Improved Opioid Treatment Programs Would Expand Access to Quality Care


Editor’s notice: This temporary was up to date on March 24, 2022, to mirror the share of patients with opioid use disorder who had acquired medication for the situation in 2020. 

Overview

Drug overdose deaths have skyrocketed in the course of the COVID-19 pandemic. In accordance to provisional knowledge, there have been greater than 100,000 fatalities in the 12-month interval ending June 2021—a 20.6% enhance over the earlier 12 months.1

To handle this crisis, states ought to broaden their treatment choices and take away pointless rules in order that extra people can entry lifesaving treatment for opioid use disorder (OUD). Though medication is probably the most effective treatment for OUD, solely a fraction of the people who want medication receive it: In 2020, simply 11% of the two.7 million people with OUD in the U.S. acquired medication for opioid use disorder (MOUD).2

A lot consideration has been given to increasing treatment utilizing buprenorphine, one of the three FDA-approved drugs for OUD, in primary care and different settings.3 However much less has been paid to opioid treatment programs (OTPs)—the one services the place all kinds of MOUD will be supplied, and the one care setting the place methadone is on the market.

Methadone was first permitted for the treatment of OUD in the Seventies and for a long time was the one FDA-approved medication to deal with OUD.4 Analysis performed in the years since its approval has bolstered methadone’s security and effectiveness in decreasing overdose deaths, illicit opioid use, and the transmission of infectious diseases equivalent to hepatitis C and HIV—whereas enhancing retention in care in contrast with treatment with out medication.5

Opioid treatment programs have been traditionally stigmatized and siloed from the remainder of the health care system, regardless of offering effective treatment.6 They had been initially licensed by federal rules in the Seventies in the course of the Nixon administration’s “battle on drugs,” with the primary objective of decreasing crime in Black communities, together with the use of unlawful drugs and behaviors thought to be brought on by drug use.7 Sadly, these rules, based mostly on treatment programs serving predominantly Black purchasers, nonetheless embrace punitive guidelines that mirror a mistrust of patients—equivalent to noticed every day dosing, common urine drug screens, and limits on entry to take- residence medication—relatively than encouraging a collaborative setting in which the provider and patient work in partnership.8

Additional, OTPs aren’t evenly distributed throughout the nation.9 Counties with extremely segregated Black and Hispanic/ Latino communities have extra OTPs per capita than different counties, whereas predominantly White communities have extra buprenorphine providers than communities which are predominantly Black or Hispanic/Latino.10 The result’s that communities of colour are disproportionately subjected to stringent treatment necessities, equivalent to having to come in individual to receive methadone doses—guidelines that may negatively have an effect on the lives of OTP patients by requiring every day journey over lengthy distances or journeys to a clinic throughout occasions which will battle with work schedules and little one care duties.11 As a result of methadone is often administered as a liquid, these guidelines are sometimes referred to as “liquid handcuffs.”12

Though the federal authorities units minimal fundamental requirements for regulating OTPs, states have the discretion to set up extra insurance policies. In accordance to the American Society of Habit Medication, these extra state guidelines typically aren’t evidence-based13—which means that even when people with OUD can entry an OTP, they could have markedly totally different experiences in getting the medication they want or the associated providers they require, relying on the place they entry care. These variations throughout states can exacerbate racial disparities in treatment entry and retention.

So as to promote high-quality, effective, and equitable addiction care, state officers ought to implement insurance policies that be sure that OTPs are accessible, patient-centered, and built-in with medical and mental health care, and that they provide providers tailor-made to their patient populations.

OTPs needs to be accessible to all patients in want

Sufferers with OUD ought to have entry to the medication that works greatest for them as quickly as they’re prepared to have interaction in treatment. For some, this implies having a close-by OTP in order that they’ll receive methadone. But, in many states, significantly in their rural areas, these providers are out of attain.14 For instance, Wyoming has no OTPs, so people should go to one other state to receive methadone.15

In different instances, entry is hindered by state rules that prevent or discourage new OTPs, equivalent to prohibiting OTPs near faculties, requiring new OTPs to acquire a certificates of want (a authorized doc demonstrating public want for new facility providers), or requiring licensure by the state board of pharmacy, a level of oversight not required by the federal authorities.16 West Virginia regulation even prohibits new clinics from opening at all.17

The flip facet is represented by Indiana, which has set an instance that states with restrictions that discourage new OTPs ought to observe: After lifting its moratorium on new OTPs in 2015, the Hoosier state is now actively working to open new websites in order that nobody is greater than an hour’s drive from a facility.18

As well as to opening new websites, OTPs can prolong their attain by establishing medication models that may provide dosing and urine screens, however not drug counseling.19 These websites could make treatment extra handy for patients who receive dosing every day or a number of occasions every week by offering medication in extra locations. States can help OTPs open these websites by making a regulatory pathway to accomplish that. For instance, Ohio rules enable medication models in homeless shelters, jails, prisons, native boards of public health, community health centers, residential treatment providers, small counties, and counties in Appalachia.20

Cellular methadone is one other manner to provide dosing shut to the place people live or in websites the place they in any other case couldn’t entry it. For instance, in Atlantic Metropolis, New Jersey, a mobile methadone treatment unit provides care to people in the Atlantic County jail.21

Till lately, federal guidelines didn’t allow the institution of any new mobile methadone models. Nonetheless, the Drug Enforcement Administration in 2021 established new guidelines that may enable OTPs to add mobile providers for the primary time since 2007.22 To help providers ship this care the place wanted, states ought to revise any rules which will function limitations to the institution and use of mobile models, be sure that Medicaid will reimburse for mobile treatment, and provide financial sources to cover startup costs of mobile models.23

Some people additionally face financial limitations to accessing OTP providers. Medicaid is the biggest insurer for people with substance use disorders, with federal regulation requiring states to cover methadone and different drugs for OUD via September 2025, until the state certifies to the U.S. secretary of Health and Human Providers that doing so is just not possible as a result of of provider or facility shortages. Nonetheless, two states—Mississippi and South Dakota—haven’t any OTPs that settle for Medicaid.24 States ought to cover methadone in their Medicaid programs with out exception, and OTPs ought to settle for this cost in order that people with OUD wouldn’t have to select between paying for essential care and paying for different wants equivalent to housing and transportation.

As soon as methadone is roofed, policymakers can act to enhance OTP participation in Medicaid by making certain that reimbursement rates are sufficient—or even requiring services to settle for Medicaid as a situation of licensure, as Massachusetts has carried out.25

OTPs ought to provide patient-centered care

Individuals with OUD fluctuate in their objectives, how their physique responds to medication, and what they want from treatment providers. However too typically, OTP care takes a one-size-fits-all approach that gives a single medication at a dose too low to scale back opioid cravings, an assumed objective of abstinence from all illicit substances, and strict treatment guidelines that create excessive limitations to care by punishing noncompliance with discharge from care or requiring extra visits to the clinic to receive medication.26

As an alternative, OTPs ought to provide care that’s guided by a patient’s wants and preferences—and based mostly on shared decision-making with the provider.27 This patient-centered care ought to prioritize:

  • A selection between all FDA-approved drugs for OUD.
  • Clinically effective doses.
  • Low-barrier, versatile treatment that doesn’t create restrictions past these stipulated by federal rules.

A selection between FDA-approved drugs

Provided that patients have various treatment wants and might reply to every medication otherwise, it is crucial that patients and providers have a selection of drugs out there at OTPs. However though practically all OTPs provide methadone, the 2 different FDA-approved drugs for OUD—buprenorphine and injectable extended-release naltrexone—are much less available. Almost a fifth of OTPs nationally didn’t provide buprenorphine in 2020, whereas simply six states provide buprenorphine at all of their services.28 As well as, solely 39.5% of OTPs provide naltrexone.29

It’s particularly essential to provide buprenorphine since analysis reveals that, like methadone, it’s effective at decreasing deadly overdoses. Some patients with OUD favor it to methadone as a result of they really feel it’s much less stigmatizing or has fewer uncomfortable side effects.30

Clinically effective doses

As with different drugs, MOUD dosage issues. If the dose is just too low, the patient is not going to expertise decreased drug cravings and decreased drug use and might drop out of treatment.31 One examine discovered that greater than 40% of methadone patients receive a dose that’s, on common, too low to be effective—an issue discovered to be extra common at programs that primarily serve Black patients.32

To handle this problem, Pennsylvania requires OTP physicians to assessment dose levels at least twice a 12 months33— offering clinicians and patients an alternative to verify in and modify the dose if essential.

Low-barrier, versatile treatment

Many states create extra restrictions on treatment past federal rules, ensuing in practices that aren’t evidence-based and make it more durable for patients to stay in treatment. To handle this drawback, states ought to study their OTP guidelines and be sure that they:

  • Prohibit OTPs from discharging patients from care for continued drug use. Some programs terminate patients for continued drug use, a follow often known as administrative discharge. Nonetheless, analysis demonstrates that continuing MOUD is safer than abruptly stopping medication.34 If a patient continues with substance use, federal tips advocate avoiding administrative discharge—and re-evaluating the treatment plan as a substitute.35
  • Require urine drug screens not more than the federally mandated eight occasions per 12 months, and don’t require noticed urine assortment. Though urine drug screenings can provide helpful clinical information about ongoing substance use, they may also be degrading, significantly when clinicians observe patients producing the pattern.36 Early knowledge from a Bronx OTP that suspended urine drug screenings as a result of of the COVID-19 pandemic additionally means that, opposite to a broadly held perception, these checks aren’t essential for patient security. In a month and a half with no urine drug screenings, not one of the OTP’s 3,600 patients had a deadly overdose.37
  • Don’t require a authorities ID to receive treatment. Making providers contingent on having a authorities ID can pose a barrier to treatment for many people who face challenges acquiring such an ID, together with undocumented immigrants, people experiencing homelessness, people lately launched from jail,

    and transgender people whose ID might not match their gender.38 OTPs can confirm their patients’ identities in different methods: For instance, OTPs in California can provide patient identification playing cards that embrace the individual’s picture, a singular identifier, and a bodily description.39

  • Require OTPs to provide counseling based mostly on a patient’s wants and needs, relatively than a set counseling schedule. Federal tips require OTPs to “provide sufficient substance abuse counseling to every patient as clinically essential.”40 The quantity of counseling wanted and desired by individual patients will fluctuate. Analysis reveals that strict counseling necessities can scale back retention in treatment and that medication with out counseling will be effective.41 States ought to enable clinicians and patients to come to a shared resolution about counseling, relatively than dictating commonplace necessities.
  • Don’t assume the objective of MOUD is to discontinue medication. There is no such thing as a scientific consensus that long-term use of MOUD is dangerous. Actually, analysis reveals that long-term treatment can lead to higher outcomes in employment, health, and legal justice involvement, whereas conversely there’s a excessive overdose threat in the interval instantly after discontinuing treatment.42
  • Don’t impose extra limitations to receiving take-home doses. Sufferers typically should journey every day to the OTP to receive their medication. Take-home doses enable patients to eat their medication at their comfort, as with some other prescription medication, with out having to go to the clinic every day—thus offering patients with extra flexibility in balancing work, education, and little one care wants.

    Federal take-home guidelines embrace limits on the quantity of take-home doses a patient might receive based mostly on their time in treatment, with only a single take-home dose per week permitted throughout a patient’s first 90 days of treatment in the event that they meet particular “stability” standards equivalent to not utilizing different substances or lacking OTP appointments.43 Some states prohibit clinics from offering even this restricted autonomy in the primary months of treatment.44

    However the federal authorities eased these necessities in the course of the COVID-19 pandemic to enable people to proceed treatment at a time of social distancing, and early analysis reveals that methadone diversion throughout this era has been minimal.45 Nonetheless, not all OTPs took benefit of these relaxed guidelines.46 To the extent permissible underneath federal regulation, states ought to enact these flexibilities, encourage their providers to provide them to patients, and take away all state-level regulatory limitations to receiving take-home doses, together with these requiring patients to meet a definition of “stability” past what’s in federal guidelines and these triggering automated loss of take-home privileges as a result of of a optimistic drug display.

  • Permit patients flexibility as to when and the place they receive their medication. This consists of requiring OTPs to be open on weekends and exterior of common enterprise hours and creating guidelines round “visitor dosing”—which permits patients to receive methadone from one other OTP and proceed to receive medication once they journey.

OTPs ought to provide built-in medical and mental health care

Individuals with OUD typically produce other health issues. One examine discovered that, after “drug overdose and disorder,” the main causes of dying amongst people with OUD served by a big health system included heart problems, most cancers, and infectious illness.47 Sufferers want built-in care to tackle these health issues, but OTPs are not often bodily built-in with or positioned near primary care providers. Though virtually 2 in 3 community health centers now provide medication for OUD, solely 7% of them are licensed as OTPs to provide methadone.48

The COVID-19 pandemic has made built-in care extra urgent than ever. Sufferers with OUD and different substance use disorders are extra prone to COVID-19 than these with out, in half as a result of of excessive rates of different health conditions,49 and additionally they face a higher threat of hospitalization and dying than these with out substance use disorder. The danger of hospitalization and dying is even greater for Black COVID-19 patients with substance use disorder than for White COVID-19 patients with substance use disorder.50

OTPs also needs to provide mental health providers on-site or work carefully with mental health providers. From 2015 to 2017, 1 in 4 adults with OUD had, in the previous 12 months, a co-occurring severe mental health disorder—outlined as a situation ensuing in “severe useful impairment considerably interfering with or limiting one or extra main life actions.”51 But fewer than half of OTPs (46%) in the U.S. supplied mental health providers in 2020 for their patients, and 26 states failed to provide mental health providers at greater than half of their OTPs in 2020.

To provide whole-person care, states and OTPs have a variety of choices. They will:

  • Set up totally built-in websites that provide each primary care and OTP providers. For instance, VIP Group Providers in the Bronx is each an OTP and a Federally Certified Health Heart (FQHC),52 which is a type of provider that receives federal funds to provide primary care providers in underserved areas. These providers typically provide mental health providers as nicely.
  • Place medication models in websites that supply primary care or behavioral health providers. For instance, Ohio’s medication unit rules particularly cite FQHCs as allowed locations; in Iowa, UCS Healthcare has partnered with non-OTP substance use treatment services to open medication models on-site.53
  • Develop team-based care cost fashions in OTPs to incentivize built-in providers with out requiring services to have extra on-site providers. A technique to do that is via a Medicaid health residence, which permits states to reimburse providers for care coordination and health promotion providers for Medicaid enrollees with advanced health care wants, together with these with an OUD.54 Maine, Maryland, Michigan, Rhode Island, and Vermont have OTPs as health houses.55

Regardless of the pathway they select, states ought to design these built-in providers rigorously to be sure that the providers assist the objectives and needs of OTP patients, relatively than create one other one-size-fits-all system in which all patients are required to have interaction in primary care and mental health providers to receive medication for OUD. For instance, cost fashions shouldn’t incentivize providers to steer patients to providers they don’t need. That is particularly essential as a result of people who use drugs typically report having unfavourable experiences with medical providers, equivalent to being shamed for their drug use or receiving inappropriate treatment.56

To keep away from these pitfalls, state policymakers ought to have interaction patients early in the process of designing built-in providers to be sure that OTPs can provide built-in care to those that need it—and proceed to focus on offering lifesaving medication to those that don’t..

OTPs ought to provide providers tailor-made to the populations they serve

Past medication, OTPs are required by federal guidelines to provide counseling, vocational, and instructional providers.57 In planning these programs, OTPs ought to contemplate the distinctive wants of their inhabitants: Treatment environments can affect whether or not people stay in treatment, and seeing people who share an identical tradition or experiences can help construct belief and consolation, which is perfect for engagement.58 Nonetheless, as with built-in medical and mental health providers, patients shouldn’t be required to take part in these providers.

State officers ought to work with their OTPs to help them provide providers that meet the wants of a spread of patients:

  • Pregnant people. Charges of opioid misuse and OUD amongst pregnant people have risen for the reason that early 2000s, which has contributed to antagonistic maternal and neonatal outcomes.59 Though the pregnant/ postpartum inhabitants might require specialised care, the share of OTPs that had a tailor-made program for pregnant/postpartum people in 2020 different broadly from state to state—and ranged from 0% in Nebraska and South Dakota to 100% in Alaska, Idaho, Mississippi, and Montana.
  • Veterans. In accordance to a dialogue paper from the Nationwide Academy of Medication, veterans are extra seemingly than the overall inhabitants to have threat components for OUD and overdose.60 In addition they face particular treatment challenges equivalent to excessive rates of post-traumatic stress disorder.61Nonetheless, lower than 1 / 4 of OTPs nationwide provide veteran-specific providers.
  • LGBTQ purchasers. In accordance to a national survey, people who describe themselves as lesbian, homosexual, or bisexual had been extra seemingly to have misused opioids in 2019 in contrast with the overall inhabitants.62 Analysis means that specialised treatment that addresses homophobia and different issues distinctive to this inhabitants can enhance substance use treatment outcomes.63 Nonetheless, 4 states (Hawaii, Idaho, Louisiana, and South Dakota) haven’t any OTPs with LGBTQ-specific providers.
  • Adolescents. In accordance to the American Academy of Pediatrics, MOUD is acceptable for adolescents with OUD.64 These younger people additionally profit from tailor-made providers involving their households in treatment. But solely 4.7% of OTPs nationwide provide adolescent-specific programming,65 maybe at least in half as a result of federal Health and Human Providers rules prohibit OTPs from serving patients underneath 18 until they “have had two documented unsuccessful makes an attempt at short-term detoxing or drug-free [nonmedication] treatment inside a 12-month interval.”66

And though OTPs also needs to provide culturally delicate care that respects patients’ beliefs, languages, and communication wants, many don’t provide providers in languages aside from English. Though fewer people in Montana communicate a language aside from English in contrast with Nebraska, North Dakota, and South Dakota, in 2020 all Montana OTPs supplied providers in a number of languages whereas in North Dakota just one did, and in Nebraska and South Dakota none did.67

However, Massachusetts has made culturally and linguistically acceptable providers a spotlight of its substance use treatment system via ongoing provider coaching, investing in a various workforce, and serving to providers strategize on how to successfully handle their budgets whereas partaking the communities they serve.68

Conclusion

OTPs’ treatment and providers fluctuate broadly throughout the nation, and there are lots of alternatives to broaden their attain and enhance the standard of providers they provide. State policymakers ought to work to implement these adjustments to guarantee entry to high quality, patient-centered care for all of their residents.

Endnotes

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  2. Substance Abuse and Psychological Health Providers Administration, “Key Substance Use and Psychological Health Indicators in the United States: Outcomes from the 2020 Nationwide Survey on Drug Use and Health” (2021), https://www.samhsa.gov/knowledge/websites/default/information/studies/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf.
  3. The Pew Charitable Trusts, “Insurance policies Ought to Promote Access to Buprenorphine for Opioid Use Dysfunction” (2021), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/05/policies-should-promote-access-to-buprenorphine-for-opioid-use-disorder.
  4. Federal Register: 37 Fed. Reg. 26701 (Dec. 15, 1972). 37, https://www.loc.gov/merchandise/fr037242/; Substance Abuse and Psychological Health Providers Administration, “Advisory: An Introduction to Prolonged-Launch Injectable Naltrexone for the Treatment of Individuals With Opioid Dependence” (2012), https://retailer.samhsa.gov/websites/default/information/d7/priv/sma12-4682.pdf; Substance Abuse and Psychological Health Providers Administration, “Medicines for Opioid Use Dysfunction: For Healthcare and Habit Professionals, Policymakers, Sufferers, and Households” (2020), https://retailer.samhsa.gov/websites/default/information/SAMHSA_Digital_Download/PEP20-02-01-006.pdf.
  5. R.P. Mattick et al., “Buprenorphine Upkeep Versus Placebo or Methadone Upkeep for Opioid Dependence,” Cochrane Database of Systematic Critiques, no. 2 (2014), https://doi.org//10.1002/14651858.CD002207.pub4; R.P. Schwartz et al., “Opioid Agonist Therapies and Heroin Overdose Deaths in Baltimore, Maryland, 1995-2009,” American Journal of Public Health 103, no. 5 (2013): 917-22, https://www.ncbi.nlm.nih.gov/pubmed/23488511; C. Timko et al., “Retention in Remedy-Assisted Treatment for Opiate Dependence: A Systematic Assessment,” Journal of Addictive Ailments 35, no. 1 (2016): 22-35, https://pubmed.ncbi.nlm.nih.gov/26467975; J.I. Tsui et al., “Affiliation of Opioid Agonist Remedy With Decrease Incidence of Hepatitis C Virus An infection in Younger Grownup Injection Drug Customers,” JAMA Inner Medication 174, no. 12 (2014): 1974-81, https://www.ncbi.nlm.nih.gov/pubmed/25347412.
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  7. Institute of Medication Committee on Federal Regulation of Methadone Treatment, “Federal Regulation of Methadone Treatment,” in Federal Regulation of Methadone Treatment, eds. R.A. Rettig and A. Yarmolinksy (Washington, D.C.: Nationwide Academies Press, 1995), https://www.ncbi.nlm.nih.gov/books/NBK232105/; W.C. Goedel et al., “Affiliation of Racial/Ethnic Segregation With Treatment Capability for Opioid Use Dysfunction in Counties in the United States,” JAMA Network Open 3, no. 4 (2020): e203711-e11, https://doi.org/10.1001/jamanetworkopen.2020.3711; M. Raz, “Treating Habit or Lowering Crime? Methadone Upkeep and Drug Coverage Beneath the Nixon Administration,” Journal of Coverage Historical past 29, no. 1 (2017): 58-86, https://www.cambridge.org/core/journals/journal-of-policy-history/article/abs/treating-addiction-or-reducing-crime-methadone-maintenance-and-drug-policy-under-the-nixon-administration/5C7779395D4B4AC7ECAB77F5D91BA455.
  8. A. Pattani, “Syringe Exchanges Deemed ‘Life-Sustaining’ Throughout Pa. Coronavirus Shutdown, Elevating Hopes for Eventual Legalization,” The Philadelphia Inquirer, March 30, 2020, https://www.inquirer.com/information/pennsylvania/spl/pennsylvania-coronavirus-syringe-exchange-life-sustaining-legalization-20200330.html; D.C. Des Jarlais et al., “Regulating Controversial Programs for Unpopular Individuals: Methadone Upkeep and Syringe Alternate Programs,” American Journal of Public Health 85, no. 11 (1995): 1577-84, https://pubmed.ncbi.nlm.nih.gov/7485676; V.P. Dole and M.E. Nyswander, “Methadone Upkeep Treatment: A Ten-12 months Perspective,” JAMA 235, no. 19 (1976): 2117-19, https://doi.org/10.1001/jama.1976.03260450029025; D. Frank et al., “’It’s Like Liquid Handcuffs’: The Results of Take-Dwelling Dosing Insurance policies on Methadone Upkeep Treatment (MMT) Sufferers’ Lives,” Hurt Discount Journal 18, no. 1 (2021): 88-88, https://pubmed.ncbi.nlm.nih.gov/34391436; P.T. Korthuis et al., “Sufferers’ Causes for Selecting Workplace-Primarily based Buprenorphine: Desire for Affected person-Centered Care,” Journal of Habit Medication 4, no. 4 (2010): 204-10, https://pubmed.ncbi.nlm.nih.gov/21170143; J.A. Peterson et al., “Why Don’t Out-of-Treatment People Enter Methadone Treatment Programmes?,” Worldwide Journal of Drug Coverage 21, no. 1 (2010): 36-42, https://www.sciencedirect.com/science/article/pii/S0955395908001692.
  9. H. Hansen and S.Okay. Roberts, “Two Tiers of Biomedicalization: Methadone, Buprenorphine, and the Racial Politics of Habit Treatment,” in Vital Views on Habit, ed. J. Netherland (Emerald Group Publishing Restricted, 2012), https://doi.org/10.1108/S1057-6290(2012)0000014008.
  10. Goedel et al., “Affiliation of Racial/Ethnic Segregation.”
  11. Frank et al., “’It’s Like Liquid Handcuffs’”; P.J. Joudrey, E.J. Edelman, and E.A. Wang, “Drive Instances to Opioid Treatment Programs in City and Rural Counties in 5 U.S. States,” JAMA 322, no. 13 (2019): 1310-12, https://doi.org/10.1001/jama.2019.12562; H.S. Reisinger et al., “Untimely Discharge From Methadone Treatment: Affected person Views,” Journal of Psychoactive Medicine 41, no. 3 (2009): 285- 96, https://pubmed.ncbi.nlm.nih.gov/19999682/; A. Rosenblum et al., “Distance Traveled and Cross-State Commuting to Opioid Treatment Programs in the United States,” Journal of Environmental and Public Health (2011), https://www.hindawi.com/journals/jeph/2011/948789/.
  12. Frank et al., “’It’s Like Liquid Handcuffs.’”
  13. American Society of Habit Medication, “The Regulation of the Treatment of Opioid Use Dysfunction With Methadone” (2021), https://www.asam.org/advocacy/public-policy-statements/particulars/public-policy-statements/2021/11/16/the-regulation-of-the-treatment-of- opioid-use-disorder-with-methadone.
  14. Joudrey, Edelman, and Wang, “Drive Instances”; J.D. Lenardson and J.A. Gale, “Distribution of Substance Abuse Treatment Amenities Throughout the Rural-City Continuum” (Institute for Health Coverage, Muskie Faculty of Public Service, College of Southern Maine, 2007), http://muskie.usm.maine.edu/Publications/rural/wp35b.pdf.
  15. Substance Abuse and Psychological Health Providers Administration, “Nationwide Survey of Substance Abuse Treatment Providers (N-SSATS): 2019” (2020), https://wwwdasis.samhsa.gov/dasis2/nssats/NSSATS_2019/2019-NSSATS-R.pdf.
  16. J.R. Jackson et al., “Characterizing Variability in State-Stage Rules Governing Opioid Treatment Programs,” Journal of Substance Abuse Treatment 115 (2020): 108008, https://doi.org/10.1016/j.jsat.2020.108008; Substance Abuse and Psychological Health Providers Administration, “Federal Tips for Opioid Treatment Programs” (2015), https://retailer.samhsa.gov/product/Federal-Tips-for-Opioid-Treatment-Programs/PEP15-FEDGUIDEOTP. For instance rules, see Ga. Comp. R. & Regs, r. 480-18-.02; La. Rev. Stat. Ann.,§ 40:2159; Ohio Rev. Code Ann., § 5119.371.
  17. W. Va. Code § 16-5y-12.
  18. B. Connolly, “How Indiana Is Working to Enhance Access to Opioid Treatment Programs Throughout the State,” The Pew Charitable Trusts, accessed Oct. 19, 2021, https://www.pewtrusts.org/en/research-and-analysis/articles/2021/07/07/how-indiana-is-working-to-improve-access-to-opioid-treatment-programs-across-the-state. Senate Invoice 464, Indiana Common Meeting (2015), http://iga.in.gov/legislative/2015/payments/senate/464.
  19. Substance Abuse and Psychological Health Providers Administration, “Certification of Opioid Treatment Programs (OTPs),” final modified Oct. 19, 2021, https://www.samhsa.gov/medication-assisted-treatment/become-accredited-opioid-treatment-program.
  20. Ohio Administrative Code, Remedy Models, 5122-40-15 (2019), http://codes.ohio.gov/oac/5122-40-15v1.
  21. A. McBournie et al., “Methadone Limitations Persist, Regardless of A long time of Proof,” Health Affairs Weblog (weblog), Health Affairs, Sept. 23, 2019, https://www.healthaffairs.org/do/10.1377/hblog20190920.981503/full/#_ftnref1.
  22. The Pew Charitable Trusts, “Opioid Treatment Programs: A Key Treatment System Part” (2021), https://www.pewtrusts.org/en/research-and-analysis/issue-briefs/2021/07/opioid-treatment-programs-a-key-treatment-system-component.
  23. T. El-Sabawi et al., “The New Cellular Methadone Guidelines and What They Imply for Treatment Access,” Health Affairs, accessed Oct. 21, 2021, https://www.healthaffairs.org/do/10.1377/hblog20210727.942168/full/.
  24. H.R. 6—Substance Use-Dysfunction Prevention That Promotes Opioid Restoration and Treatment for Sufferers and Communities Act, 115-271, One hundred and fifteenth Congress (2018), https://www.congress.gov/invoice/One hundred and fifteenth-congress/house-bill/6/textual content#toc-HE7D6B79AFB0447CD9D2F6F189A1586 FE; S. Doyle and V. Baaklini, “Lifesaving Habit Treatment Out of Attain for Many People,” February 2022, https://www.pewtrusts.org/en/research-and-analysis/articles/2022/02/17/lifesaving-addiction-treatment-out-of-reach-for-many-americans#0-many-opioid- treatment-programs; Okay. Orgera and J. Tolbert, “The Opioid Epidemic and Medicaid’s Function in Facilitating Access to Treatment” (Kaiser Household Basis, 2019), https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/.
  25. C.M. Andrews, “The Relationship of State Medicaid Protection to Medicaid Acceptance Amongst Substance Abuse Suppliers in the United States,” The Journal of Behavioral Health Providers & Analysis 41, no. 4 (2014): 460-72, https://doi.org/10.1007/s11414-013-9387-2; Commonwealth of Massachusetts Gl Ch. 111e, § 7, https://malegislature.gov/Legal guidelines/GeneralLaws/PartI/TitleXVI/Chapter111e/Section7.
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  33. Commonwealth of Pennsylvania, 28 Pa. Code § 715.15.
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