Modernizing addiction regulations: How licensing, telehealth, and delivery reform can expand access to care

More than 80,000 Americans died from drug overdoses in 2024. While this represents a 26 percent decline from the previous year, the crisis is far from over. Many of those lives could have been saved by proven therapies, like medication for opioid use disorder (MOUD), a treatment that combines counseling with lifesaving opioid replacement medication. MOUD is one of the most effective tools we have to reduce the risk of overdose, according to the evidence. Yet, access is still constrained by scope-of-practice and supervision laws that dictate which medications clinicians can prescribe and in which settings they may do so. 

These rules are often shaped by professional and regulatory organizations like the American Medical Association, whose influence on state and medical boards, as well as legislatures, affects who is authorized to prescribe and manage MOUD care. While rural areas frequently lack clinicians due to lower population densities, these restrictions make existing shortages worse by preventing qualified providers from offering care where it is most needed. 

Beyond these restrictions, outdated regulations on how and where patients can receive care, such as limits on telehealth and medication delivery, further compound access barriers. Reducing these unnecessarily restrictive occupational licensing and delivery barriers is a practical and evidence-based way to close these gaps and expand access to lifesaving care.

Nurse practitioners (NPs) are already a significant part of the solution. In 2016, Congress passed a law enabling some NPs to prescribe buprenorphine, one of three approved medications for opioid use disorder. However, in 22 states, NPs are not permitted to do so without a supervising physician. This limitation reduces access to MOUD, especially in areas where doctors are in short supply. In states that grant NPs autonomy in prescribing, the number of available MOUD prescribers roughly doubles and significantly increases local treatment access. A national analysis shows that expanding prescribing to NPs had a particularly significant impact in very rural areas, where NPs and physician assistants were responsible for 1.3 times more buprenorphine prescriptions than in urban areas. 

Additionally, the study found that areas where NPs were allowed to prescribe had roughly twice as many registered NPs compared to regions where NPs are barred from prescribing. This may be due in part to the fact that the lack of prescribing authority makes NPs seem less valuable to employers, who then instead opt for physicians. Because NPs are more likely than physicians to relocate to rural communities and to remain there long term, granting them prescribing power would be a meaningful step toward closing treatment gaps where they are most severe.

Pharmacists undergo the most extensive training in pharmacology of any healthcare professional. Idaho has successfully authorized pharmacists to prescribe medications for a range of conditions. Through House Bill 191, which passed in March of 2017, the state granted the Idaho Board of Pharmacy the authority to determine when pharmacists can prescribe medications independently using clinical judgment consistent with the standard practices of healthcare providers. This applied to minor or time-sensitive conditions that did not require a new diagnosis. Within the first year, pharmacists were able to treat over 20 common ailments, and the state reported no safety complaints, showing that pharmacist-led prescribing can safely expand access to care in underserved areas. 

At the national level, the 2021 Mainstreaming Addiction Treatment Act (MAT Act) eliminated the requirement for clinicians to register for and receive a waiver from the Drug Enforcement Administration (DEA) to prescribe buprenorphine for opioid use disorder. Any clinician who can prescribe DEA Schedule III drugs, such as buprenorphine, may now prescribe them in states that recognize pharmacists as prescribers. Within the first year of implementation, pharmacist-issued prescriptions increased eightfold, rising from about 0.1 percent to 0.8 percent of all buprenorphine dispensations nationwide. The increase was most pronounced in states that had already authorized pharmacist prescribers, such as Idaho, New Mexico, and Rhode Island. Still, 90 percent of states continue to restrict pharmacists from prescribing buprenorphine independently. Where pharmacists can prescribe independently, they primarily serve rural and medically underserved areas, increasing the number of filled buprenorphine prescriptions by 5 to 10 percent in counties that previously had no such prescribers. 

The Department of Veterans Affairs (VA) offers a clear example of how pharmacist prescribers can operate successfully as part of a coordinated healthcare team. Veterans experience disproportionately high rates of chronic pain and opioid dependence. Overdose deaths among veterans increased by more than 50 percent between 2010 and 2019, and as many as one in three service members prescribed opioids during active duty met the criteria for dependence. 

Building on the flexibility established under the MAT Act, the VA authorizes clinical pharmacist practitioners (CPPs) to initiate and manage buprenorphine treatment for opioid use disorder under collaborative practice agreements. In 2023, the first full year after the MAT Act’s passage, 110 CPPs prescribed buprenorphine to 1,090 veterans across 36 states, accounting for 4.8 percent of all veterans receiving buprenorphine in the VA system and 4.2 percent of total treatment episodes. Collectively, CPPs issued more than 5,200 prescriptions, over half delivered through telehealth, and served as the sole prescriber in 16 percent of cases. 

International approaches provide additional examples, with Canada, Australia, and the United Kingdom integrating pharmacists into the MOUD treatment infrastructure. 

Psychologists often serve as the first and most consistent point of contact for patients with addiction due to their role in addressing underlying mental or emotional health issues, and could serve as an important access point to medication for addiction treatment. The U.S. Department of Defense (DoD) demonstrated as early as 1991 that psychologists can be trained to safely prescribe medications. An independent review of the program found that the prescribing psychologists trained by DoD filled critical gaps in care, reduced patient wait times for treatment,  and safely managed medications with no reported adverse events linked to their prescribing. 

Today, just seven states allow psychologists with specialized training to prescribe medication. However, most of these states still prohibit them from prescribing the controlled substances that form the foundation of medication-assisted addiction therapy. In Illinois, for example, psychologists are barred from prescribing Schedule II drugs, including methadone—one of three FDA-approved drugs that serve as the foundation of medication-assisted addiction treatment. Granting psychologists this authority could create a crucial new pathway to treatment, especially for individuals managing co-occurring mental health and substance use challenges. 

These profession-specific reforms are a practical and low-cost way to expand access to treatment and care, but they are not the whole answer. These reforms must be paired with broader changes necessary to update America’s health delivery system. America needs to maintain telehealth access for addiction treatment and remove outdated licensing and delivery barriers that restrict how and where patients can receive care.

One of the most entrenched obstacles in expanding access to addiction treatment is the federal system governing methadone delivery. The current system, designed in the 1970s and changed little since, stipulates by law that methadone for opioid use disorder can only be dispensed through opioid treatment programs (OTPs) certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the DEA. OTP clinics operate under strict requirements, including daily observed dosing for new patients, regular drug testing, and frequent in-person counseling. 

Though intended to boost safety, these requirements often have the opposite effect by limiting the number of clinics patients can access. Clinics are concentrated in urban centers, forcing rural patients to travel daily, sometimes hours away for a single dose of medication—an impossible burden for many in rural areas. In many states, methadone access is severely limited—Wyoming has no opioid treatment programs at all, while West Virginia prohibits new clinics from opening, leaving some patients to cross state lines or travel hours each day to receive care.

During the COVID-19 pandemic, the United States implemented emergency waivers that allowed patients to take home several days’ worth of methadone instead of reporting daily to a clinic in person. The change proved safe and effective, improving patient retention without sacrificing safety outcomes or diverting the medication into the illicit market. 

These changes proved effective enough that SAMHSA made the COVID-19 flexibilities permanent. In its 2024 final rule, SAMHSA authorized prescribing up to 28 days of take-home methadone doses for stable patients and 14 days for less stable patients. It also permitted first-time prescribing of buprenorphine via telehealth, as well as expanded authorization for mobile medication units—mobile components of OTPs that can dispense medications at remote locations—to operate without requiring separate DEA registrations, improving access to care in rural and underserved communities.

Telehealth reform offers another opportunity to greatly increase access to care. Before COVID-19, clinicians were required to see patients in person before prescribing buprenorphine. The DEA temporarily waived this rule in March 2020, allowing treatment to begin through telehealth, including audio-only visits. A 2025 JAMA Network Open study analyzing more than 228,000 buprenorphine initiations from 2020 to 2022 found that about 10 percent occurred via telehealth, and roughly 20 percent of those would not have been possible under the DEA’s proposed post-pandemic rule requiring an in-person visit before or within 30 days of tele-initiation. Patients treated through telehealth had similar or better engagement and lower overdose rates than those treated in person, echoing earlier findings from JAMA Network Open and the Journal of General Internal Medicine. Telehealth tools have enabled clinicians to reach patients in rural communities, single parents unable to travel, and others who otherwise would have gone untreated.

The potential for telehealth to expand access to care, however, greatly depends on clinicians’ ability to practice across state lines. During the COVID-19 pandemic, many states temporarily permitted cross-state practice, allowing out-of-state healthcare providers in good standing elsewhere to deliver telehealth services when in-person visits were not possible. Those emergency measures demonstrate that interstate care can be safe and effective. Many states are making this flexibility permanent with universal recognition laws.” These laws permit licensed health professionals in good standing from other states to begin practicing immediately, whether they relocate to the state or provide care remotely. Twenty-eight states and Puerto Rico have already implemented such reforms. 

Research from the National Bureau of Economic Research shows that universal recognition improves physician distribution and increases access, particularly in underserved regions. Allowing addiction psychiatrists in Boston to treat patients in Nebraska or West Virginia without redundant licensing barriers could immediately relieve provider shortages in high-need areas.

These reforms form a coherent strategy for expanding access to evidence-based addiction care. Modernizing rules on methadone delivery, protecting access to telehealth, and enabling licensed healthcare providers to care for patients across state lines would allow trained clinicians, including pharmacists, psychologists, nurse practitioners, and physician assistants, to put their skills to work to treat opioid use disorder.

The path forward includes:

Leveraging underused professionals: Empower pharmacists, psychologists, and advanced practitioners to prescribe within their training, building on successful state and federal models such as Idaho’s pharmacist framework and the VA’s clinical pharmacist program, which achieved 87 percent retention among veterans treated for opioid use disorder.

Modernizing methadone delivery: Authorize office-based prescribing and pharmacy dispensing for stable patients under appropriate monitoring, following models proven in France, the U.K., and Canada.

Making telehealth permanent: Codify pandemic-era flexibilities for initiating buprenorphine virtually and reimburse telehealth visits for addiction care at parity with in-person treatment.

Promoting license portability: Expand universal recognition laws to allow qualified clinicians to serve patients across state lines without redundant requirements.

The opioid crisis is not a single-issue problem, and it cannot be solved by one profession alone. But we can drastically reduce the toll on individuals, families, and communities. By embracing practical, evidence-based reforms, we can strengthen the national response to the opioid epidemic. When more qualified people are empowered to provide care, more people survive.

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Source: https://reason.org/commentary/modernizing-addiction-regulations-how-licensing-telehealth-and-delivery-reform-can-expand-access-to-care/