A hidden obstacle to opioid treatment: pharmacies that don't stock buprenorphine (or won't say).
Imagine deciding that a prescription for buprenorphine, a safe opioid replacement, might save your life. Think about how hard it must be to come to that realization.
For people with opioid use disorder (what laypeople might call being “dangerously addicted to opioids”), deciding to start taking oral buprenorphine is what I sometimes call a “holy moment.” There are many “holy moments” in medicine. Holy moments are metaphorical forks in the road. One path may save a patient’s life, while the other could cost it.
It takes a lot of introspection, if not an outright logical fear of death, for an IV drug user to decide to get help. The deck is heavily stacked against getting help. Lots of barriers must be overcome. First, there’s the sense of invincibility many patients have. (“I’ve been fine so far.”) Then there’s the stigma in seeking help and admitting that there’s a problem. Finally, once those are overcome, there’s the lack of resources in many communities.
What is buprenorphine?
Bupe (as it is referred to by many clinicians and patients and which is the active ingredient in “Suboxone”) offers tremendous advantages in the treatment of opioid use disorder. Like methadone, bupe saves lives. Unlike methadone, it is not cloistered into dispensaries which must be visited on a daily basis. Bupe users can get a prescription, fill it, take their dose, and live normal lives. Bupe is a long-acting, “partial opioid agonist,” meaning that it binds to opioid receptors, but has far less abuse potential.
Imagine getting as far as seeking out a safe opioid alternative,—which indeed is the evidence-based standard of care for high-risk opioid use disorder patients—finding a doctor or clinician willing to prescribe it, only to run into yet another problem: pharmacies that don’t stock buprenorphine.
Why can’t patients get buprenorphine?
In early 2023, the federal government made it a lot easier for patients to get bupe. That was great progress, after many of us had been calling for decreased red tape for years. As of this year, clinicians no longer need “special training” to prescribe bupe.
But that doesn’t mean that getting the medication is a sure-thing for patients in need. In May, my colleagues and I published a study in JAMA Network Open looking at how many pharmacies actually say that they carry buprenorphine. The work was led by my friend, mentor, and Brigham/Harvard colleague, Dr. Scott Weiner.
Our research revealed a large spectrum among the US states. In some states, north of 80% of pharmacies contacted reported that they in fact stock buprenorphine. In Florida, by contrast, just 37% of contacted pharmacies reported that they stock it. That means a majority of pharmacies in Florida either don’t carry a life-saving medication, or they aren’t willing to tell anyone that they do. While Florida was the state whose pharmacies least frequently say they carry bupe, a majority of pharmacies in a handful of other states including Alabama, California, and Maryland don’t either.
The heat map above shows where information is hard to come by (red-shaded states) and where it is easier (green-shaded states).
What are patients to do, especially in moments of need?
To put this into a real-world perspective, let’s consider a patient who has just been given a prescription for buprenorphine in Florida. Now, they want to simply fill it. Suppose they try filling the prescription at a pharmacy which doesn’t carry the medication. Rather than potentially traveling several miles to another pharmacy, the patient wises up and decides to call and see if that facility actually stocks the medication. The odds that the first two places the patient calls either does not carry bupe or won’t say they do is 39.7%. The odds that the first three places the patient calls either does not carry bupe or won’t say they do is lower, but still 25%. At some point, a patient will give up. Relapsing to IV opioid use prior to starting medication-assisted therapy for opioid use disorder is all too common. It’s sad to think that for a patient on the verge of going into withdrawal, it’s often a lot easier to relapse and find IV heroin or fentanyl on the street than it is to get access to a prescribed oral opioid medication that safely replaces these dangerous options.
In a previous study led by Dr. Weiner, researchers also found that 5.5% of emergency room patients treated for a near-fatal opioid overdoses were dead within a year, or around 1 in 18 such patients. I can think of no other disease with such a high short-term mortality rate that we would ever discharge from the ER or hospital without virtually guaranteeing them access to the evidence-based best standard of care.
So, the fact that the federal government finally made it easier for clinicians to prescribe buprenorphine in 2023 was good news. But if pharmacies don’t stock it—or won’t say they do when patients need to know that information— we are likely missing the chance to save lives. And wasn’t that the point of removing the red tape?
A simple solution.
What can we do to improve things on the ground? Here’s an idea: How about a law that requires pharmacies to list the medications they have in stock and keep that list up-to-date, or to say on the phone whether they do. This would help patients with all kinds of needs avoid the rigamarole of trying to chase down a pharmacy that carries the prescribed medication they need. This would be especially useful now that many drugs are in shortage.
A similar law governs information about hospitalized patients. While we are not allowed to disclose specific medical details about patients in our care, we can and do confirm that a patient is or is not being treated in our facility when asked (with exceptions for patient safety, of course). That way, missing persons reports are not filed needlessly.
Let’s make our patients’ lives easier.
Perhaps you can discuss the reasons pharmacies either don't carry or admit to carrying Buprenorphine for the treatment of opioid use disorder. A therapy, as you mentioned, may be life-saving. Thank you.