Counseling Co-Requirement Laws for Office-Based Buprenorphine Treatment

Research SummaryPublished Dec 21, 2023

Require patients receiving buprenorphine in an office-based setting to receive counseling. The state law does not explicitly protect against termination of buprenorphine treatment due to counseling non-adherence.

A panel of experts rated how they expect this type of policy to affect four outcomes: OUD treatment engagement, OUD treatment retention, OUD remission, and OUD overdose mortality. Another panel of experts rated the policy on four decisionmaking 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
Yes
No
No

Summary of Expert Ratings

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

Summary of Expert Comments

  • Experts expect counseling requirements to deter treatment engagement and retention for many patients, counteracting any beneficial effects of counseling for other patients. Minimal impacts on treatment engagement and retention translate to little-to-no impacts on OUD remission and overdose mortality.
  • Experts think the public generally supports this policy due to a naive understanding of and stigma around substance use disorders (SUDs); thus, counseling requirements are viewed as an appropriate way to treat SUDs.
  • Experts view this policy as moderately feasible and affordable because of issues related to limited workforce capacity, monitoring capabilities, and insurance coverage.
  • Experts believe the policy would exacerbate inequities by creating barriers to medication for opioid use disorder (MOUD) access that are likely to disproportionately impact those already facing access challenges to MOUD and counseling.

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 Counseling, when appropriately implemented and adequately reimbursed, increases treatment engagement. “Depends in part on how holistically ‘counseling’ is defined—I believe it has the potential for a modestly salutary effect appropriately implemented”
Little-to-no
(selected)
 Benefits of counseling for some may be countered by counseling requirements that act as a deterrent to treatment engagement for other patients. “Some people may be deterred from seeking treatment because they do not have time for counseling, have had bad experiences with counseling, or for other reasons do not want counseling”
Harmful Requiring counseling is a counter-productive barrier to initiating MOUD, which the evidence suggests is just as effective without counseling. “A requirement for counseling can be a counterproductive barrier to engagement in medication treatment for OUD”

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 Counseling, when appropriately implemented by qualified providers, increases treatment retention. “If counseling is delivered in an adaptive step-wise fashion as clinically indicated, by skilled providers, and if it is done in a way that it is valued by the patients, they may stay in treatment longer”
Little-to-no
(selected)
 Benefits of counseling for some may be countered by counseling requirements that act as a deterrent to treatment retention for other patients. “Counseling is great but could be a deterrent for some patients to engage and remain in treatment. The policy can also be counterproductive for retention if clients are terminated because they fail to attend counseling”
Harmful Requiring counseling could be a counterproductive barrier to staying in treatment. “The number of people who would continue OUD treatment for 6 months is lower because of this requirement and the time commitment associated with it”

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 Continuous engagement with high-quality counseling will translate into improved patient outcomes. “The individuals who remain in treatment will receive a higher level of care and learn coping mechanisms, etc. that greatly improve the likelihood that they go into remission. Many individuals who get medications but do not receive counseling still use opioids and other illicit substances, and the medication-only approach tends to be more about harm reduction rather than making substantial gains in functioning”
Little-to-no
(selected)
 Net-neutral impacts on treatment engagement and retention will lead to little-to-no impacts on patient outcomes. “A counseling requirement may discourage participation in medication treatment and perhaps have no effect on OUD remission”
Harmful Counseling co-requirements have a negative consequence of reducing the continued use of MOUDs, yielding worse outcomes on OUD remission than without the requirements. “Because of the negative impacts on engagement and retention, it would seem likely that there's a negative impact on the odds of remission”

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 Continuous engagement with high-quality counseling will translate into reductions in overdose mortality. “Contact with caring counselor would likely reduce overdose mortality risk”
Little-to-no
(selected)
 Little-to-no impacts on treatment engagement and retention will lead to little-to-no impacts on overdose mortality. “I am persuaded more that the impact on engagement and retention will be negative, but little impact overall on overdose mortality”
Harmful As a barrier to access to and continued use of MOUDs, these requirements could increase overdose mortality. “I believe withholding medication in the case of non-adherence to counseling will result in more deaths. And if a counseling requirement deters people from treatment, overdoses are much more likely”

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)
 A naive understanding of and stigma around SUDs lead the public to view counseling requirements as an appropriate approach to treating SUDs. “I think that there is a lot of anti-medication stigma and so in general, much of the public believes that people treated with MOUD should also have counseling and not 'just get a script'”
Moderate Some pushback against the burdensome requirement, though also some acceptability due to the stigma associated with substance use and its treatment. “Some might view this as important and others as unnecessary. I think it depends on underlying views of MOUD”
Low Pushback is likely against a burdensome, one-size-fits all requirement that is counter to the research evidence. “An across-the-board recommendation, for all patients, regardless of their unique circumstance, is not favorable. Additionally, if the counseling is not integrated or co-located, it may be seen as a burden by some. Lastly, medication management has been found to be a valid intervention and may be sufficient for many patients”

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 Consistent with many existing laws, regulations, and systems. “Many current laws are already consistent with this (e.g., prior authorization)”
Moderate
(selected)
 Possible though difficult to implement due to limited workforce capacity, monitoring capabilities, and insurance coverage for counseling. “Less feasible because provider practices often lack resources (e.g., social worker, counselor, other available/trained clinician) to provide this service—it is burdensome to providers”
Low Insufficient workforce capacity, monitoring capabilities, and insurance coverage for counseling to meet these requirements. “There will never be enough counsellors who are actually trained for treatment as opposed to peer support personnel which is adjunctive but not clinical treatment, to treat this population”

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 Affordable to the state, as the increased costs fall on providers and patients. “There is little cost to the state considering the clinics or the provider pays for all of this”
Moderate
(selected)
 Substantial costs related to workforce capacity, insurance coverage, and monitoring adherence. “Would require significant investment to build out SUD counseling workforce, and importantly to better train existing workforce on things like [motivational interviewing, cognitive behavioral therapy, contingency management] matrix model, etc.”
Low Concerns about significant workforce costs (i.e., having enough providers to meet the counseling requirements) and evidence that this policy would not result in beneficial outcomes. “Unclear evidence of benefit and potential for harm. Cost to state of reimbursing for counseling in state Medicaid programs or through [the Substance Abuse Prevention and Treatment] block grant funding without clear benefit”

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 N/A N/A
Moderate Depends on the quality of implementation. “It has the potential to increase access to counseling services in a group that is traditionally excluded from being able to access such services”
Low
(selected)
 Creates even more inequities by creating barriers to MOUD access that are likely to disproportionately impact those already facing difficulties with access to both MOUD and counseling. “Many [primary care] clinics don't have access to counseling and/or it is not readily available in the community. Plus, for people who don't have insurance this would be a MAJOR barrier. This would disproportionately negatively impact people in rural areas and individuals without insurance”
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Counseling Co-Requirement Laws for Office-Based Buprenorphine Treatment. Santa Monica, CA: RAND Corporation, 2023. https://www.rand.org/pubs/research_briefs/RBA3054-29.html.
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