(53) Pharmacy Barriers to Receiving Buprenorphine Addiction Treatment Through Telehealth

Background & Introduction: Opioid use disorder is a major public health crisis in the United States with opioid overdose contributing to nearly 74,000 overdose deaths in 2022. Buprenorphine is a first-line medication for opioid use disorder, yet many individuals face barriers filling buprenorphine prescriptions. To date, there have been limited studies that have assessed the prevalence of pharmacy barriers in rural and non-rural settings. However, available evidence indicates telehealth prescriptions for buprenorphine may be questioned and rejected more frequently than those from local prescribers due to the prescriber’s physical distance from the pharmacy or patient being viewed as a “red flag” for diversion. Patients living in rural areas may be disproportionately impacted by pharmacy-related barriers given the lack of other available pharmacies in reasonable geographic proximity. We assessed pharmacy challenges in filling buprenorphine prescriptions among adults receiving telehealth treatment for opioid use disorder and examined differences between patients living in rural and non-rural areas.

Methods: We conducted a web-based, cross-sectional survey in August 2024 among adult patients currently in treatment for opioid use disorder at a multi-state telemedicine practice who provided a valid zip code during enrollment. Patients were divided into two sampling strata by rural and non-rural residence determined by zip codes mapped to Rural Urban Commuting Area (RUCA) codes and were randomly selected in three survey waves balancing the proportion of participants in rural and non-rural areas. Demographics, health history, and substance use characteristics were self-reported and pharmacy issues with filling buprenorphine prescriptions were measured using an adapted questionnaire from Winstanley et al. Patients were invited to participate through a 2-week email and text message campaign and participants received $20 e-gift cards as compensation for their time and effort. Descriptive analyses were used to assess participant characteristics and experiences of pharmacy barriers overall and by rural and non-rural residents.

Results: A total of 601 patients receiving opioid use disorder treatment through telehealth completed the online survey, with 300 participants (49.9%) residing in non-rural areas and 301 residing in rural areas (50.1%). The mean age of respondents was 41.44 years with approximately 60% of respondents identifying as women (n=360) and 90.4% identifying as White (n=534). Over 60% of participants (n=358) reported being in treatment for opioid use disorder for 12 months or longer. A greater percentage of participants residing in rural areas reported diagnoses for depression (73.8%) and stimulant use disorder (19.9%) compared to participants in non-rural areas (63.0% and 12.3% respectively).
Approximately a quarter of patients (n=165, 27.5%) reported having problems filling their buprenorphine prescription in the previous 12 months. Among participants who reported a pharmacy issue, the most common problems were that buprenorphine was out of stock and needed to be ordered (n=90, 54.5%), insurance coverage issues (n=37, 22.4%), and pharmacy hesitancy in filling a prescription from a telehealth provider (n=32, 19.4%). Of those respondents reporting pharmacy issues, 85.5% (n=141) were able to resolve the issue at the pharmacy. A total of 192 (31.9%) of all survey participants reported having to go without buprenorphine at some time in the past 12 months due to pharmacy issues, with 47 participants reporting going without buprenorphine for 7 days or longer. We found no statistically significant differences in the experience of buprenorphine fill problems between respondents in rural and non-rural areas.

Conclusion & Discussion: Challenges filling buprenorphine prescriptions evenly affect patients residing in rural and non-rural areas receiving treatment for opioid use disorder through telehealth. While most patients reported issues with filling buprenorphine prescriptions were eventually resolved, nearly one-third reported having to go without buprenorphine because of pharmacy challenges emphasizing the need for broadly expanded buprenorphine access. Policies removing buprenorphine ordering limits and requiring minimum levels of buprenorphine inventory for pharmacies could support greater medication availability for patients with opioid use disorder. Additionally, innovations in pharmacy operations to remove red flags in computer systems for geographically distant providers or to offer buprenorphine home delivery could improve the experience of patients with OUD seeking treatment through telemedicine.

References: Winstanley EL, Thacker EP, Choo LY, Lander LR, Berry JH, Tofighi B. Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use. Drug Alcohol Depend Rep. 2022 Sep 8;5:100091. doi: 10.1016/j.dadr.2022.100091. PMID: 36844166; PMCID: PMC9949336.
Textor L, Ventricelli D, Aronowitz SV. 'Red Flags' and 'Red Tape': Telehealth and pharmacy-level barriers to buprenorphine in the United States. Int J Drug Policy. 2022 Jul;105:103703. doi: 10.1016/j.drugpo.2022.103703. Epub 2022 May 10. PMID: 35561484; PMCID: PMC10962060.
Hill LG, Loera LJ, Torrez SB, Puzantian T, Evoy KE, Ventricelli DJ, Eukel HN, Peckham AM, Chen C, Ganetsky VS, Yeung MS, Zagorski CM, Reveles KR. Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in 11 U.S. states. Drug Alcohol Depend. 2022 Aug 1;237:109518. doi: 10.1016/j.drugalcdep.2022.109518. Epub 2022 Jun 6. PMID: 35691255.