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

The impact of buprenorphine prescriber data on geospatial access to treatment in HEALing Communities Study communities, 2022

INTRODUCTION

The location of buprenorphine treatment providers in the United States is pivotal to the understanding of regional factors associated with prescription and uptake. We evaluated how distinct data sources of treatment providers and their associated locations contribute to the differences observed when measuring buprenorphine accessibility.

METHODS

We compared buprenorphine treatment provider data from the Drug Enforcement Administration (DEA) and data from the behavioral health treatment locator from the Substance Abuse and Mental Health Services Administration (SAMHSA) for July 2022. Both DEA and SAMHSA data, while similar in spirit, vary substantially in how and why each data set is collected. DEA registration was required by law, while SAMHSA data was an opt-in registry of provider-submitted details. Analyzing the underlying semantics of the data is important for understanding the contextual factors driving observable differences in analytical outputs. We measured accessibility using enhanced two-step floating catchment area (E2SFCA) analysis in three states participating in the HEALing Communities Study (Kentucky, Ohio, Massachusetts). Within communities, we compared decile rankings of accessibility per census tract using each data source. We linked prescribing data from Kentucky's prescription drug monitoring program (PDMP) to measure accessibility using providers prescribing buprenorphine. We explored the significance of localized rank exchanges using neighbor set local indicators of mobility association (LIMA).

RESULTS

The number and rate of providers per capita differed substantially at the community level between data sources in the three states. These differences were less impactful in the spatial context of buprenorphine accessibility, which required both supply and demand in regions smaller than our intervention communities. Shifts did occur when measuring the intercommunity decile ranking of accessibility of census tracts, but LIMA results indicated that these rank exchanges were not significant.

CONCLUSIONS

When analyzing accessibility within a community using E2SFCA analyses, either DEA or SAMHSA data sources are acceptable; linkage to Kentucky's PDMP demonstrated that SAMHSA provider data is equally suitable to PDMP data for research studies involving spatial relationships with providers while being both significantly easier to obtain and less sensitive. When analyzing treatment provider rates per capita, results may vary substantially across these different data sources. Therefore, context must be considered when choosing an appropriate data source to use.

Barriers and facilitators to prescribing buprenorphine for treating opioid use disorder among emergency department and other practice setting physicians

Despite federal legislation intended to increase the prescribing of buprenorphine as medication for opioid use disorder (MOUD), such as the Drug Addiction Treatment Act (DATA) of 2000, most providers have continued to prescribe to some patients or to not prescribe at all. We aimed to determine the continuing barriers and supports needed for expanding buprenorphine prescribing and compared barriers experienced by emergency department (ED) physicians with those in other practice settings, given the unique aspects of the ED practice setting. We obtained survey data from August through November 2021 from 412 X-waivered Illinois physicians licensed to prescribe buprenorphine as MOUD, 95 (23.1%) of whom worked primarily in a hospital-based ED. Survey questions included: 1) Professional background, practice characteristics, and prescribing practices; 2) barriers to prescribing buprenorphine; 3) barriers to expanding prescribing; and 4) training/additional supports needed to facilitate buprenorphine prescribing. We used bivariate crosstabulations and multivariable OLS and binary logistic regressions to compare the responses of physicians practicing in the ED versus other practice settings and to compare physicians who prescribed buprenorphine in the past year with those who had not. There were few statistically significant differences among the examined subgroups indicating general agreement regardless of practice setting and prescribing status. The most frequently perceived barrier was having an inadequate community-based behavioral health treatment system to which OUD patients could be referred. Insurance reimbursement, difficulties building practice- and community-based systems to support buprenorphine prescribing, and challenges knowing where and how to refer patients for follow-up and ongoing support services were also prominent concerns. Based on study findings, efforts to expand buprenorphine for OUD might focus on providing support to make and manage treatment referrals and expanding the availability of community-based behavioral healthcare services. Building networks of care could potentially have a greater impact on MOUD availability than increasing the number of practitioners trained to prescribe buprenorphine.

Pharmacist-prescriber collaborative models of care for opioid use disorder: an overview of recent research

PURPOSE OF REVIEW

Collaborative models of care where pharmacists work alongside physicians have been developed for a range of physical health conditions, with benefits including improved patient outcomes and increased access to ongoing care. Opioid agonist treatment (methadone and buprenorphine) is a clinically effective and cost-effective treatment for opioid use disorder that is under-utilized in many countries due to a shortage of prescribers. In recent years, there has been increased interest in the development of collaborative models that utilize pharmacists to overcome barriers to treatment. In this article, we present a narrative review to synthesise recent work in this rapidly developing area.

RECENT FINDINGS

Two key aspects of opioid agonist treatment were identified: Collaborative models have utilized pharmacists to facilitate buprenorphine induction, and collaborative models provide increased capacity for delivering ongoing care in a variety of settings and patient groups where prescriber access is limited. Pharmacists have undertaken direct patient care responsibilities with varying degrees of autonomy, with benefits including a reduction in prescriber workload, and improvements in treatment retention and continuity of care.

SUMMARY

Collaborative models in which pharmacists are responsible for buprenorphine induction and ongoing management with methadone and buprenorphine have been shown to reduce demands on prescribers while improving or maintaining patient outcomes, and appear feasible and acceptable in a wide range of outpatient settings.

Protocol for the development of a consensus practice guideline To address clinical and regulatory barriers to buprenorphine dispensing in community pharmacy

BACKGROUND

Less than half of community pharmacies in the United States stock buprenorphine products indicated for the treatment of opioid use disorder. This lack of access to buprenorphine in community pharmacies is a significant barrier to care. To address this issue, this protocol outlines a comprehensive approach to develop a practice guideline aimed at improving access to safe and effective opioid use disorder treatment in community pharmacies.

METHODS

The guideline development process will proceed in three phases, following a technique closely aligned with the Institute of Medicine's guidance on guideline development. The first phase will involve conducting qualitative interviews with pharmacists in three states to identify their beliefs toward buprenorphine dispensing. As limitations on buprenorphine supply are related to constraints at all levels of the drug supply and regulatory system, the second phase, we will recruit representatives from regulatory agencies, pharmacy organizations, the Drug Enforcement Administration, pharmaceutical wholesalers as well as addiction medicine physicians and psychiatric pharmacists to develop consensus recommendations through a modified Delphi design. This will be followed by a public comment period and external expert review of the recommendations led by the National Association of Boards of Pharmacy. Finally, in the third phase, a national, mixed media dissemination campaign will be led by the National Community Pharmacists Association (NCPA) to convey recommendations to practicing pharmacists.

DISCUSSION

The guideline development process aims to incorporate the perspectives of multiple stakeholders and emphasize the importance of addressing the regulatory and pharmacy-specific aspects of care in addition to clinical evidence and guidance. The development of this guideline will provide targeted, multidisciplinary guidance for pharmacists, improving access to safe and effective opioid use disorder treatment in the community setting.

PREREGISTRATION

This protocol was registered with the Open Science Framework in March of 2023. Registration may be found at: https://doi.org/10.17605/OSF.IO/6S9DY .

Relationships Between Stigma, Risk Tolerance, and Buprenorphine Dispensing Intentions Among Community-Based Pharmacists: Results From a National Sample

BACKGROUND

Concerns have been raised that pharmacists sometimes act as barriers to patients with opioid use disorder (OUD) accessing buprenorphine treatment. The present research explores how community pharmacists' endorsement (vs non-endorsement) of stigmatizing beliefs about patients taking buprenorphine relate to intentions, comfort, and decisions regarding dispensing buprenorphine for OUD. In addition, we assessed attitudes toward risk in pharmacy practice as a novel correlate of dispensing intentions and decisions.

METHODS

A sample of 207 active community-based pharmacists practicing in the United States responded to survey items measuring stigma, risk tolerance, and intentions to dispense buprenorphine. The survey included 2 vignettes in which patients presented to the pharmacy with a prescription for buprenorphine, and respondents rated their comfort with dispensing and decisions regarding dispensing in the vignette.

RESULTS

Results suggest that both stigma toward patients taking buprenorphine to treat OUD and tolerance for risk in pharmacy settings are related to differences in pharmacists' intentions to and willingness to dispense buprenorphine for OUD.

CONCLUSIONS

Findings support the need for interventions to reduce stigma associated with buprenorphine use among pharmacists and suggest that risk tolerance is an important determinant of pharmacists' behavior that merits further study.

Addressing buprenorphine supply barriers: A guidance commentary

The current supply-side constraints limiting buprenorphine availability at pharmacies may reduce the potential impact of recent initiatives to improve medications for opioid use disorder (MOUD) access. The recent opioid litigation combined with existing federal regulation and enforcement has resulted in significant restrictions to the distribution and dispensing practices of pharmaceutical wholesalers and pharmacies countrywide. Previously discussed solutions to these problems do not seem to have produced actionable improvements to the current landscape. However, a novel solution to this problem may exist in the form of a Drug Enforcement Administration (DEA) guidance letter. These guidance letters allow the DEA to communicate directly to registrants, providing detailed interpretation and clarity regarding the DEA's expectations and enforcement realities. Recently, the DEA guidance letter portal was used to remind registrants that the DEA does not create quantitative thresholds or volume limits on controlled substance distribution. An additional guidance letter could be issued to ease the concerns about liability connected to the distribution and dispensing of buprenorphine. In particular, this guidance could acknowledge certain terms of the distributor settlement agreement as legal precedent and clarify that buprenorphine is not subject to the same restriction as other defined "highly diverted" controlled substances. Such guidance may also serve to provide both pharmaceutical wholesalers and pharmacies with assurance that an increase in buprenorphine distribution would not directly result in increased DEA scrutiny. This strategy represents an actionable step toward the goal of providing better access to MOUD by reducing existing supply-side limitations.