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,” said Dima Mazen Qato, senior scholar at the Schaeffer Center and the Hygeia Centennial Chair at the USC Mann School of Pharmacy and Pharmaceutical Sciences. “Federal and state policymakers must reduce barriers that make it difficult for pharmacies to stock buprenorphine, especially in some of the more vulnerable communities.”

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.

About the Study
Sarah Axeen of the USC Schaeffer Center and the Keck School of Medicine of USC is also an author. This study was supported by a grant from the Foundation for Opioid Response Efforts.

Notably, Black American respondents were most likely to incorrectly believe they could not receive medications for opioid use disorder via primary care, pointing to an important disparity in information that may further impede access to treatment. The findings suggest there is an important opportunity to increase awareness of these treatments and how to access them – using efforts that employ culturally specific strategies to reach different groups. Decades of research have shown the overwhelming benefit of existing medications for opioid use disorder, such as buprenorphine and methadone.

“Primary care is often people’s first point of contact in the health care system and can serve as a crucial setting to talk about addiction and receive lifesaving medications,” said Nora D. Volkow, M.D., Director of NIH’s National Institute on Drug Abuse (NIDA). “We need to provide education and support so that patients feel empowered to seek help from their primary care physician, and their doctors feel prepared to help them.”

Recent federal policy changes have removed some barriers to prescribing buprenorphine by primary care physicians, such as specialized training requirements (elimination of the X-waiver in 2023) and patient caps. Despite these changes, there remain barriers to receiving medication for opioid use disorder. A recent study found that, in the year after elimination of the waiver requirement to prescribe buprenorphine, the number of prescribers increased, but the number of persons who received the medication did not.

Studies estimate that fewer than 2,500 physicians specialize in addiction medicine in the U.S. With approximately 209,000 primary care physicians in the U.S., channeling addiction treatment through primary care could have a significant public health impact.

Researchers at Brown University, Providence, Rhode Island, hypothesized that public health factors may impede access to these medications. They formulated survey questions on people’s awareness of and comfort around opioid use disorder treatment in primary care. In collaboration with NIDA, the researchers added these questions to a survey conducted in English and Spanish by the Justice Community Opioid Innovation Network (JCOIN), led by NIDA and supported through The NIH Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative. JCOIN researchers administered this survey in June 2023, targeting a nationally representative sample of adults aged 18 and older.

Among 1,234 respondents, 57% were female, 43% were male, 12% were Black, 15% were Hispanic/Latino, 68% were white, and 5% reported other or two or more races. Most respondents agreed (53%) or strongly agreed (24%) that the office of a primary care physician should be a place where people can receive treatment for an opioid use disorder.

“We’ve made great strides in making it easier for primary care doctors to prescribe these safe and effective treatments, but our study indicates a critical disconnect between the need for medications for opioid use disorder and people’s knowledge about how to access them,” said Brandon del Pozo, Ph.D., assistant professor at the Warren Alpert Medical School of Brown University and Brown University School of Public Health and lead author on the study. “Science, public health, insurance, policy, and public perception all must align to improve access to treatment.”

The authors note that future research should explore targeted strategies to enhance public awareness and investigate the impact of increased primary care physicians’ involvement in providing medications for opioid use disorder. Awareness campaigns akin to those for HIV testing and cancer screening – including educational materials in medical settings and proactive screening by primary care physicians – may help address this gap in public knowledge. By increasing public awareness and demand, primary care physicians may be more incentivized to offer medications for opioid use disorder, especially with appropriate clinical and administrative support, the authors say.

This study, published in JAMA Network Open, was supported by NIDA, with additional support from NIH’s National Institute of General Medical Sciences.

The NIH Helping to End Addiction Long-term^SM and NIH HEAL Initiative^SM are registered service marks of the Department of Health and Human Services.

If you or someone you know is struggling or in crisis, help is available. Call or text 988 or chat at 988lifeline.org. To learn how to get support for mental health, drug or alcohol issues, visit FindSupport.gov. If you are ready to locate a treatment facility or provider, you can go directly to FindTreatment.gov or call 800-662-HELP (4357).

Reference: B del Pozo, et al. Knowledge, attitudes, and beliefs of US adults about opioid use disorder treatment in primary care. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2024.19094 (2024).

The findings, published online today in the journal JAMA Health Forum, provides a glimmer of hope amid a national overdose epidemic that has claimed more than 100,000 lives in the United States in each of the past few years.

The study examined community health centers serving low-income people primarily in West Coast states. Researchers found the number of health care professionals prescribing buprenorphine increased from 8.9% to 37.5% from 2016 to 2021 — a substantial increase that researchers attribute to increased state and federal efforts to ease the ability of clinicians to prescribe medication to treat addiction.

Buprenorphine, approved by the Food and Drug Administration in 2002, relieves withdrawal symptoms, cravings and pain. It normalizes brain function by acting on the same target in the brain as opioids or heroin. It’s one of three medicines approved by the FDA for treatment of opioid dependence, along with methadone and naltrexone.

“It’s heartening,” said lead author Daniel Hartung, Pharm.D., M.P.H., associate professor in the OHSU-Oregon State University College of Pharmacy. “Over a third of the providers in these community health centers are writing prescriptions for buprenorphine.”

Researchers examined data from 166 clinics in the network supported by Portland-based OCHIN, Inc. The study included more than 1,300 health care professionals that provided care for some 570,000 people in 2021.

In clinics in rural areas, the proportion of health care professionals able to prescribe buprenorphine was even greater, growing from 20.3% to 52.7% in five years.

“There’s still a lot of work to be done,” Hartung said. “But it’s a step in the right direction when more providers have the capacity to write prescriptions to treat patients who want to be treated.”

In addition to Hartung, co-authors included Robert W. Voss, M.S., of OCHIN, Inc.; Steffani R. Bailey, Ph.D., and Nathalie Huguet, Ph.D., associate professors of family medicine in the OHSU School of Medicine; and John Muench, M.D., M.P.H., professor emeritus of family medicine in the OHSU School of Medicine.

The research was supported by the grant R01DA046468 from the National Institute on Drug Abuse of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the officials views of the NIH. It was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network, which is led by OCHIN in partnership with Health Choice Network, Fenway Health and OHSU, funded through contract R1-OCHIN-01-MC from the Patient-Centered Outcomes Research Institute.