San Diego Law Review
Document Type
Article
Abstract
Lack of access to evidence-based care for drug addiction is an urgent problem amid a decades-long overdose crisis that kills more than one hundred thousand Americans a year. Opioid addiction is the primary driver of overdoses today, and medicines exist to treat such addiction that can dramatically improve quality of life while reducing the risk of deadly overdose by more than half. Yet fewer than one in four of the nine million Americans who need such evidence-based medical care for their addiction receive it. Chief among barriers to access are restrictive and burdensome federal requirements limiting the use of narcotic medications in addiction treatment to a small class of specially licensed providers and forcing punitive standards of care on those providers. While scholars have proposed numerous substantive reforms to this licensure regime and its standards that could revolutionize access to care, making significant changes to the one-size-fits-all regulatory regime has proven difficult.
This Article argues that the solution to the nation’s addiction treatment problem is not substantive but structural and makes the normative and legal case for defederalizing addiction care. Medical care for addiction is unique in the law of American health care in its partial federalization. Whereas health care licensure and practice standards are ordinarily governed by states and evolve over time, the Narcotic Addict Treatment Act (NATA) of 1974 partially federalized addiction treatment by creating a unique federal system of medical licensure and standard-setting for addiction care using narcotic drugs that is controlled by the Drug Enforcement Administration (DEA) and the Substance Abuse & Mental Health Services Administration (SAMHSA). NATA’s federalization of core forms of addiction treatment, and so partial federalization of addiction care more generally, has not previously been addressed from a federalism perspective. The Article argues that federalization has contributed to the ossification of addiction treatment. Whatever one thinks of the DEA’s and SAMHSA’s judgment on the substance of individual policies, the partially federalized structure of addiction policymaking creates a structural catch-22. It prevents substantial change unless multiple distinct federal and state actors are each persuaded by evidence change will be beneficial, but it also imposes a one-size-fits-all system in which developing evidence about alternatives to the status quo is all but impossible.
While scholars’ assumption that major substantive addiction treatment reform would require difficult-to-obtain federal legislation may be correct, the same is not true of structural change. The Article identifies a novel legal route through which interested states could use underappreciated administrative waiver flexibilities to defederalize addiction treatment for their residents without legislation. If the DEA, SAMSHA, or the White House Office of National Drug Control Policy were willing—or were forced using post-Loper Bright administrative law—to permit states to make use of the statutory flexibilities the Article describes, states could be empowered to effectuate major addiction treatment policy change for their own residents while building an evidence base to inform revolutionary improvements in other states or nationwide.
Recommended Citation
Matthew B. Lawrence,
Defederalizing Opioid Addication Care,
62
San Diego L. Rev.
193
(2025).
Available at:
https://digital.sandiego.edu/sdlr/vol62/iss2/2