Switching pharmacies leads to gaps in medication possession in individuals treated with buprenorphine

Understanding the financial barriers to treatment among individuals with opioid use disorder: a focus group study

INTRODUCTION

Despite the established effectiveness and relatively widespread availability of Medications for Opioid Use Disorder, individuals seeking treatment frequently encounter various structural and social barriers, including costs of treatment. This study aimed to understand the financial barriers that affect treatment continuation in individuals with opioid use disorder (OUD).

METHODS

In this qualitative study, seven semi-structured in-depth focus group interviews were conducted among 28 participants in treatment for OUD. Basic demographic information were collected in a pre-focus group survey. Focus group interviews were conducted from December 2021 to February 2022. A moderator guide was used to facilitate the discussion. Transcripts were managed using ATLAS.ti© v7. Data collected from the focus groups underwent deductive thematic analysis.

RESULTS

Data saturation was reached in 7 focus groups with a total of 28 participants (17 [60.7%] women; 27 [96.4%] white; 24 [85.7%] non-Hispanic). All three medications for OUD were represented (18 [64.3%] buprenorphine and naloxone, 5 [17.9%] methadone, 3 [10.7%] naltrexone, and 2 [7.1%] buprenorphine) and the time in treatment ranged from 1 month to over 36 months. Nearly all participants (27 [96.4%]) indicated a financial barrier that led to delayed treatment initiation and treatment retention. Two themes were identified from the focus group interviews: (1) OUD treatment-related financial burden- the direct and indirect cost associated with the treatment, and (2) psychosocial effects associated with the cost of OUD treatment -the mental, emotional, and social effects of the disease.

CONCLUSIONS

Most participants described the desire and need for resources to offset the unaffordable cost that inhibits treatment initiation and retention. Further work is required to help identify individuals susceptible to financial barriers that can lead to early discontinuation in treatment.

The impact of the mainstreaming addiction treatment act and associated legislative action on pharmacy practice

The recent passage of the Mainstreaming Addiction Treatment (MAT) Act will expand access to treatment for opioid use disorder (OUD) by eliminating prescriber registration requirements introduced as part of the Drug Abuse Treatment Act (DATA) of 2000. Without the X-Waiver, and Drug Enforcement Administration (DEA) registered prescriber can now prescribe buprenorphine. Eliminating DATA-2000 registration is the first step in improving access to buprenorphine, but additional barriers, including unclear restrictions on wholesale buprenorphine supply and insurance coverage, remain. Recently, the DEA formally clarified that suspicious order monitoring programs were managed entirely by wholesalers and manufacturers and that DEA does not set suspicious order monitoring limits. In this commentary, we address the somewhat conflicting implications of the MAT Act and recent DEA guidance on buprenorphine dispensing in community pharmacies. We also discuss innovative practice models that leverage pharmacists' cognitive skills to manage pharmacotherapy for persons with OUD. Recent policy changes and emerging evidence suggest that pharmacists are better positioned than ever to provide low-barrier access to treatment for OUD and to show their value in this practice area by actively engaging patients with prescribed buprenorphine.

Addressing buprenorphine bottlenecks in the context of MAT Act implementation: A shared responsibility

Medications for opioid use disorder (OUD) such as buprenorphine reduce overdose mortality and other opioid related acute health events but have historically been highly regulated. The recent Mainstreaming Addiction Treatment (MAT) Act ended the requirement clinicians complete a specified training and apply for a DATA 2000 ("X") waiver on their Drug Enforcement Administration (DEA) number, to prescribe buprenorphine. With the MAT Act, any practitioner with Schedule III prescribing authority (a regular DEA number) can now prescribe buprenorphine for OUD. While this has potential to improve OUD treatment access, the impact will depend on implementation. Though the MAT Act may facilitate increased buprenorphine prescribing, ensuring adequate buprenorphine dispensing is also critical to improving Medications for opioid use disorder. Recognized buprenorphine bottlenecks arise from a complex convergence of factors in community pharmacies, threatening to undercut the benefits of the MAT Act. If prescribing increases but is not matched by increased dispensing, bottlenecks may worsen. Any worsening of buprenorphine bottlenecks could have a disproportionate impact in rural areas where residents may rely on fewer pharmacies to fill prescriptions for people in larger geographic area and where larger prescribing-dispensing gaps already exist such as in Southern states. Rigorous research will be needed to document the overall impact of the MAT Act on community pharmacists and their patients. At the federal level, pharmacists and their professional organizations should lobby the DEA to de-schedule or re-schedule buprenorphine. The DEA should announce a moratorium on enforcement actions against wholesalers and pharmacies related to buprenorphine distribution and dispensing. More supports should be offered to community pharmacies by state pharmacy boards and associations including continuing pharmacy education and technical assistance for advocating with wholesalers to increase buprenorphine order sizes, and to more effectively communicate with prescribers. Pharmacies should not have to face these challenges alone. Regulators, wholesalers, and researchers must join together with community pharmacies to further reduce regulatory barriers to dispensing, provide evidence-based interventions where needed to support pharmacy dispensing efforts, conduct rigorous implementation research, and be constantly vigilant in identifying and addressing multi-level buprenorphine bottlenecks in the wake of the MAT Act.

Demographic and socioeconomic correlates to buprenorphine access in pharmacies

BACKGROUND

Research has focused on buprenorphine prescribing with limited attention to the role of pharmacy access to buprenorphine for opioid use disorder.

OBJECTIVE

This study examines demographic and socioeconomic correlates to buprenorphine access in Georgia pharmacies.

METHODS

A 5-question (12 potential subqueries) telephone administered survey was used to investigate access and stocking patterns of specific dosages and formulations of buprenorphine in Georgia pharmacies (n = 119). Descriptive statistics characterized physician and pharmacy demographics and buprenorphine stocking practices. Correlations between various factors including buprenorphine stocking practices, geographic, and sociodemographic characteristics were identified using nonlinear regression models.

RESULTS

The majority of pharmacies stocked the most commonly prescribed 8/2 mg dosage strength of buprenorphine/naloxone films and tablets (69.0% and 63.0%, respectively). Other strengths were less likely to be readily available. Pharmacies in Suburban Census tracts were 77.0% more likely to stock any type of buprenorphine monotherapy [odds ratio (OR) = 1.77, t = 2.37, P < 0.05] and 58.1% more likely to stock the 8 mg buprenorphine monotherapy formulation [OR = 1.58, t = 2.15, P < 0.05] than Urban tracts. Pharmacies in areas with above-average non-White populations were 29.6% more likely to stock a monotherapy product [OR = 1.30, t = 2.16, P < 0.05], and those in areas with above-average poverty rates were more likely to stock the 8 mg/2 mg buprenorphine/naloxone tablets [OR = 1.04, t = 2.02, P < 0.05]. There were no additional differences across the sample in formulation or dosage strengths. Pharmacists who endorsed challenges dispensing buprenorphine (23.3%) cited issues around insurance coverage, payment difficulty, prior authorization issues, and low stock of specific formulations.

CONCLUSIONS

Results suggest that low availability of certain dosages or formulations of buprenorphine in local pharmacies could obstruct access for patients. Future research should address barriers to supplying buprenorphine and collaborative measures between pharmacists and prescribers to improve access.