Telehealth Policy Interactions Across the Buprenorphine Care Cascade: A System Mapping Analysis

OBJECTIVE: The COVID-19 Public Health Emergency prompted multiple policies that expanded telehealth care, including buprenorphine treatment for opioid use disorder (OUD). Prior research has reviewed these policies, but not their structural relationships. We used a system mapping approach to visualize how those policies interacted to influence care delivery. METHOD: We developed a diagram based on system dynamics conventions to capture patient status and care transitions and provider capacity change, telehealth adoption, and attrition, informed respectively by the cascade-of-care framework and innovation diffusion models. We identified state or U.S. national policies involving telehealth buprenorphine prescribing for OUD from peer-reviewed studies published from 2020 to 2025. We mapped relevant policies onto patient and provider transitions to identify where bottlenecks or synergies might occur and thus undermine or support policies' intent. RESULTS: We identified 17 policies that affected buprenorphine delivery via telehealth, spanning prescribing without an in-person visit, insurance changes reducing patient financial burden, provider reimbursement, lowering technological barriers, and scope-of-practice flexibilities. Only four policies specifically targeted buprenorphine prescribing, while the remaining facilitated access to buprenorphine treatment. Most policies affected multiple transitions, and all transitions were affected by multiple policies. We mapped six policies to diagnosis, nine to buprenorphine initiation, eight to treatment discontinuation, four to changes in provider capacity, eight to telehealth adoption, and three to its attrition. CONCLUSIONS: System mapping shows how telehealth-related policies jointly shape access to buprenorphine care through their alignment across patient pathways and provider participation. Policy interactions create constraints or reinforcement at key points in care delivery.