Many pharmacies still do not stock buprenorphine despite eased prescribing rules

Faced with a worsening drug crisis, policymakers in recent years have made it much easier for doctors to prescribe the highly effective opioid addiction treatment buprenorphine. However, many patients may still struggle to find pharmacies carrying the treatment, finds new research led by the USC Schaeffer Center for Health Policy & Economics.

Buprenorphine was available at just 39% of U.S. retail pharmacies in 2023, a modest increase from 33% in 2017, according to the study published Sept. 2 in Health Affairs. But disparities in who can access the treatment have persisted. Pharmacies in predominantly Black neighborhoods (18%) and Latino neighborhoods (17%) remain significantly less likely to carry buprenorphine as those in white neighborhoods (46%).

Buprenorphine is one of several medications that can ease opioid cravings and withdrawal, and it is the only one that can be prescribed in primary care settings and dispensed at retail pharmacies. Because these treatments are milder opioids and considered controlled substances, they historically have been subject to tight prescribing and dispensing rules.

Recent efforts to ease prescribing rules include the 2023 elimination of the so-called "X-waiver" that required doctors to receive specialized training and registration to prescribe the treatment. However, dispensing rates have changed little, suggesting that pharmacy regulations aimed at preventing opioid (and buprenorphine) diversion, abuse and misuse continue to discourage pharmacies from carrying the treatment, particularly in minority neighborhoods and some areas hit hardest by the opioid epidemic.

Relaxing buprenorphine prescribing rules was an important step in making this critical treatment more accessible, but too many patients lack a nearby pharmacy that carries it. Federal and state policymakers must reduce barriers that make it difficult for pharmacies to stock buprenorphine, especially in some of the more vulnerable communities."

Dima Mazen Qato, senior scholar at the Schaeffer Center and the Hygeia Centennial Chair at the USC Mann School of Pharmacy and Pharmaceutical Sciences

Limited access in some hard-hit areas

Researchers analyzed buprenorphine claims from 2017 to 2023 from an IQVIA pharmacy database from covering 93% of U.S. retail prescription claims. Among their key findings:

• Although buprenorphine availability increased in most states, there were significant declines in five states (Florida, Ohio, Tennessee, Washington, Virginia) and Washington, DC.
• In nearly every state, buprenorphine availability was lowest in Black or Latino neighborhoods. In some states (California, Illinois and Pennsylvania), availability in these neighborhoods was about four to five times lower than in white neighborhoods.
• Independent pharmacies in Black and Latino neighborhoods were significantly less likely to stock buprenorphine and were also more likely to stop carrying it over time. But when these pharmacies did stock the treatment, they persistently filled about twice as many prescriptions per month compared with other types of pharmacies.
• Pharmacies in rural counties and those with high rates of opioid-related overdose deaths were persistently more likely to carry buprenorphine. Yet in 73 hard-hit rural counties, less than 25% of pharmacies carried the medication, and another 25 counties lacked a pharmacy.

Areas with fewer dispensing barriers had better access

Researchers said states should consider easing tight controls on buprenorphine dispensing, which can restrict access to the treatment in several ways.

When buprenorphine demand rises, suppliers may delay or pause shipments to pharmacies to avoid scrutiny from the Drug Enforcement Agency (DEA), and pharmacies often refuse to stock buprenorphine out of concern the orders will be flagged to the DEA. Some pharmacies carry the medication but refuse to dispense it for fear of running afoul of the federal Controlled Substances Act and similar state pharmacy regulations and laws, which require pharmacists to ensure that prescriptions for controlled substances are valid.

The researchers found buprenorphine availability was greatest in states with the least restrictive prescription drug monitoring programs, including those that limited how law enforcement could access the electronic databases to investigate suspicious prescribing.

The researchers said state and local governments should consider requiring pharmacies to maintain buprenorphine stock, noting that some have issued similar orders for the overdose reversal treatment naloxone and emergency contraception in an effort to improve access.

"If policymakers fail to introduce policies that increase equitable access to buprenorphine at local pharmacies, existing racial and ethnic disparities in opioid use disorder treatment and recovery will likely worsen," said first author Jenny S. Guadamuz, an assistant professor at the University of California, Berkeley School of Public Health.