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Pharmacist and Prescriber Perceptions on Buprenorphine Prescribing and Dispensing

By: Henry Larweh and Hridika Shah

Buprenorphine is an evidence-based medication for opioid use disorder (MOUD) that, until December 2022, could only be prescribed by obtaining a DATA waiver, also known as the X-waiver. Until its removal, the X-waiver was considered one of the largest barriers to MOUD access, and activists campaigned Congress to remove the requirement for prescribing. With one obstacle removed, questions remain of other existing barriers to buprenorphine access for patients with opioid use disorder.

During July 2023, researchers at Johns Hopkins University Bloomberg School of Public Health conducted a review of academic literature on pharmacists’ and prescribers’ perceptions on buprenorphine dispensing in the United States. This literature review provided context about current knowledge on perceived barriers to buprenorphine prescribing and dispensing to patients with opioid use disorder (OUD) among healthcare providers. While the purpose of this review was to inform a future research project, insights from selected literature may prove useful to states and localities as they consider opioid remediation efforts and how to spend their settlement funds for MOUD expansion.

Key Takeaways

1. Policy and Practice Barriers

Across all healthcare providers surveyed or interviewed, barriers to providing buprenorphine other than the X-waiver included managed care insurance policies such as prior authorization and concerns about being investigated and punished by the DEA for providing buprenorphine to patients. Fears about DEA investigations and punitive actions were higher among independent pharmacies, highlighting a key difference in willingness to dispense buprenorphine between chain pharmacies and independent pharmacies.

Among prescribers there were several barriers to prescribing buprenorphine. Aside from the X-waiver, physicians cited barriers to be:

  • Lack of knowledge and training 
  • Limited staff capacity
  • Competing demands

Support and mentorship from experienced clinicians and strong referral networks (to addiction specialists or pharmacists) were identified as facilitators to increase buprenorphine prescriptions/ing. There was also an identified need for interventions to catalyze organizational change. By dismantling stigma and norms surrounding OUD, as well as building robust referral pathways and peer mentorships, providers will have the support to prescribe buprenorphine. Several studies have evaluated interventions to improve uptake of buprenorphine prescribing, including learning collaboratives, physician champions, and multicomponent implementation strategies

2. Buprenorphine Stocking

Analysis of audit surveys pulled for review revealed that differences exist in stocking and availability of buprenorphine depending on the clinical setting and pharmacy type, independent/community or a chain pharmacy. Buprenorphine was found to be more available in chain pharmacies as compared to independent or community pharmacies. Additionally, among Certified Community Behavioral Health Centers in the United States, about one third reported offering buprenorphine or methadone. Another third reported being able to offer patients referrals to prescribers for buprenorphine or methadone in their immediate area.

3. Sentiments among Healthcare Providers

Among pharmacists, studies indicated a general sentiment to limit dispensing to local prescribers and patients. Some pharmacists refused to dispense to individuals who lived outside of the immediate area of service for a pharmacy. This was especially true for independent pharmacies, potentially due to fear of DEA investigation for diversion. These cautionary practices may be a direct result of pill mills and people traveling across state lines to “doctor-shop”, as the National Association of Boards of Pharmacy identifies traveling long distances to obtain medication is a “red flag protocol” for opioid diversion. Indeed, policies like Ohio’s “It’s OK to just say no” campaign are targeted towards pharmacists’ role in improving opioid safety. Another study found 57% of North Carolina pharmacists reported refusing to fill buprenorphine prescriptions if they happened to come from a nonlocal patient. Among 15 North Carolina rural pharmacies contacted in secret shopper surveys, 46% of all interactions reported additional conditions given to patients attempting to fill prescriptions from out of state. Negative perceptions were also often related to a shorter time in between prescription refills. One survey found that 36.16% of Texas pharmacists did not believe that MOUD leads to abstinence or recovery among patients with opioid use disorder.

There is some evidence of lack of trust between pharmacists and prescribers regarding the prescribing and dispensing of buprenorphine medication. Tennessee community-practice pharmacists reported believing that only 30% of MOUD prescribers used evidence-based care practices when prescribing buprenorphine. Limited methods of communication between pharmacists and prescribers, which is usually facilitated by patients themselves, contribute to some of the distrust between healthcare providers. Some pharmacists reported having “[d]ifficulty reaching prescribers with questions” about the prescriptions they received from patients.

The literature also identified several positive factors and motivators for buprenorphine prescribing and dispensing. In Michigan, pharmacists were more willing to dispense buprenorphine if they were in an urban location, received Accredited Continuing Pharmacy Education (ACPE) training, and were more confident about patient-prescriber communication regarding buprenorphine. A survey conducted in Texas found that pharmacists were positively motivated to dispense buprenorphine if they felt it was aligned with their personal connections and beliefs, would benefit patients’ wellness, and would aid the community.

Recommendations

It should be noted that most of this review is based on research conducted prior to the removal of the X-waiver, and as such, some of the conclusions drawn from the literature may prove to be outdated. However, this policy shift presents a window of opportunity to survey and evaluate prescribers and pharmacists about buprenorphine dispensing without the X-waiver. Additionally, states and jurisdictions should review and consider which of their policies may still restrict access to buprenorphine despite the removal of the federal limitation, especially if they are using their settlement dollars to expand access to MOUD. For example, examining state-level Medicaid policies regarding prior authorization requirements for buprenorphine prescriptions may help states identify a significant barrier to MOUD access among patients with opioid use disorder.

About the Authors:

Henry Larweh, BA is a Master of Science in Public Health in Health Policy candidate and Graduate Research Assistant with the Bloomberg Overdose Prevention Initiative at the Johns Hopkins Bloomberg School of Public Health.

Hridika Shah is a Senior Research Coordinator with the Bloomberg Overdose Prevention Initiative and a second year MSPH candidate.