Dear Colleague Letter on Expanding Access to Medications for Opioid Use Disorder Through Pharmacist State Scope-of- Practice Flexibility
DCL 06182026
AUTHORS:
Dr. Mehmet Oz, Administrator, Centers for Medicare & Medicaid Services
Alex J. Adams, Assistant Secretary, Administration for Children and Families
Christopher Caroll, Principal Deputy Assistant Secretary, Substance Abuse and Mental Health Services Administration
Dear Colleague:
The Administration for Children and Families (ACF), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA) and Centers for Medicare & Medicaid Services (CMS), is committed to addressing the overdose crisis and supporting the Great American Recovery Initiative in the United States. A key component of this work is supporting states in their efforts to strengthen families, prevent unnecessary foster care entry, and expand timely access to evidence-based treatment for the chronic disease of addiction to help more Americans achieve long-term recovery and self-sufficiency.
Parental substance use — particularly untreated opioid use disorder — remains one of the leading drivers of child welfare involvement nationwide. When parents and caregivers are unable to access effective treatment early, families are more likely to experience crisis, instability, and separation. In fact, it is estimated that more than 300,000 children have lost a parent to overdose in the past decade.1
Access to treatment, including medications for opioid use disorder (MOUD), remains limited in many communities, particularly in rural and remote areas. Further, workforce shortages, long travel distances, stigma, and restrictive scope-of-practice laws often serve as barriers to care or delay care at the very moment when treatment can be most effective.
Fortunately, states can take actions to address these challenges. In particular, we write to highlight the support our agencies have provided to states to promote policies that can have an immediate effect on expanding access to medication treatment, including authorizing appropriately trained and licensed pharmacists to prescribe these medications consistent with federal law and state standards of care.
Pharmacists are among the most accessible health care providers in America. In many communities, a local pharmacy is the most consistent—and sometimes the only—point of contact with the health care system. More than 95 percent of people in the United States live within 10 miles of a pharmacy, and pharmacists are often the first touchpoint in the continuum of care for people with opioid use disorder. Accumulating evidence shows that in states that permit pharmacists to prescribe or initiate MOUD, pursuant to federal authority and state law, this practice results in improved access, reduced delays in treatment, and better continuity of care, particularly in underserved areas.2, 3, 4
Importantly, pharmacist prescribing is governed by the same core principle that applies to all licensed clinicians: adherence to an established standard of care, enforced through state professional regulation and accountability mechanisms. As of 2025, at least 10 states allowed pharmacist prescribing of controlled medications such as buprenorphine used in the treatment of opioid use disorder.
Additionally, research shows that patients with opioid use disorder often have co-occurring physical and behavioral health conditions that are treated with medications, further underscoring the potential therapeutic value of having pharmacists directly engaged in the ongoing care of these patients to optimize health outcomes. While some patients with opioid use disorder may require long-term treatment with medications, others may benefit from a shorter course of treatment and consider tapering and medication discontinuation when other social and recovery supports are in place. Pharmacists are well-positioned to engage with patients and others on the clinical care team to regularly assess progress toward treatment goals and the role medications play in ongoing recovery based on the patient’s individual circumstances, and to support tapering and discontinuation when clinically indicated.
To support states and pharmacists in these efforts, ACF recently announced (PDF) that it has designated FDA-approved medications for opioid use disorder—buprenorphine, methadone, and extended-release naltrexone—as “well-supported” services under the Title IV-E Prevention Services Clearinghouse. States may now claim Title IV-E prevention funding for these services when children are at imminent risk of entering foster care but can remain safely with their parents or kin if treatment is provided.
Additionally, in conjunction with the release of this Letter, SAMHSA is publishing an Advisory — Expanding Access to Medications for Opioid Use Disorder: The Role of Pharmacists and the Settings in Which They Work. The Advisory provides pharmacists, substance use disorder treatment providers, and public health and public policy professionals with practical information and tips about how pharmacists and the settings in which they work can help support expanding access to medication treatment. SAMHSA also has published its Treatment Improvement Protocol 63 (TIP 63) Medications for Opioid Use Disorder (PDF), Buprenorphine Quick Start Guide, and a recent Dear Colleague letter on medication treatment (PDF) to provide guidance to physicians, pharmacists, and other health care professionals involved in providing MOUD care.
CMS has similarly recognized the importance of supporting the health care workforce and expanding access points in rural communities. Through CMS’s Rural Health Transformation Program, CMS has encouraged states to empower pharmacists as essential clinical partners in rural settings. This includes optimizing their role in patient care through incentives and payment models that support pharmacist prescribing and expanded clinical duties as a means of improving access, strengthening care delivery, and stabilizing rural health systems.
ACF, SAMHSA, and CMS encourage states to review their statutes, regulations, and professional practice laws to assess whether changes may be needed to:
- Authorize pharmacists to prescribe or initiate MOUD consistent with current federal authorities and standards of care;
- Support timely access to treatment for parents and caregivers whose recovery is essential to child safety and family stability and overall community health; and
- Maximize the effective use of Title IV-E prevention funding and other federal resources that can be used to improve the lives of individuals and families struggling with substance use disorders.
Our intent is not to mandate a particular approach or policy action, but to highlight an option that may help states address workforce shortages, expand access to life-saving care, especially in rural and underserved communities, and advance prevention, treatment, and recovery goals consistent with key Administration priorities such as Family First and the Great American Recovery.
ACF, SAMHSA, and CMS encourage collaboration across child welfare, behavioral health, Medicaid agencies; state pharmacy boards; and other state licensing agencies to ensure policies promote access to care while maintaining patient safety and professional accountability and interprofessional collaboration.
Saving lives, restoring families, including by preventing unnecessary family separation, strengthening our communities, and building the Great American Recovery requires practical solutions that reflect the realities of local communities. Expanding access to evidence-based treatment—through thoughtful use of the pharmacy workforce—is one such solution deserving careful consideration.
Sincerely
Footnotes
1Jones CM, Zhang K, Han B, et al. Estimated number of children who lost a parent to drug overdose in the U.S. from 2011 to 2021. JAMA Psychiatry. 2024;81(8):789-796.
2Green TC, Serafinski R, Clark SA, et al. Physician-delegated unobserved induction with buprenorphine in pharmacies. N Engl J Med. 2023;388(2):185-186.
3Wu LT, John WS, Ghitza UE, et al. Buprenorphine physician-pharmacist collaboration in the management of patients with opioid use disorder: results from a multisite study of the National Drug Abuse Treatment Clinical Trials Network. Addiction. 2021;116(7):1805-1816.
4O’Connor SK, Adams JL, Kreider K, et al. Expanding access to MOUD through pharmacist independent prescribing: Early findings from a community pharmacy-based clinical service. J AM Pharm Assoc. 2026;103048.