On June 22 the Substance Abuse and Mental Health Services Administration published a resource document covering the role of pharmacists in expanding access to medications for opioid use disorder (MOUD). Though it doesn’t mention harm reduction explicitly, it’s a surprisingly harm reduction-compatible report from an agency that’s currently not supposed to subscribe to that kind of thing.
The Advisory covers all three Food and Drug Administration-approved MOUD, but the crux of it is about buprenorphine (commonly known by brand name Suboxone). Unlike methadone, which is confined to its own clinic system, and naltrexone, which is unhelpful, bupe is an evidence-based medication that can be picked up from a pharmacy once a month like most other prescriptions. It’s the most widely prescribed of the three MOUD, but access is still limited in many regions and for many demographics, and patients and prescribers alike still face inordinate surveillance from the Drug Enforcement Administration. In recent years, there’s been a growing push for pharmacists to be able to prescribe bupe to patients directly.
Some pharmacists have been able to prescribe bupe through collaborative practice agreements with licensed physicians—but only in the minority of states that authorize them. In 2022, the Mainstreaming Addiction Treatment Act eliminated the X-waiver and allowed bupe to be prescribed to more patients by more types of providers, including pharmacists, with fewer bureaucratic hurdles. But pharmacists’ ability to prescribe bupe was still restricted at the state level.
In late 2025, the SUPPORT Act authorized DEA-licensed pharmacists to prescribe bupe independently after completing an eight-hour training that’s specific to buprenorphine (rather than one more broadly focused on substance use disorder). But to date, only California and Idaho have approved pathways for pharmacists to prescribe bupe independently.
“A pharmacist’s ability to prescribe and dispense MOUD is especially important for communities that have limited access to or awareness of OUD treatment,” the Advisory states. “[P]harmacists are often the first point of contact on the continuum of care for people with OUD, and most pharmacies have longer hours of operation than other medical providers. These considerations mean that, where state laws allow, DEA-registered pharmacists are well-positioned to provide patients with streamlined, low-barrier access to MOUD.”
“Medication diversion is a complex topic and is often misunderstood,” the Advisory states.
SAMHSA has recently been shifting its rhetoric around long-term MOUD maintenance toward tapering, validating the very dangerous idea that bupe and methadone are only step-downs on the road to “full” abstinence—which encourages scrutiny of the many people who have been stable on those MOUD for years or even decades. But rather than push the concept, the Advisory frames tapering only as a possibility that some patients might decide to pursue, while “clinical experience shows that [others] may require long-term treatment with medications.”
It also addresses pharmacists who might be wary of prescribing bupe to patients who also use other substances besides opioids, stating that in the context of the overdose crisis “it is safer to initiate MOUD without requiring abstinence from multiple substances.”
Urine drug-testing is discussed only briefly, to note that the practice “may be useful for assisting with treatment adherence,” but in isolation “has limited utility and effect on patient outcomes,” and “may be viewed as punitive by patients.”
For pharmacists concerned about “diversion,” meaning the bupe getting used in some way it wasn’t meant to, or by someone it wasn’t prescribed to, SAMHSA states that they shouldn’t decline to fill a prescription without first talking to both the patient and provider.
“Medication diversion is a complex topic and is often misunderstood,” the Advisory states. “Pharmacists who have concerns about the prescribed buprenorphine treatment regimen should not automatically decline to dispense it … buprenorphine is rarely associated with fatal overdose, and, when it is, other substances are almost always present.”
The government is always lamenting how there are too many barriers to accessing bupe even though its risks are negligible, how the overdose crisis makes this a matter of utmost urgency, how only a fraction of the people eligible for a prescription are able to get one. Then when the people take matters into their own hands it’s called “diversion,” and we have to stop them before too much life-saving medication gets into the community, where just anyone could take it. This is why these resource guides always overlook the fact that the more appropriate way to dispense bupe, compared to the current restrictive setup, would be to just launch it into the streets with a T-shirt cannon.
Image (cropped) via California State Board of Pharmacy