Latest Obstacle to Treatment of Opioid Use Disorders: Pharmacies

Recent studies show some pharmacies refuse to stock buprenorphine products. This is a disappointment and a barrier to effective treatment of opioid use disorder. I’m not talking only of buprenorphine monoproduct; some pharmacists also refuse to stock or dispense buprenorphine combination products. Some do not stock naloxone kits for reversal of opioid overdoses.

Last week my husband tipped me off to an interesting podcast done by Jeffrey Bratberg, Pharm D, on an AMERSA podcast. AMERSA stands for The Association for Multidisciplinary Education and Research in Substance use and Addiction, a non-profit organization dedicated to promoting education and research into substance use disorders. You can read more about them at www.amersa.org

Dr. Bratberg had two researchers on his podcast, Dr. Lucas Hill, and Dr. Lindsey Loera, who described the outcome of a study they did on the availability of buprenorphine in community pharmacies. You can listen to the podcast here: https://attcniatx.blogspot.com/2021/09/amersa-people-passion-attc-network-podcast-barriers-treatment-opioid-use-disorder-buprenorphine.html.

During the podcase, both doctors talked about the study they did where they had a “secret shopper” protocol. They called 800 randomly selected pharmacies out of the 5078 pharmacies licensed by the state of Texas. Their first study was done only in Texas but later they made similar calls to all states, with similar results.

On their phone protocol, they asked to speak with the pharmacists, and asked about the availability of buprenorphine 8/2mg films. They selected this product and strength because addiction medicine physicians told them this was the most prescribed product. If the pharmacists said that medication was not in stock, they asked if the pharmacists were willing to stock it and if so, they asked how long it would take to get the medication ready to dispense. They also asked if the pharmacy had naloxone nasal spray kits in stock. [1]

This study was done from May of 2020 until June of 2020.

Only 34% of pharmacies were willing and able to fill one week of buprenorphine/naloxone films and a naloxone kit right away. Of note, chain pharmacies were much more likely than independently owned pharmacies to stock these medications (45% versus 12%).

When looking only at the buprenorphine/naloxone medication without the nasal naloxone kit, 42% were able to fill the prescription. Of those who did not have the medication in stock, most (62%) were willing to order it. The average wait time for pharmacies needing to order it was two days. This is an unacceptably long time to wait for a patient in withdrawal, so that’s one kind of problem.

But their data showed that 38% of the pharmacies that didn’t stock this medication were unwilling to order it.

This is appalling. Of course, we could say yes but this is Texas and maybe there’s more stigma in that state than elsewhere, but the authors of the study say that results were similar when they called pharmacies in other states.

Why are pharmacists not willing to stock and dispense a medication that has been proven to save lives?

The study authors said they heard misconceptions from these pharmacists, such as overblown concerns about euphoria, misuse, or diversion of buprenorphine products. Of course, we know from studies that most people using illicit buprenorphine are trying to avoid withdrawal rather than trying to get high from it. And, as the authors pointed out on the podcast, all these pharmacies surely had oxycodone in stock, which is much more likely to cause euphoria, so that reasoning is fuzzy.

Some pharmacists said there were costs issues. If a pharmacy orders a supply of buprenorphine/naloxone films and no patients seek to fill that medication, the pharmacy could lose money. But isn’t that true of any medication the pharmacy stocks?

One of the study authors pointed to another possible reason pharmacists don’t stock buprenorphine products, based on a Kentucky study done by Cooper et al. [2]

This was a qualitative study done in 2020 of fourteen pharmacies in rural Kentucky. Some of these pharmacists said they would refuse to fill some, or all, buprenorphine product prescriptions written for opioid use disorder. When asked why, many of them said they feared increased scrutiny from the DEA and wholesalers.

To back up a bit, this opioid epidemic debacle we find ourselves in now had plenty of contributing factors. Among them, drug wholesalers were blamed for not reporting large orders of opioids to small communities, in violation of DEA law. The DEA faced some criticism that it didn’t detect and stop large shipments of opioids that were being overprescribed in some communities. And doctors at pill mills were blamed for overprescribing for financial incentive.

As all these failings are being addressed, pharmacies say they fear increased scrutiny from wholesalers and from the DEA, as the pendulum swings towards tighter regulation. They say they can’t accept new buprenorphine patients because they are being rationed by wholesalers.

However, there is no shortage of buprenorphine. There’s only the perception of increased risk to the pharmacy and pharmacists if they have too many patients on the medication, but nobody has defined how many is too many.

Some pharmacists are distrustful of buprenorphine prescribers and see them as bad doctors. That’s just an extension of the stigma that some people – including some pharmacists – still have toward people with substance use disorders. These pharmacists think there must be something wrong with a provider who wants to treat “those people.”

I’ve felt this when I’m on the phone with some pharmacists. One pharmacist told a patient of mine that he didn’t accept “out of town” prescriptions. I called to ask about this, since his pharmacy is twenty miles from my office, about the same distance as the next closest buprenorphine prescriber. Literally, my patient could not see a prescriber who was closer to this pharmacy. I felt his distain for me as we talked, and he didn’t budge. My patient had to go elsewhere to fill his buprenorphine/naloxone tablets prescription.

Electronic prescribing is more difficult when pharmacies don’t stock buprenorphine products. When I send a prescription to a patient’s preferred pharmacy, if they don’t have it, I must send a cancellation so that I can send it to a second pharmacy. That happens more with new patients, of course.  

The authors of the Hill study reasoned that efforts to increase buprenorphine prescribing must be matched by policy changes to encourage increased dispensing of buprenorphine medication. That conclusion is correct, of course. We can have the best treatment plans and the best warm hand-offs of new patients from the emergency department to prescribers, and it can all come undone at the pharmacy level when patients can’t fill their prescriptions.

  1. Hill et al., Addiction, 2021 Jun;116(6):1505-1511.
  2. Cooper et al., International Journal of Drug Policy, Vol. 85, November 2020.

9 responses to this post.

  1. Posted by Matthew C. McClure, D.O. on October 4, 2021 at 6:56 pm

    In my region pharmacists have been very supportive. They have seen the changes with their patients as they transition from (some, not all) the madness associated with getting X number of oxycontin a month to a steady 60 films a month. I deal with about 15 pharmacies locally but have interacted with another 40 or so regionally. Rarely have I had anyone refuse to dispense or order it. Recently one did not want to fill a one week supply because he didn’t want to ‘break a box.’ So we moved the Rx, as well as the patients other prescriptions to another pharmacy. They plan to move the rest of the family prescriptions so his little move is going to cost him at least a dozen monthly refills. He had it in stock because other patients fill it there. He should have been savvy enough to realize it isn’t a onetime Rx like an antibiotic.
    During patients’ travel I have called pharmacies in Illinois, N.M. Arizona and Florida, treated cordially and respectfully and getting assistance for patients.
    One of the chains has been a leader in getting Naloxone treatment kits into the hands of users and families without requiring a prescription.
    I have read similar articles or posts on patient forums and realize we are really fortunate here.
    As always I appreciate your blog posts. Keep up the good fight.

    Reply

  2. Posted by Ryan Anthony Zondervan on October 4, 2021 at 7:35 pm

    Thankfully the two pharmacies I’ve dealt with here in the Midwest during my 5+ years of treatment have always been willing to fill my prescriptions (and have been extremely helpful in doing so). I use the pills – the biggest problem I’ve had is with disruption of production. The quality of the different generic manufacturers is all over the place, and the one that has worked best for me (Activis) keeps getting sold and having production issues, so I’ve had some very stressful mad scrambles to get my medication (and on a couple occasions have had to switch to a different manufacturer). The other interesting side note – for the first several years I had to pay for my medication; it was a basic generic and cost about $60/month (my wife and I utilize a high deductible HSA plan). Then in 2020 my cost dropped to zero – apparently the pills ONLY were considered “preventitive” medication and were covered 100%. Great! However, now instead of charging my plan $60 for a monthly supply, the pharmacy charged over $600 for a monthly supply of the exact same medication. Gotta love our system…

    Reply

  3. Posted by Theodore D Fifer MD FASAM FACS on October 4, 2021 at 9:08 pm

    Many of my patients have reported that they are received less than cordially with their buprenorphine prescriptions at pharmacies where they had speedy, cheerful service when they were filling a prescription
    for 120 oxycodones in the past.
    I encourage them to seek a more receptive site.
    One pharmacist, on the other hand, was quite supportive. She told me that buprenorphine kept her son alive for some years until he eventually succumbed to a fentanyl analogue.

    Reply

    • Yes, I’ve talked to more pharmacists who are friendly than who are not, and it’s important to keep that in perspective. It’s just that the unfriendly ones stick in my memory.

      Reply

  4. Posted by Greg on October 10, 2021 at 3:23 pm

    I used Walgreens for years.They always had the Reckitt Benkiser brand name films.As is normal for me anyway, they would not release them early unless it was just a day or two early. Wal-Mart on the other hand is out of the 2 mg. pills half the time so I adjusted my use and make sure I don’t run out the day my script is due.Walmart is good nonetheless.I don’t know about Walgreens I haven’t been there in 3 years.My guess is they would order in the buprenorphine which takes about 2 days while the out of buprenorphine patient is dealing with MASSIBE RESTLESS LEG SYNDROME AND ANXIETY AND SEVERE WEAKNESS. WHY BUPRENORPHINE HAS TO BE SO EXPENSIVE IS JUST RUDE. IT IS MUCH BETTER THAN GOING TO A METHADONE CLINIC EVERYDAY AT 4 A.M. SO I CAN GET TO WORK BY 6 A.M. METHADONE AND BUPRENORPHINE HELP REAL PEOPLE GET THEIR REAL LIVES BACK. HOW ABOUT THE FDA SUBSIDISING THIS ASPECT OF MIRACULOUS MEDICAL TREATMENT. ESPECIALLY AFTER THIS COVID THING.

    Reply

  5. Posted by majority Ruhl on October 16, 2021 at 4:04 pm

    The state I live in Indiana, only just recently began Medicaid coverage of medicated assisted treatment or MAT. The most affordable outpatient methadone clinic receiving state appropriations & discounted was still a struggle for most of the “clients” paying out of pocket expenses. No one could be medicated w/o their money. Period-NO EXCEPTION.
    Many patients were denied their methadone for lack of fees only. And Suboxone wasn’t offered as a maintenance drug. Instead it was used strictly for detoxing purpose. Fourteen days. In addition patients who wanted to use Suboxone were told by the clinic’s doctor to make an appointment at his private practice. He made referrals from his job at the community outpatient clinic to his own “private” clinic. It cost anywhere from $250-400 for the initial appointment. Subsequent appointments were anywhere from$150-250. And guidelines required a patient be seen in office six times during the first month or so. That’s cash ONLY of course.
    Given the Inspector General investigation resulting in civil monetary penalties and violations of Stark law, I’m left wondering if it’s unethical to take advantage of addicts who are desperately searching for a specialist who can prescribe Suboxone. Nobody’s happy to dose every twenty four hours, seven days a week. Even Xmas day. Drug dealers embrace similar philosophies. As long as you’ve got the cash, medicated assisted treatment was a reality. When you didn’t it was a nightmare!!!

    Reply

    • Thanks for writing. I agree with what you are saying…and yet, the reality is that in the U.S., healthcare is not a right but a privilege available to those who can pay or those who can pay for insurance. That makes care unaffordable and unavailable for people with all sorts of chronic illnesses, not only substance use disorders.
      If you don’t think that’s right…vote.
      Talking of opioid treatment programs specifically, they should offer a medical taper off methadone rather than just denying treatment for a patient who doesn’t have financial means to pay for that day’s dose. I think our state says it needs to be 21 days, but OTPs usually dictate that it be faster than that.
      I don’t know if it is illegal to refer patients to one’s own private office for services not covered by the opioid treatment program, but it feels unethical. The right thing would be give patients a list of local buprenorphine providers in your area, so they could call around to get the best deal. Six visits in one month may be appropriate for some patients but surely some don’t need that much attention. In those office-based settings, physicians can decide how often patients need to be seen. They don’t have to follow anyone else’s rules.
      The state government decides if they will use their Medicaid dollars to pay for treatment of opioid use disorder medications.

      Reply

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