Laws for expanding access to medications for opioid use disorder: A legal analysis of 16 states & Washington D.C.

Abstract

Background:

Medications for opioid use disorder (MOUDs) are the gold standard for opioid use disorder treatment but are underused. No study has systematically identified and categorized state policy innovations for expanding MOUD utilization.

Objective:

We sought to identify and categorize state MOUD policy innovations.

Methods:

Within a stratified random sample of 16 U.S. states and Washington D.C., we searched for 2019 state statutes and regulations related to MOUD in Westlaw legal database. We then identified laws that appeared designed to increase MOUD utilization and categorized them using a template analysis approach.

Results:

We found 82 laws with one or more MOUD expansion policies. We identified six high-level MOUD expansion policy categories: 1) policies expanding the availability of waivered buprenorphine providers; 2) needs assessments and policies increasing public MOUD awareness; 3) criminal justice system policies; 4) SUD treatment and sober living facility policies; 5) insurance policies; and 6) hospital policies. SUD treatment and housing facility policies, as well as insurance policies, were most common.

Conclusions:

Multipronged approaches are being pursued by several states to increase MOUD access. Our results can inform policymakers of MOUD expansion approaches in other jurisdictions. Policy categories can serve as the basis for policy variables for future analyses of policy effects.

1. Introduction

The number of drug overdose deaths in the US is at an unprecedented high, with a nearly 27% increase in deaths between 2019 and 2020, of which 75% included an opioid (1). The most effective treatments for opioid use disorder (OUD), a key predictor of opioid-related death, are medications for opioid use disorder (MOUD), which includes formulations of methadone, buprenorphine, and naltrexone (2). Methadone and buprenorphine treatment halve the mortality rate for people with OUD compared to treatment without medication (3). Some studies suggest that only 57% of individuals recognized in the health system with OUD utilize MOUD(4), with some studies showing even lower rates of MOUD utilization (5). Numerous access barriers to MOUD have been identified, including insufficient numbers of MOUD providers, insurance restrictions, cost, stigma, and transportation (6–8).

In response to unmet need for effective treatment for OUD, policymakers have developed a range of policies to expand access to MOUD, including allowing advanced practice clinicians to prescribe buprenorphine (9, 10), expanding hospital provision of MOUD, developing telehealth infrastructure to support MOUD use, and implementing MOUD in criminal justice settings and harm reduction programs (11). Enacting or changing state statutes, regulations, and other policies (hereafter referred to as “policies”) can enhance access to MOUD, including by decreasing barriers to prescribing or decreasing patient costs. Identifying and categorizing the range of policy approaches policymakers are using to pursue improved MOUD access could highlight innovative but less commonly adopted policy options. Furthermore, better understanding the different types of policies states are implementing to expand MOUD can facilitate empirical analyses examining the implementation and effectiveness of different approaches for increasing MOUD utilization.

We are unaware of studies systematically identifying the different types of state policy approaches being implemented in efforts to increase MOUD utilization. To address this gap in the literature, this study reports on the results of a qualitative analysis that identified and categorized state MOUD-related statutes and regulations in a stratified random sample of 16 states from four major US geographic regions and Washington D.C.

2. Methods

a. Data Collection

To decrease bias in sample selection, we used random stratified sampling to select 16 states, plus Washington D.C., stratifying our state selection based on major US geographic region, legislative partisan affiliation, and population density. Our final sample consisted of the following: Alabama, Arizona, California, Georgia, Kentucky, Louisiana, Massachusetts, Minnesota, Missouri, Nevada, New Mexico, Rhode Island, South Dakota, Texas, Vermont, Washington D.C., and Wisconsin. States in our sample are comparable to the nation with respect to geographic location, legislative partisan affiliation, population density, and opioid overdose death rates. See Table 1 for a comparison of our sample states’ characteristics to those nationally.

TABLE 1: COMPARISON OF CHARACTERISTICS AMONG SAMPLE STATES VERSUS THE UNITED STATES.

Characteristic	Sample (n=17)	United States (n=51)
	n (%)	n (%)
Geographic Region a
Northeast	3 (18%)	9 (18%)
Midwest	4 (24%)	12 (24%)
South	6 (35%)	17 (33%)
West	4 (24%)	13 (25%)
Legislative partisan affiliation b
Democrat	7 (41%)	20 (39%)
Republican	9 (53%)	29 (57%)
Nonpartisan/Split	1 (6%)	2 (4%)
Population Density c
Lower	9 (53%)	25 (49%)
Higher	8 (47%)	26 (51%)
Opioid Overdose Mortality (per 100,000) d	16.0	15.5

^a2020 data from: https://www.nationsonline.org/oneworld/US-states-by-area.htm

^b2020 data from: https://www.ncsl.org/research/about-state-legislatures/partisan-composition.aspx

^cLower = below median; Higher = above median. 2020 data from: https://worldpopulationreview.com/state-rankings/state-densities

^d2019 age-adjusted mortality rate per 100,000 population. Data from: https://www.kff.org/other/state-indicator/opioid-overdose-death-rates/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

We searched the Westlaw, an online legal database and research service, for state statutes and regulations in our 17 jurisdictions using key words related to MOUD (e.g., “buprenorphine,” “methadone,” “naltrexone”) (see Appendix A for the full list) and found 758 laws in effect during 2019. Skimming the title and text of the full law, we excluded 610 laws unrelated to MOUD treatment, such as laws that do not regulate treatment of OUD (e.g., laws regulating treatment of pain with opioid analgesics); general licensing requirements for clinicians not specific to MOUD; laws regulating professionals who do not treat OUD (e.g., veterinarians, optometrists); laws not applicable to the entire state (e.g., only applicable to certain counties); laws creating task forces; laws regulating detoxification rather than maintenance treatment; and generic pharmacy dispensing laws not specific to MOUD. The remaining 158 laws were uploaded into Dedoose qualitative software (12).

b. Data Analysis

First, each law in our sample was assigned to one of two pairs of qualitative researchers who independently coded data as an “MOUD expansion policy” in Dedoose software (12) if the text either explicitly stated an intent to increase MOUD access or implicitly appeared designed to expand MOUD access (e.g., a law requiring residential treatment facilities to offer MOUD.) Due to our focus on state policies, mere restatements of federal law were not coded. The pairs of researchers then met to make final decisions regarding the application of the “MOUD expansion policy” code. Laws without any application of the “MOUD expansion policy” code were then dropped from Dedoose (12), resulting in 82 laws remaining across 16 jurisdictions (South Dakota had no relevant laws in the sample.)

Next, we coded the 82 laws using a template analysis (13) approach, which involves creation of an initial codebook based on preliminary review of data and the research questions, followed by inductive refining of the codebook through addition, removal, merging, and reorganization of codes, with the high-level categories of data in the codebook reflecting themes. During this process, qualitative researchers independently coded laws and then regularly met to negotiate any differences in coding application. Additionally, the qualitative team met biweekly to discuss codebook refinement. Once all laws were coded, the entire qualitative team met to review the final coding template and negotiated any proposed changes until the team arrived at a consensus.

As a quality check, three members of the research team reexamined codes applied to the 82 laws to confirm appropriateness of codes, meeting as a team to discuss any proposed changes. Lastly, the template and example laws were shared with three senior MOUD treatment/policy experts, who reviewed and provided feedback on the categorization of MOUD expansion policies, resulting in a finalized version of the high-level policy categories.

c. Ethics

Institutional review board approval was not required, as no human subjects were involved in this research.

3. Results

We identified 82 laws having at least one MOUD expansion policy. Among states with such laws, the median number of laws in a state was 9.5 (range 1 to 25). We identified six different high-level categories of MOUD expansion policies, including: policies expanding the availability of waivered buprenorphine providers; policies increasing public MOUD awareness; criminal justice system policies; SUD treatment facility policies; insurance policies; and hospital policies. See Figure 1 for high-level categories and sub-categories.

FIGURE 1: MOUD EXPANSION POLICY THEMES & SUB-THEMES.

Some policies fell into more than one category. For example, a policy requiring hospitals to educate patients about MOUD would be categorized both as a hospital policy and as a policy increasing public MOUD awareness. Several policies were short-term pilot or demonstration projects, while others appeared designed to be permanent. Representative quotations of state law for each policy type can be found in Table 2 and Appendix B. The presence of different policy categories by state is depicted in Table 3.

TABLE 2: REPRESENTATIVE QUOTATIONS.

Policy Category	Sample Law 1	Law 1 Citation
Policies for expanding the availability of waivered buprenorphine providers	“Subject to appropriations, the department shall create and oversee an “Improved Access to Treatment for Opioid Addictions Program”.... The IATOA program shall facilitate partnerships between assistant physicians, physician assistants, and advanced practice registered nurses practicing in federally qualified health centers, rural health clinics, and other health care facilities and physicians practicing at remote facilities located in this state. The IATOA program shall provide resources that grant patients and their treating assistant physicians, physician assistants, advanced practice registered nurses, or physicians access to knowledge and expertise through means such as telemedicine and Extension for Community Healthcare Outcomes (ECHO) programs established under section 191.1140.”	Mo. Ann. Stat. § 630.875 (West 2019)
Policies for assessing MOUD need and increasing MOUD awareness	“A community relations and education plan that includes policies and procedures to measure and minimize the negative impact the opioid treatment program may have on the community, to promote peaceful coexistence and to plan for change in the program and program growth, including: ... Developing and implementing a community relations plan that is specified to the needs of the program within its community and that includes the following actions: … (iii) Serving as a community resource on substance use and related health and social issues as well as promoting the benefit of medication-assisted treatment in preserving the public health.”	Ariz. Rev. Stat. Ann. § 36–2907.14 (2019)
Criminal justice institution policies	“As part of reentry planning, the Department shall commence medication-assisted treatment prior to an inmate’s release if: (A) the inmate screens positive for an opioid use disorder; (B) medication-assisted treatment is medically necessary; and (C) the inmate elects to commence medication-assisted treatment.”	Vt. Stat. Ann. tit. 28, § 801b (West 2019)
State-licensed SUD treatment/housing facility policies	“A resident has the following rights: 1. Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis; 2. To receive services that support the resident’s sobriety, including, if applicable, continuing to receive medication-assisted treatment while a resident;”	Ariz. Admin. Code § 9–12-203 (2019)
Insurer policies	“The following services provided by a provider other than the member’s PCC do not require a referral from the member’s PCC in order to be payable: … (gg) medication assisted treatment (MAT) for opioid use disorder.”	130 Mass. Code Regs. 450.118 (2019)
Hospital policies	“During or after a substance use disorder evaluation conducted pursuant to subsection (b), treatment may occur within the acute-care hospital or satellite emergency facility, if appropriate services are available, which may include induction to medication-assisted treatment.”	Mass. Gen. Laws ch. 111, § 511/2 (2019)

TABLE 3: POLICY CATEGORIES ACROSS STATES WITH SAMPLE CITATIONS.

State	Policies for expanding the availability of waivered buprenorphine providers	Policies for assessing MOUD need and increasing MOUD awareness	Criminal justice institution policies	State-licensed SUD treatment/ housing facility policies	Insurance policies	Hospital policies
AL
AZ
CA
DC
GA
KY
LA
MA
MN
MO
NV
NM
RI
SD
TX
VT
WI

Policies for expanding the availability of waivered buprenorphine providers often appear intended to facilitate education of clinicians who are not yet waivered or prescribing buprenorphine. These policies include development of infrastructure and funding for MOUD specialists to train non-MOUD specialists, such as through Project ECHO(14) establishment of a learning collaborative between state-designated Centers of Excellence for treating Opioid Use Disorder(15), dissemination of information about MOUD to obstetricians(16), and maintenance of lists of MOUD education programs in the state(17). For example, a law in Missouri stated: “The IATOA program shall provide resources that grant patients and their treating assistant physicians, physician assistants, advanced practice registered nurses, or physicians access to knowledge and expertise through means such as telemedicine and Extension for Community Healthcare Outcomes (ECHO) programs established under section 191.1140.” (14)This category also includes state laws allowing advanced practice clinicians to prescribe buprenorphine(18–24). Missouri, for example, created the Improved Access to Treatment for Opioids Addiction program (IATOA), which among other activities, is meant to design advanced practice clinician trainings and knowledge examinations in collaboration with medical schools, after which an IATOA certification would enable the practitioner to serve as a liaison to courts, provide education in hospitals to patients who have overdosed, and collaborate with physicians to prescribe buprenorphine (14, 25). A law in California prevented prohibiting clinicians from providing or administering buprenorphine, saying, “This chapter…shall not … prohibit a physician assistant from administering or providing buprenorphine to a patient, or transmitting orally, or in writing on a patient’s record or in a drug order, an order to a person who may lawfully furnish buprenorphine”.

Policies for assessing MOUD need and increasing MOUD awareness either promote public education about MOUD or require community needs assessments of MOUD provider availability. For example, a Minnesota policy states that “An opioid treatment program must carry out activities to encourage an individual in need of treatment to undergo treatment. The program’s outreach model must:… (2) contact, communicate, and follow up with individuals with high-risk substance misuse, individuals with high-risk substance misuse associates, and neighborhood residents within the constraints of federal and state confidentiality requirements.”

Policies include initiatives for developing and distributing of pamphlets about MOUD to healthcare providers for distribution to patients, requirements of OTPs to conduct community outreach informing the public of their services and the benefits of MOUD, including benefits to pregnant women(26–29), development of a public-facing website with information about each state-designated Center of Excellence for Treating Opioid Use Disorder(15), and creation of a database listing available MOUD providers in real time(30). One policy requires insurers to maintain an updated list of MOUD providers in network and to make this list available to beneficiaries upon request(31). Additionally, this category included policies for developing and funding statewide MOUD needs and barrier/facilitator assessments(32–34). For example, Alabama designed a process to “identify, by region, need for additional treatment facilities to ensure the continued availability, accessibility, and affordability of quality opioid replacement treatment services for residents of Alabama.” However, the Alabama policy allows for only one new OTP to be approved within any region during any application cycle(33).

Criminal justice institution policies appear designed to expand MOUD access for people involved in a specific justice institution, such as probation, parole, prison, jail, or diversionary programs. Such policies include: funding MOUD for people involved in the criminal justice institution(35, 36); requiring the criminal justice institution to provide or connect people to MOUD, particularly prior to community reentry if the individual is incarcerated(35, 37–41); forbidding the criminal justice institution from banning the starting of MOUD(40, 42–44) or requiring the justice authority to continue previously begun MOUD(40, 42, 45); and forbidding the criminal justice institution from placing restrictions on the dose, duration, or type of MOUD(37, 39–41). For example, a Missouri law requires the following: “If a treatment court participant requires treatment for opioid or other substance misuse or dependence, a treatment court shall not prohibit such participant from participating in and receiving medication-assisted treatment under the care of a physician licensed in this state to practice medicine.” Another example includes a California law which “requires the CDCR [California Department of Corrections and Rehabilitation] to establish a Pilot program at one or more institutions that will provide a medication assisted treatment model for inmates with a history of substance abuse problems.” (44)The requirements of these criminal justice policies seemed nuanced. For example, the policy may require that only institutions in specific counties offer MOUD if advised to do so by an addiction specialist(39), that MOUD be offered for the 90 days prior to reentry from prison/jail(41), or that the correctional facility need only offer MOUD formulations reimbursable by Medicaid(39). Several criminal justice system policies were part of pilot programs established by the Department of Corrections or the Department of Health to expand SUD treatment to justice-involved populations.

State-licensed SUD treatment/sober living facility policies prohibit state-licensed SUD treatment/housing facilities from banning people who use MOUD(27, 46, 47), require facilities to educate patients about MOUD(48), require facilities to refer patients to MOUD or to offer MOUD when desired by patients(49–51), require the state department of health to create new opioid treatment programs(52, 53), provide funding for facilities to offer MOUD(36), or require residential or outpatient facilities to publicly disclose whether they offer MOUD(37). For example, a California law states that “A licensee shall not deny admission to any individual based solely on the individual having a valid prescription … for the purpose of narcotic replacement treatment or medication-assisted treatment of substance use disorders.” Louisiana requires that each licensed SUD treatment facility that offers OUD treatment provide onsite access to at least one antagonist MOUD and one agonist MOUD.

To facilitate compliance with this requirement, Louisiana requires that all SUD facilities attest to adherence with the rule during initial and annual licensing renewals(51). Minnesota, on the other hand, does not require all licensed residential facilities to offer MOUD; but Minnesota created a pilot program wherein facilities can obtain higher Medicaid reimbursement if they meet certain criteria, including offering MOUD(54). Policies could also increase access to existing opioid treatment programs (OTP), such as requirements for OTPs to set hours based on patient need(55), for OTPs in the state to collaborate with each other in setting open hours to ensure maximum accessibility(56), or for OTPs to maintain flexible hours and dosing schedules enabling access for patients who work, lack reliable transportation, or have childcare responsibilities(27, 55–58).

Additionally, some policies require OTPs to accept income-based sliding scale payments from patients who lack health insurance(59), require OTPs to provide “affordable treatment to all needing it”(55), or prioritize licensing of OTPs that affordable(33). For example, in its certificate of need application process for OTPs, Alabama clarifies the following: “In considering [certificate of need] applications filed under this section, whether pursuant to the regular need methodology or an adjustment, preference shall be given to those applicants demonstrating the most comprehensive plan for treating patients regardless of their ability to pay”(33). Interestingly, California permits OTPs to expand certain services into office-based (i.e., non-OTP) locations(60). Finally, this category also included policies requiring state licensed recovery houses to accept people using MOUD and to not prohibit residents from using MOUD(61, 62).

Insurer policies existed in almost all jurisdictions in our sample. Types of policies included the following: mandatory formulary coverage of MOUD(37, 63–66), lowest cost-sharing tier placement of MOUD(37), mandatory inclusion of MOUD providers accepting new patients in the insurance network(31), provision of information to beneficiaries and the government about available MOUD providers in the network(31), and waiving of requirements for primary care provider referrals to MOUD(67). This category also includes policies preventing insurers from imposing certain quantitative or qualitative limits, such as MOUD prior authorization requirements on one or more MOUDs(37, 65, 68–70), step therapy requirements(37, 65, 71), or lifetime limits on MOUD utilization(37, 65, 72). MOUD insurer policy details substantially varied across jurisdictions. For example, a policy might apply to all insurers in the state(31, 37, 63, 70–72) or only Medicaid(37, 54, 64–67, 73–76), and might prohibit prior authorization for all types of MOUDs(70) or require that at least one MOUD is not subject to prior authorization requirements(71). Wisconsin law states that “Medicaid shall provide coverage for medication-assisted treatment prescribed for the treatment of substance use disorders; provided, that medication assisted treatment covered in accordance with this section shall not be subject to: (1) Utilization control… (2) Prior authorization… (3) Step therapy… or (4) Lifetime restriction limits.”

Rather than an automatic prohibition on MOUD prior authorization within its Medicaid program, Wisconsin required a phasing out over time:

“On November 1, 2018, and every 6 months thereafter, the department shall … a report describing the department’s findings on the prior authorization policy on buprenorphine-containing products and its progress on eliminating prior authorization requirements for buprenorphine-containing products in populations where removal of prior authorization is appropriate.”(77)

Some Medicaid-related policies appeared to require a waiver from the Centers for Medicare and Medicaid Services(74), typically because they envisioned the provision of Medicaid-services in a manner not typically authorized under program rules. This included payment for MOUD during residential treatment (bypassing the Institutions of Mental Disease Medicaid rule), elimination of MOUD copayment requirements(73), increased Medicaid reimbursement for MOUD providers(54, 73), and creation of separate funds for purposes of MOUD expansion(75). For example, one Massachusetts law requires creation of a fund that will allow the Secretary of Health, without further appropriation, to spend $14 million annually for purposes of “expand[ing] access to medication assisted treatment,” though details of how these funds are to be used were lacking(75).

Hospital policies include creation and dissemination of educational materials about MOUD to at-risk patients(30), requirements for hospitals to offer MOUD to patients and then refer them to community MOUD providers(30, 78). Rhode Island requires that patients presenting with substance use disorder or opioid overdose in a hospital or free-standing emergency department are presented with “clinically appropriate inpatient and outpatient services for the treatment of substance-use disorders, opioid overdose, or chronic addiction, including: (A) Detoxification; (B) Stabilization; (C) Medication-assisted treatment or medication-assisted maintenance services”. The state of Massachusetts requires that patients presenting with opioid overdose in the emergency department be provided buprenorphine, then connected with a community MOUD provider: “Prior to discharge, any patient who is administered or prescribed an opioid agonist treatment in an acute care hospital emergency department or satellite emergency facility shall be directly connected to an appropriate provider or treatment site to voluntarily continue said treatment.” Rhode Island

4. Discussion

MOUDs are life-saving treatments for OUD (3) underutilized in the US(79). State-level policies could help to facilitate MOUD access. While there is a longstanding history of federal and state regulations that have constrained or limited access to MOUD (25, 80–83), there has been comparatively less state policy activity directed toward expanding MOUD access. In our analysis of seventeen jurisdictions, we found a variety of policies that appear to be designed to expand MOUD access that fall within six policy domains: 1) expanding the availability of waivered buprenorphine providers, 2) expanding MOUD awareness, 3) criminal justice, 4) licensed SUD facilities, 5) insurers, and 6) hospitals. The number of MOUD expansion policies across our jurisdictions ranged widely, from none to 25, possibly reflecting the heterogeneity of cultures and health service challenges faced.

The MOUD expansion policy categories we identified are a preliminary step toward creating a typology of state law approaches for expanding MOUD. They could also facilitate policymakers’ awareness of MOUD expansion approaches in other jurisdictions, a potential benefit given the variability of policy approaches observed across jurisdictions. This variability is not surprising as state governments, legislatures and agencies focus on different responses because of the needs of their populations (e.g., states with higher versus lower drug supply), the state’s political climate (with different emphasis on punitive versus enabling policies and varying support for robust regulation of the health care safety net), and policymakers’ awareness of policy options.

Some states appear to have taken more substantial policy efforts than others toward MOUD expansion, such as by requiring SUD treatment providers or the criminal justice system to provide MOUD, rather than to merely conducting needs assessments or expanding educational opportunities for patients/providers. For example, Louisiana requires all licensed residential facilities to offer at least one agonist and one antagonist OUD treatment, likely among the first states in the country to pass a law with such stringent requirements on residential programs. By contrast, Alabama, California, and Washington D.C. merely prohibit residential facilities from excluding patients based on their MOUD utilization(27, 46). Relatedly, with respect to insurance some states prohibit prior authorization for MOUD among all insurers offering plans in the state, while others only restrict MOUD prior authorization practices within Medicaid.

We found that insurer policies were among the most common types of MOUD expansion policies, present in most states we examined. Prior authorization requirements and limited MOUD insurance coverage have frequently been discussed as MOUD utilization barriers in the literature (6, 8, 84, 85). That many insurer policies address Medicaid may reflect state policymakers’ relative ease in making Medicaid policy changes, which often do not require statutory changes. In contrast, policies applicable to all insurers may require policymakers to overcome more political hurdles, as well as be less feasible given the limited purview of state insurance regulations over multi-state plans. Similarly, SUD treatment facility/housing policies were common in our study, potentially reflecting policymaker concerns about low rates of MOUD utilization in SUD treatment facilities (Huhn et al. 2020; Stewart et al. 2019; Alderks 2017). State authorities may also be seeking to prevent emerging lawsuits against SUD treatment facilities that prohibit access to patients using MOUD(86, 87). Finally, states’ prominent role in licensing and regulating SUD treatment/housing facilities may also enable policy experimentation in that space.

The diversity of state lawmaking around MOUD may be seen as encouraging to the extent that states appear to be moving toward broadened access and fewer restrictions, although their authority remains limited under federal law. It is unclear, however, whether the piecemeal laws passed by state are sufficient to bring treatment to scale for people at greatest risk of overdose. Removal of certain federal regulatory barriers, such as the federal waiver and patient limits for buprenorphine treatment, could help increase MOUD access nationally.

Our study is subject to several important limitations. We only examined laws present in 2019 within a random sample of seventeen jurisdictions, and do not know to what extent our findings would generalize to other states. We have no information on when these policies were enacted, and the policies may have since been amended, repealed, or new MOUD expansion policies may have been enacted. We focus on state policies and have no information regarding county or municipality policies. Our legal search criteria focused on laws that include MOUD-related terminology, and we recognize that other laws could affect MOUD access without explicitly using MOUD-related terminology. For example, lack of public transportation is a barrier to MOUD access, but such laws don’t commonly mention MOUD and thus were not included in our searches. Importantly, our analysis focused on laws that we consider relevant to MOUD expansion, but we cannot be certain that the laws were intended to expand MOUD access. Nor did we examine whether the laws were implemented or enforced, whether the policies impacted MOUD utilization, or effects on health outcomes, such as hospitalizations for OUD, all of which are important areas for future research. Also, while the states in our sample had similar geographic, legislative partisan affiliation, and opioid-overdose rate characteristics to those nationally, we did not collect policies from all U.S. states.

5. Conclusion

State policies are tools that can shape the delivery of opioid use disorder treatment, and by extension, the health experiences and outcomes of patients. We identified several frontiers on which states are changing laws in ways that could potentially translate to better access to care. For example, several states now have laws to ensure that MOUD is more widely available in general medical care settings and regulations that make it the standard of care in specialty treatment (e.g., state licensure laws). The creativity pursued by states in using these tools is notable. Also notable is that the laws are dispersed across all regions of the US and exist in states that typically belong to both sides of the political spectrum. However, the relative recency of most of these laws makes it unclear what their ultimate impact might be, and how widely they will diffuse. Passing innovative laws is a first step in a larger process of change that also requires evaluation and monitoring, aggressive enforcement of new requirements, and resources to ensure that services are adequately covered. The staying power of these policies will ultimately require substantial attention from policymakers and advocates, which will determine whether they live up to their lifesaving potential.