This week was difficult for several of my patients trying to fill their buprenorphine prescriptions.
A long-time and very stable patient suddenly lost his pharmacy in mid-October, when they told him they were closing their store and weren’t accepting any new prescriptions.
This patient has been seeing me for about fifteen years. He’s so stable that I only see him once every two months, which means I send an electronic prescription to his pharmacy, and I put one refill on it. He filled the original buprenorphine/naloxone 12/3mg prescription for sixty films and wasn’t due to get the refill until after the store would be closed for business, making that refill unavailable to him. After he called me to explain all of this, I told him it wasn’t a problem; I canceled his refill at his old pharmacy (even though it was now closed) and sent another electronically to the next closest CVS pharmacy to him.
A few days before he was due to pick up this prescription, he called this second pharmacy to make sure they had it in stock. They told him no, and they could not fill his prescription until after the first of the month, since they had already filled their “allotment” of buprenorphine products and could not get any new buprenorphine in their store until November 1st. It did not matter, they said, that he had been a CVS patient at another pharmacy that closed.
I’ve heard this kind of thing from many patients. I’ve called a few of their pharmacies to inquire and pharmacists told me that the DEA limits the amount of buprenorphine products they can fill per month, and that they cannot take on any new patients because of these limits, and sometimes don’t have enough to fill for the patients they have.
Obviously, this is a problem.
At a national level, public health workers at all levels are trying to get more people with opioid use disorder to start on buprenorphine products. More than eighty percent of these people aren’t in treatment, which means their risk of dying is elevated three- fold compared to people with opioid use disorder who are in treatment with either buprenorphine or methadone.
But it won’t help if patients can’t find a pharmacy that will fill their buprenorphine prescriptions.
I saw another patient yesterday and started to send his usual prescription, for buprenorphine/naloxone 8/2mg twice daily to his usual pharmacy when he stopped me. He said he needed to call them to make sure they would have it in stock. He called them on his cell phone and sure enough, this Walgreen’s said they wouldn’t have any more buprenorphine until after November 1st, and that they were unable to tell him if any other Walgreens in his area had it in stock.
In the end, I didn’t send in an electronic prescription for him. I’m still waiting for him to tell me where to send it, after he finds a pharmacy that has it in stock and is willing to dispense to a “new” patient…who has been on this medication for fifteen years.
I’m fortunate that I also work with an opioid treatment program. Recently one of my office-based patients switched to the opioid treatment program because she was so tired of having anxiety about getting her monthly prescription filled at a local pharmacy. She lives in a small town to our north, about thirty minutes away, and the pharmacies are frequently out of her medication, saying they have already dispensed their “limit” for the month. Sometimes I’ve had to send her electronic prescription three times before we found a pharmacy to dispense. It caused her much anxiety, and I wasn’t too happy with the problem either.
Now that she is treated under the opioid treatment program license, she comes in once per month and gets twenty-seven take home doses. She knows we won’t run out of medication. She knows that on the day she’s due to pick up her medication, we will have it for her. That is a great relief to her, and it saves me time.
We order stock bottles of both buprenorphine products and methadone liquid. We must account for every milligram of both medications that we give to patients, on-site or as take homes doses. Our OTP keeps meticulous records and we’ve never had any problems with the DEA. They periodically inspect the facility, as they do all OTPs. I’ve found them to be helpful and professional, eager to answer any questions. So far as I know, we have never had any problems ordering the medications we need for our patients.
Congress is now considering new legislation, called the Modernization of opioid Treatment Access Act, which seeks to move treatment of patients with opioid use disorder from opioid treatment programs to community providers and pharmacies. The routine occurrence of difficulties like I’ve described above make me skeptical if the Act would be of any use, even if it were passed. Maybe it’s different in large cities but around here, if we can’t even get pharmacies to remain stocked with enough buprenorphine to meet patient demand, methadone will be out of the question.
The DEA disagrees with what pharmacists tell me about buprenorphine. They say they do not set limits on the amount of buprenorphine pharmacies can order and dispense. So why do pharmacies seem to be convinced otherwise? I don’t know. I do know both the DEA and retail pharmacies have been criticized for their inaction during the early days of the opioid epidemic. I think both are being cautious now, not wanting to make that mistake again. But it hurts patients seeking recovery.
I wish someone could get the DEA to sit down with the people running CVS and Walgreen’s and work out this misunderstanding.
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