While opioid addiction and other substance use disorders are often thought of as medical issues, legislation passed in Washington, sometimes decades ago, can have a huge impact on your treatment experience.
1. Controlled Substances Act of 1970
Before the CSA, the federal government had several laws regulating controlled substances. When it was signed by President Richard Nixon in 1970, all federal regulations were pooled into five “schedules”:
Schedule I is for substances with a high potential for abuse and no accepted medical use. They are also not considered safe. Schedule I controlled substances include marijuana*, heroin, LSD, ecstasy, and bath salts.
*Marijuana is still Schedule I even though it is fully legal under state law in ten states and D.C.
Schedule II is for substances with a high potential for abuse but do have accepted medical uses. Abuse of these substances can lead to serious physical and mental health problems. These controlled substances include prescription stimulants (e.g. Adderall and Ritalin) and most prescription opioids (e.g. Oxycontin and Norco).
Schedule III is for substances that have less addiction potential than those in Schedule I and II. They have accepted medical uses but abuse can lead to moderate physical health problems and severe mental health problems. Schedule III controlled substances include testosterone and estrogen replacements, medicines with codeine and buprenorphine (e.g. Suboxone and Sublocade).
Schedule IV is for substances that have accepted medical uses and a lower potential for abuse as compared to Schedule III. They include Xanax, Ambien, and Valium.
Schedule V is for substances that have less abuse potential than any other schedule. Most drugs occupy this schedule.
The CSA is enforced by the US Drug Enforcement Agency (DEA) which was established by a separate act in 1973. You can read more about the CSA here and find out which drugs are in which schedule here.
2. Narcotic Addiction Treatment Act of 1974
This bill amends the CSA to legalize the use of methadone (a Schedule II controlled substance) to treat opioid use disorder. It established the system where methadone for addiction treatment must be dispensed in clinics, called opioid treatment programs (OTPs), that are registered with the DEA, the federal Substance Abuse and Mental Health Administration (SAMSHA), and their state’s methadone agency. Before the Narcotic Addiction Treatment Act, the Hatch Narcotics Tax Act of 1912 (yeah, it’s OLD) prevented clinicians from prescribing opioids to those with an addiction. You can read more about this law here.
3. Drug Addiction Treatment Act of 2000
Note: The DATA Waiver was eliminated in 2023, but this law is important to know about. Before the 1990s, methadone was the only FDA-approved drug for medication-assisted treatment. That was until buprenorphine (Suboxone, Zubsolv, Sublocaid) entered the scene. Before buprenorphine was approved for MAT in 2002, Congress passed the Drug Addiction Treatment Act of 2000 (DATA 2000) which would allow physicians to treat opioid addiction with opioids that are Schedule III-V (buprenorphine is Schedule III) in settings outside of OTPs provided they get a waiver from the DEA. In order to obtain the waiver, a physician had to take a course, often online, on opioid addiction treatment. DATA 2000 also established a cap on how many patients a clinician can have on buprenorphine depending on their qualifications and year as a waivered provider. You can read more about DATA 2000 here.
4. Ryan Haight Online Pharmacy Consumer Protection Act of 2008
The Ryan Haight Act is named after an eighteen-year-old who overdosed on Vicodin that he bought at an online pharmacy. The bill is complex but the main concern for those seeking treatment for opioid addiction through telehealth. Under the Ryan Haight Act, a clinician cannot prescribe a controlled substance, including buprenorphine, without first seeing that patient in-person. There are other regulations on whether or not another physician can prescribe controlled substances if their original prescribing physician (who saw them in-person) is unavailable. You can watch a video about the Ryan Haight Act here.
5. Comprehensive Addiction and Recovery Act of 2016
CARA was the first addiction-related bill to be passed in Washington in 40 years. The bill, which was signed into law by President Barack Obama, allocated $181 million federal dollars for fighting the current drug overdose epidemic. CARA focused on investing in prevention and expanding access to treatment, especially evidence-based treatment. While the $181 million has been allocated, it is up to Congress to determine when and where the money goes. One of the first use of CARA funds was by SAMSHA, which gave out $2.6 million in grants to community organizations to build addiction recovery networks across the country. SAMSHA also awarded $9.8 million in grants to pilot state programs to help new and expecting mothers deal with opioid and other substance use disorders. In addition to increased funding, CARA temporarily authorized nurse practitioners and physician assistants to prescribe buprenorphine once they go through a waiver process. You can read more about CARA here.
6. SUPPORT for Patients and Communities Act of 2018
This newest opioid bill, signed by President Donald Trump last year, aims to increase access to evidence-based treatment for opioid addiction, including MAT with buprenorphine or methadone, and follow-up care for vulnerable populations such as pregnant women and people in rule areas. The bill does not do much to change the overall strategy of the federal government when it comes to the opioid crisis. The SUPPORT Act further loosens the restrictions on buprenorphine providers by making CARA’s temporary authorization for NPs and PAs permanent, temporarily authorizing other nurses with advanced training to prescribe buprenorphine, and increasing the number of patients a waivered clinician is allowed to take on. You can read more about the SUPPORT Act here.
What’s next?
There is movement in Washington to amend the Ryan Haight Act to make it easier for telehealth providers to prescribe MAT. Senator Elizabeth Warren of Massachusetts and Congressman Elijah Cummings of Maryland have introduced the Comprehensive Addiction Resources Emergency (CARE) Act which is modeled after the Ryan White Act which has been instrumental to slowing the HIV/AIDS epidemic in the United States. The CARE Act would provide $100 billion dollars to states and communities over ten years to address the drug overdose epidemic.