonwealth. Stakeholders brought up the concern that there may not be enough providers able to prescribe buprenorphine, as prescribing has been limited to those who have obtained a special X-waiver as mandated by the DATA 2000 Act (Massachusetts Health & Hospital Association, 2019). However, federal law is evolving in a way that may facilitate the greater adoption of buprenorphine by a wider network of providers; in April 2021, the Biden administration eased some of the restrictions on buprenorphine prescribing, removing the requirement for additional training to obtain the special X-waiver (Pourmand et al., 2021). It remains to be seen whether this policy change is actually effective in making it easier for patients to access MOUD, however it has the potential to aid implementation of the Massachusetts law. It may also provide a path forward to successful legislation regarding ED MOUD inductions in other states with less availability of buprenorphine providers and SUD treatment facilities, particularly for vulnerable populations such as youth, compared to the relative abundance in Massachusetts (Alinsky, Hadland, et al., 2020; Hadland et al., 2020; Substance Abuse and Mental Health Services Administration, 2018). Future research evaluating perceptions of implementation of the 2018 MA law will be helpful in understanding whether the law has been successful in its goal of expanding access to MOUD.

4.1. Limitations

Limitations of this study, as in other qualitative studies, included the possibility of bias on the part of the researchers; to minimize bias, the study team utilized a standardized interview guide and a systematic double-coding process for the development of key themes. Stakeholders who agreed to participate may represent a biased segment of all stakeholders involved in the policymaking process, in that those with more positive experiences may have been more willing to participate in our study. The study team attempted to mitigate this by recruiting participants from diverse stakeholder groups and using snowball sampling to ensure individuals that were reported to have played a large role in the process were invited, however it is possible that stakeholders with differing views were not captured in our sample. The study team was unable to reach several stakeholders identified as participating in the policymaking process, and it is possible they had divergent views from what was captured in other interviews.

5. Conclusion

These study results suggest that the research supporting the effectiveness of ED MOUD induction was the driving factor in passing the Massachusetts legislation, combined with long-term collaboration between diverse stakeholders towards a common goal of addressing the opioid epidemic by increasing access to evidence-based treatment. As states grapple with the worsening drug overdose crisis in the wake of the COVID-19 pandemic, this Massachusetts policymaking process can provide a roadmap with invaluable lessons for expanding treatment of OUD in hospitals throughout an entire state.

Abbreviations:

OUD

opioid use disorder

MOUD

medication for opioid use disorder

ED

emergency department