Cover: Facilitated Access to Medication for Medications for Opioid Use Disorder (MOUD) Requirements

Facilitated Access to Medication for Medications for Opioid Use Disorder (MOUD) Requirements

Published Dec 20, 2023

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Research Brief

Mandate that all substance use disorder (SUD) treatment programs in the state facilitate access to medication for opioid use disorder (MOUD) through (1) direct provision of the medication, (2) contracting with private prescribing professionals, or (3) linkage agreements with other office-certified programs. Agreements must ensure access sufficient to meet patient needs without undue barriers.

A panel of experts rated how they expect this type of policy to affect four outcomes: opioid use disorder (OUD) treatment engagement, OUD treatment retention, OUD remission, and opioid overdose mortality. Another panel of experts rated the policy on four implemntation criteria: acceptability to the public, feasibility of implementation, affordability from a societal perspective, and equitability in health effects.

Policy Recommendations According to Expert Ratings

Oppose Uncertain Support
No
No
Yes

Summary of Expert Ratings

Outcomes Effect Rating
Harmful Little-to-no Beneficial
OUD Treatment Engagement
No
No
Yes
OUD Treatment Retention
No
No
Yes
OUD Remission
No
Yes
No
Opioid Overdose Mortality
No
No
Yes
Criteria Implementation Rating
Low Moderate High
Acceptability
No
No
Yes
Feasibility
No
No
Yes
Affordability
No
No
Yes
Equitability
No
No
Yes

Summary of Expert Comments

  • Experts expect increased access to evidence-based MOUD would meaningfully increase OUD treatment engagement and retention and decrease opioid overdose mortality.
  • Experts believe that the public increasingly supports policies that facilitate access to MOUD.
  • Experts agree that the policy is feasible given trends of increasing prescriber availability.
  • Experts believe that using state funds on evidence-based treatment is cost-effective for society.
  • While experts emphasized that the equitability of policies depend on their implementation, the policy could equitably expand access to evidence-based MOUD, especially if implemented universally and with explicit focus on communities excluded from high-quality OUD treatment.

Outcome Summaries

OUD Treatment Engagement

Percentage of people meeting the criteria for an OUD diagnosis who receive two or more OUD treatment services (including medication for OUD) within 34 days of initiating treatment.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
Mandated access to MOUD increases engagement. Reduces stigmatization of MOUD. Patients more likely to engage knowing they will receive evidence-based MOUD. “This would seem to have a huge impact as essentially it creates a 'no wrong door' approach to care. It would likely increase MOUD access to a large degree because there would be more agencies that offer MOUD and better networks of providers”
Little-to-no Policy targets people already in treatment. “Not sure engagement is impacted as this isn't targeting folks in treatment”
Harmful N/A N/A

OUD Treatment Retention

Percentage of people meeting the criteria for an OUD diagnosis who remain continuously enrolled in OUD treatment services for at least six months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
Easier continual access to MOUD will improve symptoms, increasing retention. More providers who provide MOUD and are linked to others in SUD treatment network. “Clients engaged in the treatment system but did not have access to MOUD may initiate MOUD due to this policy. MOUD may prompt patients to stay in treatment longer if the MOUD improves their symptoms”
Little-to-no N/A N/A
Harmful N/A N/A

OUD Remission

Percentage of people meeting the criteria for an OUD diagnosis who do not experience OUD symptoms (other than craving/desire/urge for opioid) for at least 12 months.

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial Easier continual access to MOUD will improve remission. More providers who provide MOUD and are linked to others in SUD treatment network. “Having the actual ability to access [medication-assisted treatment] will certainly result in an increase in the percentage of people experiencing remission. In so many places, the vast majority of people still can't access evidence-based treatment, and this would go a long way to changing that”
Little-to-no
(selected)
Treatment dropout would be high regardless, and other factors will influence remission over 12 months. “The policy provides access but does not address quality of care. Remission has a lot to do with care quality by ensuring the patient receives the needed social services and medication dose”
Harmful N/A N/A

Opioid Overdose Mortality

Per capita rates of fatal overdose related to opioids, including opioid analgesics (e.g., oxycodone), illegal opioids (e.g., heroin), and synthetic opioids (e.g., fentanyl).

Effect Rating Summary of Expert Opinion Representative Quotations
Beneficial
(selected)
Increased access to MOUD, especially among those who historically lack access to OUD treatment. Increased facilitation and coordination of care. “Increasing access to MOUD is the number one thing that would decrease overdose rates”
Little-to-no Other factors are involved in mortality rates. “I am a little skeptical that this incentive alone will budge mortality rates very much. Possibly modest effects, at best, is what I would expect. There are so many factors that affect mortality and I'm just not sold this incentive will impact them”
Harmful N/A N/A

Implementation Criteria Summaries

Acceptability

The extent to which the policy is acceptable to the general public in the state or community where the policy has been enacted.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Increasing public support of MOUD as an effective tool in the overdose epidemic. “I think that overall the general public wants access to treatment, they would expect that treatment providers can offer the range of options”
Moderate Public is more aware of abstinence-based approaches. Resistance to MOUD and stigmatization of MOUD as enabling drug use may serve as barriers to acceptability. Such barriers could be counteracted with education and evidence-based health communication approaches. “We have strong-voiced physicians who support evidence-based care, and we have politically well-connected legacy 'treatment' providers who 'don't believe in medication,' except Vivitrol. They are pushing back against evidence-based requirements. The general public is ignorant of the science, but could be won over with a campaign on 'give people access to the stuff that works and stop wasting money' approach”
Low Less acceptance among those who support abstinence-only approaches and oppose MOUD. “There is a large community of persons in recovery that participate successfully in abstinence programs”

Feasibility

The extent to which it is feasible for a state or community to implement the policy as intended.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Growth in mechanisms to increase prescriber availability (waivers, telemedicine). Already required by some entities. Oversight related to standards and accreditation would be a light lift for states. Private sector could be leveraged. “Ensuring prescriber availability is much more feasible than prescribing itself. Waiver training isn't a huge barrier in terms of time/cost, and research shows that most waivered providers don't prescribe anywhere near the patient limits (if at all). Additionally, the rise of telemedicine availability/access should also reduce barriers to contracting/partnering when needed”
Moderate Depends on availability of providers, treatment, and resources (which currently vary across states and counties). Monitoring and enforcement would be complex. Resistance from abstinence-oriented programs and lack of insurance coverage and billing experience. “Depends on current resources of treatment facilities and the broader health system to meet the requirements of the mandate. In some areas linkage or contracting with private clinicians will be more challenging”
Low Many agencies and individual providers in addiction treatment system currently are not capable of implementing the programs and practices involved. Too many systemic barriers to implement as intended. “The state/community agencies often lack the know how to implement these programs and practices properly. So there needs to be effective training for this to be feasible”

Affordability

The extent to which the resources (costs) required to implement the policy are affordable from a societal perspective.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Cost-effective for society (reduced mortality, increased productivity, decreased hospitalizations) by using state funds on evidence-based treatment. “The financial savings from a societal perspective are massive. Medications for OUD do more to reduce the mortality and morbidity from OUD than any other single intervention”
Moderate Expensive (depending on baseline resources) but worth the resources required. Start up and maintenance costs for community providers. Non-negligible costs for systems coordination and professional education. “Could be expensive depending on current baseline resources and SUD and health system footprint in the community”
Low Large resource requirements due to staff salary and reimbursement. Transportation costs in areas with few places to receive MOUD. “This could be very expensive in communities where there is no methadone and there is a need for transportation to get to it”

Equitability

The extent to which the policy is equitable in its impact on health outcomes across populations of people who use opioids.

Implementation Rating Summary of Expert Opinion Representative Quotations
High
(selected)
Equitable expansion of access to evidence-based MOUD, especially when implemented universally and with explicit focus on communities excluded from high-quality OUD treatment. “It seems that this would make MOUD accessible to all segments of the population”
Moderate Depends on implementation in methadone clinics (which can be paternalistic), whether it would increase access only for those who already are well-resourced, and availability of MOUD and high-quality providers. “All depends on how it is implemented across different treatment programs. Could help or harm equitable access to MOUD
Low Does not involve intentional focus on equitable access. Does not allow patient beliefs to be incorporated into treatment plans. “You are doing nothing to promote equity. Equity is not just something that drops from the sky. Are you facilitating equitable access to a full continuum of community based culturally and linguistically effective service? I do not see that”

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