Mini Review - (2021) Volume 0, Issue 0
Cordant Health Solutions, Denver, Colorado, USA
Received Date: May 05, 2021; Accepted Date: May 19, 2021; Published Date: May 26, 2021
Citation: Kolb E (2021) Provider access is not enough: Clinic-based buprenorphine delivery program overcomes pharmacy-level barriers to medication access. Clin Psychiatry Vol.7 No.S4:003.
The national focus on improving access to treatment for opioid use disorder (OUD) extends beyond the provider who can prescribe buprenorphine. Efforts designed to remove barriers and lessen obstacles to receive care for those seeking treatment for OUD are vastly geared towards making it easier to find a provider and enter treatment. It can be overlooked that not until patients prescribed buprenorphine have their medication in hand can they be adherent to their treatment plan and begin medicationassisted treatment (MAT). A recent study evaluated a clinicbased pharmacy delivery program where patients obtained buprenorphine at the time of their treatment appointment as opposed to seeking to fill at community pharmacies thereafter. Retention in care, medication adherence, illicit drug use and emergency department utilization significantly improved and high patient satisfaction was observed following implementation of the pharmacy services. Efforts that strengthen and empower the prescriber pharmacist relationship and thus, bring the written prescription and filled medication closer, have meaningful implications for patients, providers, and the behavioral health community.
Buprenorphine; Opioid use disorder; Medication access; Pharmacy delivery program
Medication-assisted treatment (MAT) is a holistic approach to treating substance use or mental health disorders encompassing the use of medications in combination with counseling, behavioral therapies, and patient monitoring. Buprenorphine, an opioid partial agonist medication approved for the office - based treatment of opioid use disorder (OUD), is an evidence-based MAT option associated with positive clinical outcomes when taken as prescribed [1]. Treatment access for OUD is commonly referred to as a single entity and effort, but for patients prescribed buprenorphine, prescription access and medication access are two separate components in the recovery journey. The success of initiatives focused on improving access to providers who can prescribe buprenorphine assumes that community pharmacists will dispense the medication reliably to patients who present legitimate prescriptions. The proximity of approximately 90% of Americans living within five miles of a community pharmacy assumes easy and convenient access to medication [2]. However, a recent study that screened pharmacies across the country regarding the availability of buprenorphine revealed that one in five pharmacies reported they do not dispense buprenorphine and 30% of pharmacies noted having restrictions and limitations in place on the buprenorphine prescriptions they do fill [3]. Pharmacy-level barriers to medication access exist for patients seeking to fill buprenorphine prescriptions at traditional community pharmacies and may contribute to poor clinical outcomes. Missing buprenorphine doses for patients with OUD, especially for those early in treatment, could have fatal consequences if the lack of medication access leads to return to use. The risk of relapse and potential for overdose significantly increases with nonadherence to buprenorphine therapy, making efforts that close the gap between the written buprenorphine prescription and the filled medication critical for patients with OUD [4,5].
One advantage of utilizing buprenorphine to treat OUD is that patients are not required to report to a designated program for observed daily dosing, but rather can access their medication via community pharmacies and independently dose after filling a prescription from a waivered provider [6]. This enables providers to treat patients with OUD in a similar manner to other chronic disease states that encompass ongoing use of medications and theoretically, helps to support a change in perspective toward OUD from both the medical community and society. Yet, the perception of OUD, patients with the diagnosis, and the medications to treat it are commonly viewed more negatively than opinions associated with those living with diabetes, heart disease, hypertension, asthma, or other chronic conditions [7]. When attitudes towards people with OUD were evaluated in comparison to those with mental health conditions, significantly more respondents reported being unwilling to have a person with a substance use past marry into their family or work closely with them and significantly more respondents noted they were more skeptical about the effectiveness of MAT for OUD as opposed to medication for mental health conditions [8]. Bias towards OUD is frequently rooted in moral judgment that substance use is a choice and a personal shortcoming as opposed to OUD being a chronic disease and buprenorphine being an evidence-based medication with proven efficacy to treat OUD. This stigma surrounding OUD extends into the community pharmacy setting, many times due to lack of education and misperceptions. Specifically, survey of patients seeking to fill buprenorphine prescriptions at community pharmacies revealed 55% of respondents experienced stigma and shame while at community pharmacies. In addition to the judgment felt, the survey found transportation challenges or undue time spent obtaining buprenorphine at community pharmacies noted by 77% of respondents and inability to fill buprenorphine at community pharmacies due to unreliable or no stock of the medication noted by 34% of respondents [9].
Patients seeking recovery for OUD must overcome the initial challenges of finding a treatment provider to begin their recovery journey, then continue to attend scheduled appointments and remain active and engaged in their treatment plan, which encompasses the responsibility of consistently filling prescribed buprenorphine at community pharmacies. A combination of provider access limitations, stigma, financial circumstances, social factors, etc. must be overcome for a patient to have a buprenorphine prescription in hand. However, prescription access does not necessarily equate to medication access for patients prescribed buprenorphine. Accumulating literature supports that care coordination and collaboration between pharmacist and prescriber improves patient care and health outcomes, yet for patients with OUD, the disconnect between provider and pharmacist can be substantial. Anecdotal reasoning as to pharmacies restricting access to buprenorphine for individuals with OUD include ambiguity navigating what the Drug Enforcement Administration (DEA) regulations are, inability to meet patient demand, wholesaler limitations, stigma from pharmacy staff, and fear of patient diversion. Lack of trust in the providers treating OUD, MAT for OUD, and patients prescribed buprenorphine were also noted as hesitations contributing to pharmacies limiting quantity, capping patients served, or shying away from stocking and dispensing buprenorphine altogether [10-12].
Simplifying the traditionally two-step process of obtaining a buprenorphine prescription from a provider and then filling the prescription at a community pharmacy to be inclusive at the time of a single treatment visit provides patients with convenient, fast, and judgment-free access to their medication. Integrating buprenorphine medication pick-up at the time of a patient’s treatment visit not only alleviates the need for patients to seek a pharmacy to fill their prescriptions, providing time savings and less stress, but also presents clinically relevant benefits. Such coordination closes the time between the written prescription and the filled medication which supports medication adherence as patients leave treatment with their buprenorphine in hand. Furthermore, there is greater privacy for patients as the same support team at the clinic delivers the medication. The need to fill prescriptions at community pharmacies puts patients in situations where they may run into someone who is unaware of their substance use or recovery or someone from their past who may not be in recovery or has relapsed. Additionally, clinicbased integration of pharmacy services may serve as a motivating factor for patients to attend scheduled treatment appointments knowing that making it to the clinic means leaving with medication.
A recent study by Khan et al. (2021) details a pharmacy delivery program where clinic-based buprenorphine provision was implemented as a key tenet of a comprehensive managed program that establishes a direct, trusted relationship between prescriber and pharmacist. Patients in the clinic-based pharmacy program had their prescriptions filled by a pharmacy that coordinated medication delivery with the clinic’s appointment schedule, such that a pharmacy liaison within the office gave each patient their prescribed buprenorphine at the conclusion of their clinic visit. The pharmacist is experienced in caring for patients who have been prescribed buprenorphine and is complemented by a compliance leader with regulatory experience. The pharmacist checks the prescription drug monitoring program (PDMP), which is an electronic database that tracks controlled substance prescriptions dispensed. Review of PDMP data provides insight into prescribed medications, diagnoses, potentially dangerous drug combinations, and patient behaviors such as provider and pharmacy utilization [14]. The pharmacist reviews recent drug testing results to ensure buprenorphine is present and to identify any unexpected substance use for each patient, raising irregularities prior to filling the buprenorphine. Additionally, the pharmacist offers lifesaving naloxone to each patient in the program. A pharmacy liaison is present during clinic office hours to deliver medication to the patients as well as facilitate communication and coordination between clinic schedule and medication delivery.
Retention in care, medication adherence, illicit drug use and drug-related emergency department (ED) utilization significantly improved following implementation of this clinic-based pharmacy program. Patients were more likely to make their scheduled treatment appointments when the pharmacy delivered their buprenorphine medication in coordination with their clinic visit and demonstrated a 52.2% higher retention rate at 6 months as compared with patients prior to the pharmacy services being available. Additionally, patients in the clinic-based pharmacy program demonstrated a buprenorphine positivity rate of 92.5%, as compared with 85.8% observed for patients prior. Illicit/nonprescribed drug use was identified in 29.2% of samples tested from patients in the program as compared with 41.3% observed for patients prior. Specifically, 45.9% fewer samples tested from patients in the program revealed opiate use, with an opiate positivity rate of 15.1% for patients in the program and 27.9% for patients prior. Further, 41.4% fewer patients in the clinic-based pharmacy program utilized the ED for drug-related reasons including overdose, abscess from injection site, injury while on drugs, sickness from withdrawal, fear or sickness while on drugs, as well as drug-seeking behavior or suicide attempts where indication of illicit drug use or misuse of prescription medication was noted as compared with patients prior [13].
This clinic-based pharmacy program studied serves thousands of patients spanning 11 states today, and reports similar findings of high retention, adherence and patient satisfaction as new clinics incorporate the pharmacy program into their practice as an extension of their treatment services. An ongoing anonymous and voluntary patient experience survey has captured the feedback of over 1,100 patients from 29 office-based opioid treatment (OBOT) clinics receiving their buprenorphine at their treatment visit through this clinic-based delivery program. The survey found that 98% of patients agreed the pharmacy liaison within the clinic treats them with respect and cares about their well-being. Additionally, 93% of patients agreed that receiving buprenorphine at the time of their treatment visit makes them more likely to attend appointments and stick with their treatment plan. The survey produced a Net Promoter Score of 84, signifying patients surveyed are highly satisfied with their pharmacy program experience and service level. Furthermore, common themes of more convenient, more discreet, easier, faster, stress-free, judgment-free and helps support recovery engagement and success were noted by respondents when asked how receiving their medication at the clinic versus at a community pharmacy has impacted their recovery. Select quotes from this survey question are highlighted and shed valuable light on how removing one key barrier to access by aligning prescribing and pharmacy services makes a substantial difference:
“It's a relief I can do everything while I am here. And I don't have to worry about the pharmacy having my meds or people judging me.”
“It helps me feel normal again. Something I haven't had in a while.”
“Rather than waiting until I go to the pharmacy, I received medication at the doctor’s office. Less time in between doctor and meds means less time to make bad decisions.”
“By receiving my meds at my doctor's office, it makes me feel better about myself and no one knows what I have going on in my life. I feel like everyone else.”
“It has helped keep me from running into people that could affect my sobriety at the pharmacy.”
“It's made it less stressful. No stigma attached to Suboxone by Cordant.”
Removing harmful barriers to treatment is a top priority in the addiction treatment space, making programs aimed at improving access, reducing stigma, and enhancing patient care, such as alleviating the need to seek to fill prescriptions for buprenorphine at community pharmacies, extremely valuable. Broader implementation of the clinic-based pharmacy program presented along with similar strategies that remove obstacles to improve the likelihood that patients with OUD have the medications they need for recovery helps support positive clinical outcomes. The growing body of research supporting integration of prescribing and pharmacy services for patients with OUD helps eliminate the stigma and burdensome experiences that may exist for patients while seeking to fill buprenorphine prescriptions without care coordination. However, more research is needed to continue to accelerate the momentum behind extending the continuum of care for patients with OUD to determine causality and generalizability of the positive clinical outcomes observed in existing literature. Improved partnership between prescriber and pharmacist requires development of trust, improved education to understand OUD and the medications to treat it, and enhanced communication to align, strengthen, and empower the working relationship between the two. The full study detailing the clinicbased pharmacy program discussed herein and its findings, Supportive alternate site provision of buprenorphine: Overcoming barriers and improving patient outcomes, can be viewed in the Journal of Substance Abuse Treatment.
