(21) State Office-based Buprenorphine Treatment Laws: Counseling, Dosage, and Visit Frequency

Background & Introduction: In early 2023, the federal government eliminated longstanding patient limits and a federal waiver requirement for buprenorphine prescribers, representing an unprecedented opportunity for buprenorphine treatment expansion nationally. States and the District of Columbia, however, can still regulate buprenorphine prescribing above and beyond requirements set by federal law.

There have been relatively few studies describing state variation in laws regulating office-based buprenorphine treatment (OBBT), despite evidence that state laws related to buprenorphine may influence buprenorphine prescribing. Our earlier study from 2019 found that some states set counseling, visitation frequency, and dosage requirements above and beyond federal legal requirements. The state legal landscape may have changed dramatically since 2019 in response to increasing opioid overdoses. Therefore, our objective was to update earlier findings by identifying and describing laws in effect in the 50 states or the District of Columbia during 2022 that imposed counseling, dosage, and/or visit frequency requirements for OBBT.

Methods: We collected statutes and regulations from 50 US states and the District of Columbia (i.e., 51 jurisdictions) between August 11th and November 30th, 2022 using the NexisUni legal database and search terms related to OBBT counseling, dosage, and/or frequency of visits. We then used template analysis, a mixed deductive-inductive qualitative method, to code content in qualitative software. Coded data was then exported into tables and examined for trends across states. To ensure reliability in the law inclusion/exclusion process and coding process, we had three independent researchers guided by an attorney conduct searches and coding; and the independent researchers then met to compare results and negotiate any discrepancies.

Results: Ten jurisdictions (20%) in 2022 had an OBBT counseling, dosage, and/or visit frequency requirement. Five of these ten jurisdictions are among those with the highest overdose death rates per capita, according to publicly available data from 2021. We describe the results in more detail below.

Eight jurisdictions had counseling requirements for OBBT: Arkansas, Indiana, Kentucky, Maine, Ohio, Tennessee, Virginia, and West Virginia. Six jurisdictions had OBBT dosing-related laws: Alabama, Kentucky, Ohio, Tennessee, Virginia, and West Virginia. Six jurisdictions mandated a specific frequency of visits at OBBTs (e.g., weekly, biweekly, monthly): Arkansas, Florida, Kentucky, Ohio, Tennessee, and Virginia. Visit frequency requirements sometimes differed depending on whether the patient was at the induction or maintenance stage of treatment. States also varied with respect to the types of providers to which the laws applied (e.g., physicians only; nurse practitioners only) and whether the laws applied to Medicaid-funded providers only or to all providers regardless of payer.

Four jurisdictions had requirements in each of the three categories examined (i.e., counseling, dosing, visit frequency): Kentucky, Ohio, Tennessee, and Virginia.

Conclusion & Discussion: At a time of national efforts to improve opioid treatment access, we found that one-fifth of states have counseling, dosage, and/or visit frequency requirements that exceed requirements in federal law. These state policies were likely intended to enhance the quality of care but could potentially disincentivize the delivery of buprenorphine treatment or use of adequate dosages. In the absence of empirical evidence about the effects of these requirements on treatment quality and health outcomes, state policymakers should be cautious and thoughtful about the potential benefits and unintended consequences of implementing such requirements.

Concerted efforts are needed to better understand the impact of OBBT laws on quality of care and patient outcomes. For example, future research could examine associations between specific OBBT policies and jurisdiction-level rates of buprenorphine receipt and overdose.

References: Andraka-Christou B, Gordon AJ, Bouskill K, et al. Toward a Typology of Office-based Buprenorphine Treatment Laws: Themes from a Review of State Laws. J Addict Med. May 18 2021;16(2):192-207. doi:10.1097/ADM.0000000000000863

Harrison JM, Kerber R, Andraka-Christou B, Sorbero M, Stein BD. State Policies and Buprenorphine Prescribing by Nurse Practitioners and Physician Assistants. Medical Care Research and Review. 2022:10775587221086489. doi:10.1177/10775587221086489

Stein B, Saloner B, Golan O, et al. Association of selected state policies and requirements for buprenorphine treatment with per capita months of treatment. JAMA Health Forum. 2023;Accepted and in press