TToday’s illicit drug supply is more risky than ever, experts say. It is often contaminated with a variety of dangerous substances — from the potent opioid fentanyl to the equine tranquilizer xylazine and benzodiazepines — which make illicit drug use more unpredictable and increase the risk of overdose.
These risks make effective treatments indispensable. However, one of the most successful treatments for opioid dependence — buprenorphine — is hard to come by at most pharmacies across the country, according to a new study published in the journal Drug and alcohol addiction†
Researchers made secret phone calls to nearly 5,000 pharmacies in 11 states between 2020 and 2021 and found that buprenorphine, an opioid dependence drug shown to halve the risk of death in opioid users, was readily available in less than half of them. Some states had worse availability than others. In California, where buprenorphine was least available, only 31% of pharmacies carried it, while in Maine, where it was most widely available, 86% of pharmacies did. The study also found that naloxone, which reverses the effects of an overdose and is sold as a nasal spray as Narcan, was only available in 70% of the pharmacies surveyed.
The results suggest that many health care professionals do not view opioid-dependent drugs — especially buprenorphine — as lifesaving, essential treatments, said study co-author Lucas Hill, director of the drug addiction research and drug program at the University of Texas at Austin’s College of Pharmacy. “It’s frustrating to see health professionals of all types continue to view buprenorphine as an optional part of their healthcare practice,” he says. “Buprenorphine is our best resource to help people with opioid use disorder who are at risk of death from overdose due to the current poisoning of the illicit drug supply.”
Buprenorphine, commonly provided as Suboxone (a combination of buprenorphine and naloxone), is critical for many patients with opioid use disorders and is often preferred over the other two medications available, methadone and naltrexone. Unlike methadone, buprenorphine can be legally prescribed outside of an opioid treatment program. And compared to patients taking naltrexone — which blocks the effects of opioids — it’s easier to start because patients don’t have to detox before starting treatment. It also allows patients to maintain their opioid tolerance, making them less vulnerable to overdose if they later use an opioid.
Despite the drug’s efficacy, it has been tightly regulated since it was first approved for opioid use disorder 20 years ago, in part because buprenorphine itself is an opioid and has potential for abuse. The US Drug Enforcement Administration (DEA) has recently cracked down on pharmacies that fill many prescriptions for buprenorphine, a controlled substance. Physicians and other clinicians wishing to prescribe buprenorphine to their patients must obtain a special license called an X-waiver. Still, less than 10% of doctors have X-waivers, which proponents say cuts many patients off treatment.
Hill’s research revealed three trends that predict whether a pharmacy is likely to carry buprenorphine. Large, national chains have it in stock more often than independent pharmacies. It’s also more likely to be available in pharmacies in states that have expanded Medicaid, as well as in states where opioid overdose deaths are more common. (There are some exceptions; for example, California has expanded Medicaid, but it still has less access to buprenorphine than most other states.)
Some independent pharmacists have reported being reluctant to carry buprenorphine for fear that filling too many prescriptions of the drug could trigger a DEA investigation. Buprenorphine wholesalers are required to report large or otherwise suspicious orders to the DEA. Taleed El-Sabawi, an assistant law professor at Florida International University College of Law who studies addiction, says the DEA should issue official guidelines about dispensing buprenorphine to tell pharmacists they can give it to patients without harm. and a campaign to promote dispensing buprenorphine directly to pharmacies that do not sell it. “The DEA is feared by the pharmacists,” says El-Sabawi.
Some pharmacists also worry that there may not be enough demand for the drugs, which could end up on a shelf and cost them money, Hill says. Another deterrent, he says, is a persistent stigma against people with opioid use disorders.
In the midst of such an overdose crisis, Hill argues that pharmacists should put their doubts aside and make buprenorphine available to people who need it. “If you’re not sure, the answer is always to lean on dosing,” he says, “because this is a life-saving drug.”
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