Buprenorphine access barriers persist in rural communities, but creative solutions overcome supply, cost and stigma
Article: Bayla Ostrach et al., Ensuring Buprenorphine Access in Rural Community Pharmacies to Prevent Overdoses, Journal of the American Pharmacists Association, (2021).
Reviewed by: Stacey McKenna
An estimated two million people in the United States are living with an opioid use disorder (OUD). Although a majority report interest in treatment, evidence-based therapies are difficult to come by. Medications such as buprenorphine bind to opioid receptors to reduce withdrawal symptoms and are widely considered the gold standard treatment for OUD. When compared to abstinence-only treatments, medications for OUD (MOUD) lead to long-term reductions in use; increased likelihood of cessation; lower overdose risk; and improved health and quality of life.
Yet these medications are available in only about 40 percent of residential treatment facilities. While calls for improved community-based access to MOUD are on the rise and federal regulations are shifting to increase feasibility, substantial barriers remain. In particular, research shows that many providers and pharmacists stigmatize individuals with OUD, and spotty insurance coverage can render the medications too expensive. These challenges not only hinder the ability to initiate treatment, but can disrupt therapy once it is underway. Significantly, such interruptions in access can result in unanticipated withdrawal—elevating potential harms, especially overdose risk. Although buprenorphine and other MOUD access issues can exist across settings, they are especially common in rural areas.
To help understand factors that affect “access to buprenorphine products in rural community pharmacies,” from 2020 to 2021 Bayla Ostrach and an interdisciplinary team of researchers conducted a mixed-methods study of pharmacies’, prescribers’ and patients’ experiences in North Carolina. Ostrach et al. present findings from a qualitative phase of that research, conducted among prescribers and patients, in a paper recently published in the Journal of the American Pharmacists Association.
The research team conducted semi-structured interviews with sixteen individuals—five health department staff, two harm reduction staff and nine people who had currently or recently been prescribed buprenorphine—in rural Western North Carolina. Staff were recruited by telephone calls and emails sent to relevant health departments and harm reduction organizations; buprenorphine recipients were recruited via referral by staff and other patients. Interviews were conducted in-person or over the phone, and covered participants’ respective backgrounds; current roles related to buprenorphine; their experiences with prescribing or accessing buprenorphine at local pharmacies; and their advice for new patients or prescribers. Researchers coded the interview text in several steps and then looked for patterns to identify overarching themes and their relationship to one another.
Overall, Ostrach et al. found persistent barriers to accessing buprenorphine, including dispensing practices, drug cost and stigmatizing treatment. Often, these factors overlapped, with pharmacists refusing to dispense buprenorphine because they did not approve of the patients, or hesitating to stock the medication because of its upfront costs. When pharmacies were willing to dispense, patients still found buprenorphine to be cost-prohibitive, often due to a lack of insurance. Regardless of why patients struggled to access prescribed medication, the resulting interruptions in treatment jeopardized their well-being. Several expressed regret that they had even started on MOUD.
Despite confirming these significant barriers to buprenorphine access, Ostrach et al. also identified a creative local solution. In two cases, prescribers established relationships with a dedicated pharmacy to dispense buprenorphine. This partnership improved access for patients, enhanced financial security for pharmacies (which not only had costs offset by grant money, but often found buprenorphine recipients transferred all of their medications over) and decreased stigma. The dedicated pharmacies were, according to both patients and prescribers who engaged with them, crucial to improving overall experiences with MOUD. By ensuring patients could receive medication before withdrawal symptoms set in, such programs improve retention and reduce the risk of overdose.
These findings represent an important step in addressing MOUD interruptions and mitigating potential harms to people living with OUD. Ostrach et al.’s qualitative interviews were consistent with other qualitative and quantitative research (cited above) on accessing buprenorphine in rural communities. Although qualitative research lacks the generalizability of quantitative studies, it provides the opportunity for greater depth of nuance and understanding as well as the emergence of unexpected information. Indeed, Ostrach et al. learned about a local solution—dedicated pharmacies—not because they asked about them, but because interviewees mentioned them spontaneously.
However, the study does have some limitations. While the data presented touch on pharmacists’ motivations for not dispensing buprenorphine, this information was gleaned via prescribers’ and patients’ reported experiences and conversations with pharmacists. These experiences do represent valid data, but additional interviews with the pharmacists themselves could provide another layer of meaning. In addition, the specific landscape of buprenorphine access and prescription is likely to vary not just by regional characteristics such as population density, but also according to state and local policies. As such, additional studies that can assess issues in different rural locales are warranted.
Furthermore, because the information about the dedicated pharmacy partnerships was not anticipated, the researchers did not design the present study to systematically assess them as an intervention. While it is clear that these programs require active, ongoing communication between pharmacists and prescribers to guarantee sufficient stock and avoid medication expiration, researchers did not have a sufficient sample to identify exactly what this communication should look like. As such, Ostrach et al. suggest that a targeted trial, as well as studies of the scalability and regionalized needs of such programs, are areas for future research.
Despite these limitations, Ostrach et al.’s study enriches our existing knowledge about factors that hinder and facilitate access to buprenorphine in the rural United States and highlights important new areas for continued research.
