Posts Tagged ‘pharmacy refuses to stock buprenorphine’

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.