Buprenorphine
Loren Bonner
One in five pharmacies that dispensed other controlled substance prescriptions to Medicaid patients never filled a single buprenorphine prescription, according to new study findings published on May 17, 2024, in JAMA Health Forum.
“It’s highly unlikely that in a year’s time [pharmacists] would not receive at least one buprenorphine prescription,” said lead study author Trish Freeman, RPh, from the University of Kentucky College of Pharmacy.
Pharmacy barriers to patients accessing buprenorphine are known, but Freeman and the research team wanted to study dispensing data to try to quantify barriers patients have to obtaining buprenorphine in pharmacies.
Researchers of the serial cross-sectional study examined Medicaid pharmacy claims data in 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, and West Virginia) from 2016 to 2019 and found that 72% to roughly 80% of community pharmacies that dispensed other opioids dispensed buprenorphine.
In other words, buprenorphine was not accessible in up to 20% of community pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment.
The authors concluded that some pharmacies dispensed opioid analgesics but not buprenorphine, suggesting that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.
“I think from our work thus far talking with pharmacists across the state, they really want to do the right thing for their patients and communities,” said Freeman. “We just need to make policy changes that reduce their fear of regulatory sanctions and increase their confidence in making sound dispensing decisions.”
Regulatory enforcement and more
The fear of regulatory action for pharmacists is always present. Buprenorphine seems to be the main controlled substance pharmacists won’t stock—either because they don’t want to exceed wholesalers’ limits or to avoid throwing off their ratio of controlled versus noncontrolled prescriptions dispensed.
Based on previous research, reasons cited for pharmacies not stocking or dispensing buprenorphine include concern over diversion, fear of regulatory enforcement action by licensure boards and DEA, and wholesaler thresholds that limit the volume of buprenorphine a pharmacy can order.
“We need wholesalers to provide more concrete information about buprenorphine thresholds and how to increase thresholds without creating problems for the pharmacy,” said Freeman.
Recently, the National Association of Boards of Pharmacy and others drafted a consensus guideline to advance pharmacists’ willingness to dispense buprenorphine for the treatment of OUD.
“In addition to regulatory issues, stigma toward individuals with SUD, including OUD, remains a concern as does just overall knowledge and confidence in making decisions that balance access with corresponding responsibility,” said Freeman.
Pharmacy barriers
Findings of the study are consistent with other reports, too. Some secret shopper studies found that up to 50% of pharmacies did not stock buprenorphine.
“A limitation of these [studies] is that some pharmacies likely have it in stock but say they don’t in response to phone queries. We’ve had pharmacists anecdotally report this as store policy,” said Freeman.
Freeman was part of a 2020 study published in the International Journal of Drug Policy that showed a majority of pharmacies in 12 Appalachian counties in Kentucky did not stock or limited dispensing of buprenorphine in some way.
“This was really our first idea that pharmacy barriers might be significant,” said Freeman.
With funding from the Foundation for Opioid Response Efforts, Freeman and other researchers will conduct the Buprenorphine Resource Initiative for Dispensing Guidance and Education study, which aims to identify and limit pharmacy-level barriers to dispensing buprenorphine for OUD in rural Appalachian communities.
“Buprenorphine saves lives,” Freeman said. “We have to find ways to be part of the solution to the opioid overdose epidemic by stocking and dispensing buprenorphine when prescriptions are legitimate. Yes, we have to consider our corresponding responsibility, but our first reaction to any question about a prescription should not just be to deny to fill.” ■