Why Some Appalachian Pharmacies Refuse to Dispense Buprenorphine

April 29, 2020

Some pharmacies in Appalachia, a region hit hard by the opioid-involved overdose crisis, are denying opioid use disorder patients access to standard-of-care medication, found a study published March 26 by University of Kentucky and Emory University researchers. The pharmacies’ reasons include concerns over a Drug Enforcement Administration (DEA) limit, suspicion of manufacturers and prescribers, or stigma toward people who use drugs

Of 15 pharmacies surveyed in Kentucky’s Appalachian region, 12 declined new patients on buprenorphine, or only dispensed it to known patients or prescribers, or simply refused to dispense it. One of the key reasons the interviewed pharmacists made interventions in patients’ medication access was the fear of being flagged by pharmaceutical wholesalers, per DEA regulations, for “suspicious” medication orders of controlled substances.

The quantities needed to sound the regulatory alarm are unknown because “the wholesalers’ algorithms are proprietary,” said study author April Young, an epidemiologist at the University of Kentucky, in a press release. “Moving forward, we recommend that buprenorphine be removed from opioid monitoring systems, and if it must be tracked, it should be tracked separately.”

DEA-enforced monitoring programs have previously been known to hinder patients’ access to medically-necessary medications. For example, prescription drug monitoring programs track the opioids prescribed to a patient. They aim to empower prescribers to make informed clinical decisions, but have been associated with clinicians cutting off access or refusing to prescribe opioid analgesics to pain patients.

The Appalachian pharmacists also reported that their trust in manufacturers and prescribers had been “undermined” by the “legacy of aggressive and fraudulent marketing” around painkillers, the authors wrote. For years, major pharma companies like Purdue, Johnson & Johnson and Insys spread misleading information to prescribers about their opioid products’ potential harms and benefits, in an effort to encourage the medication’s overprescription. More recently, states attorneys general have launched lawsuits against these companies to recover economic losses incurred by the overdose crisis.

The pharmacists’ refusal to give patients their medication also came down to stigma, which the researchers attributed to the “the escalating local war on drugs.”

The connection between stigma and buprenorphine access is present in the doctor’s office, as well. A recent study found that a third of primary care doctors across the country don’t accept the efficacy of the medication, and only one in five would be open to prescribing it.

Photograph of a pharmacy by Clean Walmart via Flickr/Creative Commons

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