Table of contents
How Reform Actually Moves Under Existing Law
Executive Summary
A lot of people still talk about drug policy reform as if it requires one giant act of Congress before anything meaningful can happen.
That is not how policy usually moves.
Reform in the United States almost always moves in layers: one part through federal law and rulemaking, another through state legislation and Medicaid authority, and another through city and county implementation. The Controlled Substances Act itself already provides a mechanism to add, remove, or reschedule substances, and DEA says those proceedings can be initiated not only by DEA or HHS, but also by a petition from an interested party, including a state or local government agency or an individual citizen.[1]
That matters because it kills one of the laziest objections in this debate.
No, the country does not have to wait for a perfect federal grand bargain before anything changes.
No, states do not have to sit on their hands until Congress grows up.
No, cities and counties are not powerless until Washington fixes itself.
The real picture is more complicated and more useful.
• The marijuana rescheduling process is one federal pathway, but not the only one.
• A Medicaid 1115 waiver is one of the clearest state pathways for expanding and measuring substance use disorder treatment.[5]
• Local cannabis control shows how much authority cities and counties already have over access, licensing, and implementation.[9][10]
• Buprenorphine prescribing rules already changed at the federal level, and that one shift alone expanded what ordinary practitioners can do if state law allows.[6]
• Treatment on demand can be built step by step through federal privacy rules, state financing, local outreach, and real implementation systems.[7][11][12]
That is the point of this chapter.
Part 16 argued for pilot, measure, scale. Part 19 argued that complex administrative systems already exist. Part 30 showed how to measure outcomes without building a punitive state. Part 31 pulls those threads together and answers the practical question people keep asking:
How does reform actually move under existing law?
The Legal Myth This Chapter Solves
The myth is simple:
If Congress does not legalize everything at once, nothing real can happen.
That myth survives because people keep confusing headline reform with actual reform.
Headline reform is one big bill, one Supreme Court case, one presidential order, one sweeping announcement.
Actual reform is messier.
Actual reform looks like:
• a federal rulemaking
• a Medicaid 1115 waiver
• a state licensing statute
• a county ordinance
• a local public-health contract
• a hospital-based overdose prevention program
• changed buprenorphine prescribing rules
• stronger local cannabis control
• and a growing set of legal, medical, public-health, and administrative changes that start changing the world before the perfect law ever arrives.[1][5][6][11][12]
That is how most real reform happens in America.
The right question is not whether one law fixes everything.
The right question is which level of government can move which piece now.
1. The Federal Pathway: The Marijuana Rescheduling Process Is Real, but It Is Not the Only Lever
The cleanest federal example is the marijuana rescheduling process.
The Justice Department announced in May 2024 that it had submitted a proposed rule to consider moving marijuana from Schedule I to Schedule III under the Controlled Substances Act. DOJ said the rulemaking was initiated after HHS’s review and that formal rulemaking, public comment, and an administrative hearing were required before any final change. DOJ also said marijuana would remain Schedule I until a final rule was published.[2]
That is important for two reasons.
First, it proves federal reform can move under existing law.
Second, it proves federal reform can also be slow.
DEA announced in January 2025 that the hearing on the proposed rescheduling of marijuana was postponed pending resolution of an appeal, and a July 2025 DEA notice to the parties said the case was still in a stay status, pending the appeal, and that the DEA had no Administrative Law Judge after August 1, 2025, leaving filings to be forwarded to the DEA Administrator unless circumstances changed.[3][4]
That is the marijuana rescheduling process in a nutshell:
• real
• legally available
• politically important
• and not fast enough to be the only strategy
This is exactly why people who care about drug legalization and broader drug policy reform should stop talking as if federal scheduling is the only door.
The federal government still matters enormously. It controls scheduling, research conditions, privacy rules, FDA drug approval, interstate commerce questions, and the baseline criminal framework under the CSA. DEA’s own CSA page says substances are placed into five schedules based on medical use, abuse potential, and safety or dependence liability, and that scheduling proceedings can be initiated by DEA, HHS, or petitioners including state or local government agencies and ordinary citizens.[1]
But that same page also proves the larger point: federal law already contains pathways. It is not a static wall.
So yes, the marijuana rescheduling process matters. But it is only one federal pathway among several.
2. The Federal Pathway Also Includes Buprenorphine Prescribing Rules and 42 CFR Part 2
A lot of real reform is quieter than rescheduling.
Sometimes it happens when regulators remove a barrier that never should have existed.
That is what happened with buprenorphine prescribing rules.
SAMHSA says the MAT Act removed the federal requirement for practitioners to obtain a special waiver before prescribing buprenorphine for opioid use disorder. SAMHSA now says that practitioners with a current DEA registration that includes Schedule III authority may prescribe buprenorphine for OUD if permitted by applicable state law, and that the old waiver applications and patient caps are gone. SAMHSA also says buprenorphine can be prescribed via telehealth so long as the prescription complies with relevant federal, state, and local law.[6]
That is not theoretical reform.
That is a concrete federal change that widened access without waiting for a total rewrite of drug law.
And it matters for this series because it shows how reform actually moves:
• remove one barrier
• widen one access lane
• leave room for states to shape the details
• then measure whether more people get care
The same thing is true on privacy.
The 2024 HHS final rule for 42 CFR Part 2 did not abolish confidentiality. It updated it. HHS says the rule permits disclosure of Part 2 records to public health authorities without patient consent only if the records are de-identified according to HIPAA standards, and it restricts the use of records and testimony in civil, criminal, administrative, and legislative proceedings against patients absent consent or a court order. HHS also says the records still cannot be used to investigate or prosecute the patient without those protections.[7]
That matters because treatment on demand does not work if people think seeking help means building a file for future punishment.
So the federal layer is already doing real work on three fronts:
the marijuana rescheduling process
buprenorphine prescribing rules
42 CFR Part 2 and the privacy side of accountability
None of that finishes the job.
All of it proves the job can move.
3. The State Pathway: Medicaid 1115 Waiver, PDMP, and State Law Can Move Faster Than Congress
If federal reform is often slow, states can move faster on implementation.
The single most practical state-level pathway in this space is the Medicaid 1115 waiver.
Medicaid says the SUD section 1115 demonstration opportunity gives states flexibility to improve access to high-quality, clinically appropriate treatment for opioid and other substance use disorders while incorporating metrics to demonstrate whether outcomes are improving. Medicaid also lists a long roster of approved states using this authority, including California, Colorado, Illinois, Massachusetts, Michigan, New York, Oregon, Washington, and many others.[5]
That is a big deal.
A Medicaid 1115 waiver is not ideological branding. It is a real financing and implementation tool. It can be used to build treatment capacity, improve continuity of care, test benefit design, and require outcome measurement.
That is how treatment on demand starts becoming more than a slogan.
States also control major parts of the clinical and public-health apparatus.
CDC says a PDMP is an electronic database that tracks controlled substance prescriptions and can help clinicians identify patients at risk for overdose and provide potentially lifesaving interventions. CDC also describes the PDMP as one of the more promising state-level interventions to improve prescribing, inform clinical practice, and protect patients at risk.[13]
That is another state pathway under existing law:
• the Medicaid 1115 waiver for treatment system design
• the PDMP for prescribing oversight and overdose-risk visibility
• ordinary state licensing and criminal law for possession rules, retail rules, and expungement
• state health agencies for naloxone, hospital standards, and linkage to care
This is also where Part 19’s point comes back into view. The system is already being administered. States are already operating controlled-substance databases, treatment licensing structures, Medicaid demonstrations, and public-health monitoring systems. What changes under drug policy reform is not whether administration exists. It is what that administration is aimed at.
4. The State Pathway Also Includes State Statutes, Regulations, and Licensing
States do not just finance treatment. They write the operating rules.
California’s Department of Cannabis Control explains this clearly. It says statutes, regulations, and local ordinances all work together to set rules for businesses and consumers. The DCC says statutes are written by the state legislature, regulations are created by state agencies, and ordinances are created by cities and counties for local communities. California also says the main state cannabis statute, MAUCRSA, creates a framework for licensing, oversight, and enforcement, while regulations specify license requirements, product rules, packaging, testing, and enforcement actions.[8]
That framework matters because it shows how state reform actually moves:
• legislature sets the baseline
• agencies write the details
• local governments apply place-based rules
• enforcement, compliance, and accountability get distributed across all three
This is why risk-based drug regulation is actually a realistic state project. A state can create different lanes, different license types, different packaging rules, different testing standards, different penalties, and different age controls without waiting for Congress to rewrite the entire federal criminal code.
A state can also decide which parts of reform are mature enough for ordinary adult retail and which parts belong in a regulated pharmacy model. That is exactly how the argument in Part 14 becomes legally real.
So the state layer is not just about budgets.
It is where a lot of the actual architecture gets built.
5. The Local Pathway: Local Cannabis Control, Local Ordinances, and Local Access Matter More Than People Think
This is where a lot of outsiders get the system wrong.
They assume once a state legalizes something, access is uniform.
It is not.
California’s DCC says cannabis businesses are regulated in two ways: by the state and by the city or county. The DCC says cities and counties can license all cannabis businesses, some types, or prohibit all of them. It also says California is a patchwork: 47% of cities and counties allow at least one type of cannabis business, while 53% allow none, and 57% do not allow any retail cannabis business.[9]
That is local cannabis control in practice.
It means local governments already control huge parts of what reform looks like on the ground through:
• zoning
• licensing
• hours
• retail density
• time, place, and manner rules
• local ordinances
• nuisance enforcement
• equity programs
California’s DCC says ordinances are rules created by cities and counties to set more specific local rules and that they can govern how a business operates in a local community so long as they do not work against state statutes or regulations. The same DCC page also lists local equity ordinances designed to help people harmed by the War on Drugs enter the legal market.[8]
That matters because local cannabis control can either strengthen reform or quietly sabotage it.
If cities and counties ban all legal access while demand stays in place, they leave room for illicit sellers. California’s Local Jurisdiction Retail Access Grant page says the state created the program because nearly two-thirds of California jurisdictions did not allow any regulated cannabis retailers and that supporting local governments in establishing retail licensing programs would provide consumers with access to tested, regulated cannabis, promoting consumer safety and reducing demand in the illicit market.[10]
That is one of the clearest local lessons in the whole series:
legal reform on paper is not enough if local access never materializes.
6. The Local Public-Health Pathway: Treatment on Demand, Overdose Prevention, and Outreach Can Start Now
Local government is not just about zoning and store hours.
It is also where a lot of lifesaving work happens first.
CDC’s OD2A case study on public safety-led post-overdose outreach says people who have experienced a nonfatal overdose are at higher risk of fatal overdose and that first-responder data systems can be used to identify people for outreach after overdose. CDC says these programs can link people to care, leave naloxone, connect them to medications for opioid use disorder, and that evaluations found they reduced overdose risk through engagement and linkage to treatment. CDC also says local implementation can be customized based on resources and needs.[11]
That is a local pathway under existing law.
It does not require Congress.
It does not require national legalization.
It requires coordination, data use agreements, and local will.
New York City’s Relay program is another example. NYC Health said in February 2026 that Relay had expanded to 16 hospitals, that it connects people who have experienced a nonfatal overdose with trained peers, and that between launch and the end of 2024 the program had distributed 10,359 naloxone kits, delivered overdose risk-reduction education 14,390 times, and made 6,155 referrals to harm reduction, health care, mental health, and SUD services. In 2024 alone, NYC said Relay offered services to 1,768 patients and that 94% accepted services in the emergency department.[12]
That is what treatment on demand starts to look like at the local level:
• rapid contact after overdose
• peer-led outreach
• naloxone
• linkage to care
• support for 90 days after discharge
• local data and local implementation
This also shows why reform is never just federal or just state. If the federal layer changes but the local layer never builds response capacity, a lot of the promise dies on the ground.
7. How the Three Levels Fit Together
The real point of Part 31 is not that one level of government matters most.
It is that each level handles a different part of the job.
Federal
• scheduling and the marijuana rescheduling process
• FDA drug research and approval pathways
• 42 CFR Part 2 privacy rules
• baseline controlled-substance law
• changes like the federal update to buprenorphine prescribing rules[1][2][6][7]
State
• criminal penalties and state law
• the Medicaid 1115 waiver
• the PDMP
• licensing statutes and agency regulations
• statewide treatment standards and coverage rules[5][8][13]
Local
• local cannabis control
• local ordinances
• zoning, density, and retail access
• hospital-based overdose prevention and outreach
• public-health implementation and community trust building[8][9][10][11][12]
That is how reform actually moves under existing law.
Not as one movie scene.
As a system.
And that is why this chapter is a natural continuation of the earlier ones. A serious risk-based drug regulation model needs all three levels. A serious regulated pharmacy model needs federal and state legality plus local implementation. A serious public safety strategy needs enforcement, care linkage, and clearer rules. A serious accountability system needs metrics at every level. A serious drug policy reform plan cannot just ask what Washington should do. It has to ask what can move at each layer now.
What Can Move in the Next 12 Months Under Existing Law
If policymakers wanted to act like adults, they would stop waiting for one perfect moment and start moving pieces now.
Here is what that looks like.
At the federal level
keep the marijuana rescheduling process moving through existing rulemaking channels[2][3][4]
protect and enforce 42 CFR Part 2 so treatment data do not become prosecutorial shortcuts[7]
expand provider uptake under the changed buprenorphine prescribing rules[6]
keep supporting research, evaluation, and guidance under existing federal authority[1][2]
At the state level
use the Medicaid 1115 waiver to expand and measure treatment access[5]
improve PDMP use as a clinical safety tool[13]
rewrite state statutes and agency regulations to match risk-based drug regulation
fund real treatment on demand instead of paper referrals
At the local level
use local cannabis control to expand safe, regulated access where the alternative is illicit supply[9][10]
adopt local ordinances that support equity, zoning clarity, and enforceable rules[8]
launch or expand post-overdose outreach, peer navigation, and hospital-based linkage systems[11][12]
build trust through visible local implementation and honest reporting
That is not fantasy.
That is what existing law already allows.
The Bottom Line
The real bottleneck is not always the absence of legal authority.
A lot of the time, it is the absence of political will and the bad habit of pretending nothing counts unless Congress does everything at once.
Part 31 is the answer to that excuse.
The marijuana rescheduling process is one federal pathway.
The Medicaid 1115 waiver is one powerful state pathway.
Local cannabis control is one major implementation pathway.
Buprenorphine prescribing rules already changed under federal law.
Treatment on demand can already be expanded through state financing and local public-health design.[2][5][6][11][12]
That is how reform actually moves under existing law.
Not perfectly.
Not instantly.
But concretely.
Frequently Asked Questions
Why use “marijuana rescheduling process” as the primary pathway keyword if this chapter is broader?
Because the marijuana rescheduling process is the clearest federal example many readers already recognize. It is also a good way to show that federal reform is real but not the only lever. DOJ proposed moving marijuana from Schedule I to Schedule III in 2024, but DEA’s public notices show the matter has remained delayed and stayed.[2][3][4]
What can a Medicaid 1115 waiver actually do here?
A Medicaid 1115 waiver can give states flexibility to improve access to high-quality, clinically appropriate SUD treatment while requiring metrics to show whether outcomes are improving. Medicaid lists many states already using this pathway.[5]
Why is local cannabis control such a big deal?
Because state legalization does not guarantee local access. California’s DCC says cities and counties decide whether to license all, some, or no cannabis businesses, and many local jurisdictions still block retail access. That means local cannabis control can either support reform or quietly undermine it.[9][10]
What changed in buprenorphine prescribing rules?
SAMHSA says the MAT Act removed the old federal waiver requirement, so practitioners with DEA Schedule III authority may now prescribe buprenorphine for opioid use disorder if state law allows.[6]
How does treatment on demand fit into a legal-pathways chapter?
Because law is not just about criminal penalties. Treatment on demand depends on financing, licensing, provider rules, privacy rules, and local implementation. That means federal, state, and local pathways all matter. CDC and NYC Health both show local overdose-response systems can link people to care quickly under existing law.[11][12]
Where do risk-based drug regulation and the regulated pharmacy model fit?
They fit because broad reform still needs differentiated lanes. Risk-based drug regulation is mostly built through state statutes, agency regulations, and local implementation, while the highest-risk lane in a regulated pharmacy model would also need federal legality and privacy protections. That is why all three levels matter together.
References
[1] U.S. Drug Enforcement Administration. The Controlled Substances Act. https://www.dea.gov/drug-information/csa
[2] U.S. Department of Justice. Justice Department Submits Proposed Regulation to Reschedule Marijuana. https://www.justice.gov/archives/opa/pr/justice-department-submits-proposed-regulation-reschedule-marijuana
[3] U.S. Drug Enforcement Administration. Hearing on the Proposed Rescheduling of Marijuana Postponed. https://www.dea.gov/stories/2025/2025-01/2025-01-15/hearing-proposed-rescheduling-marijuana-postponed
[4] U.S. Drug Enforcement Administration. Notice to the Parties: Proposed Rescheduling of Marijuana. https://www.dea.gov/sites/default/files/2025-07/Marijuana%20Rescheduling_Notice%20to%20the%20Parties.pdf
[5] Medicaid.gov. Substance Use Disorder Section 1115 Demonstration Opportunity. https://www.medicaid.gov/medicaid/section-1115-demonstrations/substance-use-disorder-section-1115-demonstration-opportunity
[6] Substance Abuse and Mental Health Services Administration. Waiver Elimination (MAT Act). https://www.samhsa.gov/substance-use/treatment/resources/mat-act
[7] U.S. Department of Health & Human Services. Fact Sheet: 42 CFR Part 2 Final Rule. https://www.hhs.gov/hipaa/for-professionals/regulatory-initiatives/fact-sheet-42-cfr-part-2-final-rule/index.html
[8] California Department of Cannabis Control. California’s Cannabis Laws. https://www.cannabis.ca.gov/cannabis-laws/laws-and-regulations/
[9] California Department of Cannabis Control. Where Cannabis Businesses Are Allowed. https://www.cannabis.ca.gov/cannabis-laws/where-cannabis-businesses-are-allowed/
[10] California Department of Cannabis Control. Local Jurisdiction Retail Access Grant. https://www.cannabis.ca.gov/about-us/grant-funding/local-jurisdiction-retail-access-grant/
[11] Centers for Disease Control and Prevention. OD2A Case Study: Public Safety-Led Post-Overdose Outreach Programs. https://www.cdc.gov/overdose-prevention/php/od2a/public-safety.html
[12] NYC Health. NYC Health Department Expands Overdose Prevention Program to 16th Hospital. https://www.nyc.gov/site/doh/about/press/pr2026/health-department-expands-overdose-prevention-program-to-16th-hospital.page
[13] Centers for Disease Control and Prevention. Prescription Drug Monitoring Programs (PDMPs). https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/prescription-drug-monitoring-programs.html
If you want to follow the full series as it publishes, visit the full Drug Legalization Series. If you prefer audio conversations on recovery, reentry, and purpose, check the podcast page. For program directors building reentry and transition programming, see ReturnPath reentry curriculum. For the personal story behind this work, read A Vision of Hope. To invite Andrew for a keynote or panel, see speaking.