Response to McIlveen et al.: Collaboration and transparency are necessary to effectively estimate substance use disorder treatment need

We thank McIlveen et al. [1] for their comments. Our study investigating state-level support for federal substance use disorder (SUD) treatment expansion included any state-level written communications such as memoranda, guidelines, fact sheets, or executive orders addressing federal policy expansion as of April 13, 2020 [2]. Substance Abuse and Mental Health Services Agency (SAMHSA) stated on March 3, 2022, that “over the past two years, 45 states have taken advantage of” methadone take-home treatment expansion [3]. We are glad to know that the majority of states eventually took advantage of this policy. To clarify, when we submitted our study for publication in March 2021, there were no public reports on the extent of policy uptake. Our estimates for policy uptake in the first 6 weeks of the SARS-CoV-2 pandemic were accurate based on accessible information available at the time.

McIlveen et al. [1] argue that our estimates were inaccurate because “most states … did not need to issue announcements or guidelines or make regulatory changes to implement the blanket exception.” However, the authors then describe the multistep process each individual opioid treatment program (OTP) was “urged” to undertake to receive permission from SAMHSA to expand methadone treatment [1, 3]. Presumably, this advice was transmitted to OTPs through some form of written communication that was not made public, potentially explaining why it was overlooked in our study. Each individual OTP was required to request approval for treatment expansion from state regulators and SAMHSA directly [1, 4], further limiting our ability to effectively estimate the patient population affected by treatment expansion in these specific states. The process McIlveen et al. [1] describe underscores the multiple impediments to implementing expanded treatment policies across states and individual clinics, as well as the lack of transparency in state-level policy for treatment delivery and availability.

Although McIlveen et al. [1] describe efforts to coordinate take-home medications at OTPs, the activities described by the authors only affected OTP-enrolled patients at the onset of the COVID-19 pandemic and does not address people with SUD in need of services [5]. Furthermore, the authors did not mention guidance available to providers unaffiliated with OTPs waivered to prescribe buprenorphine. The lack of formal state-level communications may have prevented referrals to OTPs if providers were unaware that OTPs had implemented expanded access policies or reduced the number of providers implementing buprenorphine prescription via telehealth. Treatment initiation and retention was significantly impacted by the COVID-19 pandemic even in states with public communications. For example, clinics in New York City showed a 50% reduction in referrals for buprenorphine initiation from March to August 2020 compared to the same months in 2019, but significantly improved 90-day retention among patients who initiated treatment [6]. The pandemic’s variable impact on treatment initiation and retention makes estimating the patient population affected by policy expansion difficult, especially without transparent communication and analysis at multiple levels of implementation.

Transparency and collaboration across government, community, and academic partners are crucial to creating effective interventions to improve SUD treatment access and retention [7–9]. Academics rely on timely government reports and communications to identify gaps and produce impactful research agendas.