Availability Of Buprenorphine Research Articles

Strengthening Neuroplasticity in Substance Use Recovery Through Lifestyle Intervention

The incidence of substance use and behavioral addictions continues to increase throughout the world. The Global Burden of Disease Study shows a growing impact in disability-adjusted life years due to substance use. Substance use impacts families, communities, health care, and legal systems; yet, the vast majority of individuals with substance use disorders do not seek treatment. Within the United States, new legislation has attempted to increase the availability of buprenorphine, but the impact of substance use continues. Although medications and group support therapy have been the mainstay of treatment for substance use, lifestyle medicine offers a valuable adjunct therapy that may help strengthen substance use recovery through healthy neuroplastic changes.

Racial and Ethnic Disparities in Geographic Availability of Buprenorphine.

Overdose mortality has risen most rapidly among racial and ethnic minority groups while buprenorphine prescribing has increased disproportionately in predominantly non-Hispanic White urban areas. To identify whether buprenorphine availability equitably meets the needs of diverse populations, we examined the differential geographic availability of buprenorphine in areas with greater concentrations of racial and ethnic minority groups. Using IQVIA longitudinal prescription data, IQVIA OneKey data, and Microsoft Bing Maps, we calculated 2 outcome measures across the continental United States: the number of buprenorphine prescribers per 1000 residents within a 30-minute drive of a ZIP code, and the number of buprenorphine prescriptions dispensed per capita at retail pharmacies among nearby buprenorphine prescribers. We then estimated differences in these outcomes by ZIP codes' racial and ethnic minority composition and rurality with t tests. Buprenorphine prescribers per 1000 residents within a 30-minute drive decreased by 3.8 prescribers per 1000 residents in urban ZIP codes (95% confidence interval = -4.9 to -2.7) and 2.6 in rural ZIP codes (95% confidence interval = -3.0 to -2.2) whose populations consisted of ≥5% racial and ethnic minority groups. There were 45% to 55% fewer prescribers in urban areas and 62% to 79% fewer prescribers in rural areas as minority composition increased. Differences in dispensed buprenorphine per capita were similar but larger in magnitude. Achieving more equitable buprenorphine access requires not only increasing the number of buprenorphine-prescribing clinicians; in urban areas with higher racial and ethnic minority group populations, it also requires efforts to promote greater buprenorphine prescribing among already prescribing clinicians.

Addressing buprenorphine supply barriers: A guidance commentary

The current supply-side constraints limiting buprenorphine availability at pharmacies may reduce the potential impact of recent initiatives to improve medications for opioid use disorder (MOUD) access. The recent opioid litigation combined with existing federal regulation and enforcement has resulted in significant restrictions to the distribution and dispensing practices of pharmaceutical wholesalers and pharmacies countrywide. Previously discussed solutions to these problems do not seem to have produced actionable improvements to the current landscape. However, a novel solution to this problem may exist in the form of a Drug Enforcement Administration (DEA) guidance letter.These guidance letters allow the DEA to communicate directly to registrants, providing detailed interpretation and clarity regarding the DEA’s expectations and enforcement realities. Recently, the DEA guidance letter portal was used to remind registrants that the DEA does not create quantitative thresholds or volume limits on controlled substance distribution. An additional guidance letter could be issued to ease the concerns about liability connected to the distribution and dispensing of buprenorphine. In particular, this guidance could acknowledge certain terms of the distributor settlement agreement as legal precedent and clarify that buprenorphine is not subject to the same restriction as other defined “highly diverted” controlled substances. Such guidance may also serve to provide both pharmaceutical wholesalers and pharmacies with assurance that an increase in buprenorphine distribution would not directly result in increased DEA scrutiny. This strategy represents an actionable step toward the goal of providing better access to MOUD by reducing existing supply-side limitations.

Removing PA requirements for buprenorphine did not increase prescriptions

A study of 23 states from 2015 to 2019 found that the removal of prior authorization (PA) requirements, thought to be a barrier to buprenorphine prescribing, in Medicaid programs did nothing to increase prescribing. The study, “Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder,” which published in JAMA Health Forum on Oct. 4, did show some association in increased prescribing in states with low prescribing levels at baseline, but not in states with higher baseline prescribing. The findings do not mean that prior authorization—a technique used by payers to control utilization—is not a barrier, but rather, that it is not the only barrier, and that other barriers must be removed in order to increase prescribing of buprenorphine. Study results showed that: 1) six states in the sample removed Medicaid PAs for at least one buprenorphine formulation; 2) states that kept their PA requirements had lower buprenorphine prescribing and lower Medicaid managed care penetration, but similar opioid overdose rates to states that removed the PA requirements; and 3) for states with below‐median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions, while states with above‐median prescribing showed no change. The researchers concluded that more efforts are needed to increase availability of buprenorphine. The lead author is Paul J. Christine, M.D., Ph.D., of the University of Colorado School of Medicine.

A Brief Online Training to Address Pharmacists' Willingness to Dispense Buprenorphine.

The recent passage of the Mainstreaming Addiction Treatment (MAT) Act could increase the number of patients seeking to fill buprenorphine prescriptions at community pharmacies; however, multiple barriers limit community pharmacists' ability and willingness to dispense buprenorphine. We assess whether a brief online buprenorphine training program (Buprenorphine Understanding in the Pharmacy Environment) improves community pharmacists' outcomes, including willingness to dispense buprenorphine. A convenience sample of practicing community pharmacists participated in a 30-minute buprenorphine training. The training was codeveloped with pharmacy advisors and presented solutions to common buprenorphine dispensing barriers. Participants completed a pretest and posttest that assessed their buprenorphine knowledge (5 multiple-choice items based on training content), self-efficacy to engage in various buprenorphine-related behaviors (7 items), buprenorphine attitudes (8 items), and willingness to dispense buprenorphine to 4 different types of customers. Descriptive statistics were calculated, and paired-samples t tests were used to evaluate the impact of the training on pharmacist outcomes. Of 266 individuals who accessed the pretest, 104 responses were included in the analysis (response rate, 39%). Buprenorphine Understanding in the Pharmacy Environment improved pharmacists' mean buprenorphine knowledge scores (pretest, 2.2; posttest, 3.5; P < 0.001), all 7 self-efficacy items (all P < 0.001), mean buprenorphine attitudes (pretest, 3.1; posttest, 3.4; P < 0.001), and willingness to dispense to all four types of buprenorphine customers (all P < 0.01). A brief buprenorphine training increased pharmacists' willingness to dispense buprenorphine. Although generalizability of the results may be limited by use of a convenience sample, our pharmacist-oriented training showed promising results and may be an important step in increasing availability of buprenorphine in community pharmacies.

An analysis of patterns of distribution of buprenorphine in the United States using ARCOS, Medicaid, and Medicare databases.

Opioid overdose remains a problem in the United States despite pharmacotherapies, such as buprenorphine, in the treatment of opioid use disorder. This study characterized changes in buprenorphine use. Using the Drug Enforcement Administration's ARCOS, Medicaid, and Medicare claims databases, patterns in buprenorphine usage in the United States from 2018 to 2020 were analyzed by examining percentage changes in total grams distributed and changes in grams per 100 K people in year-to-year usage based on ZIP code and state levels. For ARCOS from 2018 to 2019 and 2019 to 2020, total buprenorphine distribution in grams increased by 16.2% and 12.6%, respectively. South Dakota showed the largest statewide percentage increase in both 2018-2019 (66.1%) and 2019-2020 (36.7%). From 2018 to 2019, the ZIP codes ND-577 (156.4%) and VA-222 (-82.1%) had the largest and smallest percentage changes, respectively. From 2019 to 2020, CA-932 (250.2%) and IL-603 (-36.8%) were the largest and smallest, respectively. In both 2018-2019 and 2019-2020, PA-191 had the second highest increase in grams per 100K while OH-452 was the only ZIP code to remain in the top three largest decreases in grams per 100K in both periods. Among Medicaid patients in 2018, there was a nearly 2000-fold difference in prescriptions per 100k Medicaid enrollees between Kentucky (12 075) and Nebraska (6). Among Medicare enrollees in 2018, family medicine physicians and other primary care providers were the top buprenorphine prescribers. This study not only identified overall increases in buprenorphine availability but also pronounced state-level differences. Such geographic analysis can be used to discern which public policies and regional factors impact buprenorphine access.

Pharmacy Availability of Buprenorphine for Opioid Use Disorder Treatment in the US

This cross-sectional study assesses the availability of buprenorphine for opioid use disorder treatment at local pharmacies in the US by state and retail pharmacy chain.

Augmenting project ECHO for opioid use disorder with data-informed quality improvement

BackgroundNational opioid-related overdose fatalities totaled 650,000 from 1999 to 2021. Some of the highest rates occurred in New Hampshire, where 40% of the population lives rurally. Medications for opioid use disorder (MOUD; methadone, buprenorphine, and naltrexone) have demonstrated effectiveness in reducing opioid overdose and mortality. Methadone access barriers disproportionally impact rural areas and naltrexone uptake has been limited. Buprenorphine availability has increased and relaxed regulations reduces barriers in general medical settings common in rural areas. Barriers to prescribing buprenorphine include lack of confidence, inadequate training, and lack of access to experts. To address these barriers, learning collaboratives have trained clinics on best-practice performance data collection to inform quality improvement (QI). This project sought to explore the feasibility of training clinics to collect performance data and initiate QI alongside clinics’ participation in a Project ECHO virtual collaborative for buprenorphine providers.MethodsEighteen New Hampshire clinics participating in a Project ECHO were offered a supplemental project exploring the feasibility of performance data collection to inform QI targeting increased alignment with best practice. Feasibility was assessed descriptively, through each clinic’s participation in training sessions, data collection, and QI initiatives. An end-of-project survey was conducted to understand clinic staff perceptions of how useful and acceptable they found the program.ResultsFive of the eighteen health care clinics that participated in the Project ECHO joined the training project, four of which served rural communities in New Hampshire. All five clinics met the criteria for engagement, as each clinic attended at least one training session, submitted at least one month of performance data, and completed at least one QI initiative. Survey results showed that while clinic staff perceived the training and data collection to be useful, there were several barriers to collecting the data, including lack of staff time, and difficulty standardizing documentation within the clinic electronic health record.ConclusionsResults suggest that training clinics to monitor their performance and base QI initiatives on data has potential to impact clinical best practice. While data collection was inconsistent, clinics completed several data-informed QI initiatives, indicating that smaller scale data collection might be more attainable.

Community Pharmacists' Knowledge and Perceptions of Buprenorphine for Patients with Opioid Use Disorder.

The aims of the study are to evaluate community pharmacists' knowledge and perceptions regarding buprenorphine for opioid use disorder and their willingness to dispense buprenorphine and to identify opportunities for education. An electronic survey of Michigan pharmacists (n = 11,123) assessed demographics, training, buprenorphine knowledge, dispensing, perceptions of stigma, diversion, and confidence in patient/provider interactions. Composite scores for knowledge, stigma, diversion, and confidence were calculated. Cross-tabulations and logistic regressions examined associations. There were 775 surveys returned (response 7%, n = 11,123) with 390 community pharmacists completing the survey. Twenty-five percent practiced in a rural area. Common practice sites were chain or independent pharmacies (30% each). Ninety-seven percent had buprenorphine training, 50% from Accredited Continuing Pharmacy Education. Eighty percent reported that their pharmacy dispensed buprenorphine with 90% of rural pharmacists compared with 71% urban responding yes. Composite knowledge scores did not differ between urban or rural location ( P > 0.05). Predictors of willingness to dispense buprenorphine were urban location (odds ratio, OR, 0.55; 95% confidence interval [CI], 0.34-0.91; P = 0.01), independent pharmacy (OR, 0.53; 95% CI, 0.30-0.94; P = 0.03), Accredited Continuing Pharmacy Education training (OR, 0.54; 95% CI, 0.34-0.87; P = 0.01), low stigma/diversion (OR, 0.51; 95% CI, 0.37-0.70; P = 0.00), and confidence in patient/provider interactions (OR, 0.14; 95% CI, 0.10-0.19; P = 0.00). Most survey pharmacists practice at pharmacies that dispense buprenorphine for opioid use disorder, with a larger proportion from rural pharmacies reporting availability. Pharmacists at independent pharmacies in urban locations have increased willingness to dispense buprenorphine, with urban pharmacists having lower perceptions of diversion compared with rural. Differences in buprenorphine availability, pharmacist willingness to dispense, and perceptions are opportunities for education. Limitations include one state, response bias, self-assessed competencies, and small samples.

Availability of medications for opioid use disorder in outpatient and inpatient pharmacies in South Florida: a secret shopper survey

BackgroundDespite the proven efficacy of medications for opioid use disorder (MOUD) and recent reduction in barriers to prescribers, numerous obstacles exist for patients seeking MOUD. Prior studies have used telephone surveys to investigate pharmacy-related barriers to MOUD. We applied this methodology to evaluate inpatient and outpatient pharmacy barriers to MOUD in South Florida.MethodsRandomly selected pharmacies in South Florida (Miami-Dade, Broward, and Palm Beach Counties) were called using a standardized script with a “secret shopper” approach until 200 successful surveys had been completed. The primary outcome was the availability of any buprenorphine products. Second, a list of all 48 acute care hospitals within the aforementioned counties was compiled, and hospitals were contacted by telephone using a second structured script.ResultsA total of 1374 outpatient pharmacies and 48 inpatient pharmacies were identified. 378 randomly selected outpatient pharmacies were contacted to accrue 200 successful calls (53% success rate). All 48 inpatient pharmacies were contacted to successfully complete 25 inpatient surveys (52%). Of the 200 outpatient pharmacies contacted, 38% had any buprenorphine available. There was a significant difference in buprenorphine availability by county, with Miami-Dade having the least availability and Palm Beach having the most availability (27% vs. 47%, respectively; p = 0.04). Of the 38% with buprenorphine available, 82% had a sufficient supply for a two-week prescription of buprenorphine 8 mg twice daily. Of the pharmacies that did not have buprenorphine, 55% would be willing to order with a median estimated time to receive an order of 2 days (IQR 1.25–3 days). Of the 25 surveyed inpatient pharmacies, 88% reported having buprenorphine on inpatient formulary, and 55% of hospitals had at least one restriction on ordering of buprenorphine beyond federal regulations.ConclusionsThe results of this study highlight significant pharmacy-related barriers to comprehensive OUD treatment across the healthcare system including both acute care hospital pharmacies and outpatient community pharmacies. Despite efforts to increase the number of MOUD providers, there still remain downstream obstacles to MOUD access.

Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions.

Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.

Buprenorphine and naloxone access in pharmacies within high overdose areas of Los Angeles during the COVID-19 pandemic

BackgroundBuprenorphine and naloxone are first-line medications for people who use opioids (PWUO). Buprenorphine can reduce opioid use and cravings, help withdrawal symptoms, and reduce risk of opioid overdose. Naloxone is a life-saving medication that can be administered to reverse an opioid overdose. Despite the utility of these medications, PWUO face barriers to access these medications. Downtown Los Angeles has high rates, and number, of opioid overdoses which could potentially be reduced by increasing distribution of naloxone and buprenorphine. This study aimed to determine the accessibility of these medications in a major urban city by surveying community pharmacies regarding availability of buprenorphine and naloxone, and ability to dispense naloxone without a prescription.MethodsPharmacies were identified in the Los Angeles downtown area by internet search and consultation with clinicians. Phone calls were made to pharmacies at two separate time points–September 2020 and March 2021 to ask about availability of buprenorphine and naloxone. Results were collected and analyzed to determine percentage of pharmacies that had buprenorphine and/or naloxone in stock, and were able to dispense naloxone without a prescription.ResultsOut of the 14 pharmacies identified in the downtown LA zip codes, 13 (92.9%) were able to be reached at either time point. The zip code with one of the highest rates of opioid-related overdose deaths did not have any pharmacies in the area. Most of the pharmacies were chain stores (69.2%). Eight of the 13 (61.5%) pharmacies were stocked and prepared to dispense buprenorphine upon receiving a prescription, and an equivalent number was prepared to dispense naloxone upon patient request, even without a naloxone prescription. All of the independent pharmacies did not have either buprenorphine or naloxone available.ConclusionsThere is a large gap in care for pharmacies in high overdose urban zip codes to provide access to medications for PWUO. Unavailability of medication at the pharmacy-level may impede PWUO ability to start or maintain pharmacotherapy treatment. Pharmacies should be incentivized to stock buprenorphine and naloxone and encourage training of pharmacists in harm reduction practices for people who use opioids.

Medicaid expansion and opioid supply policies to address the opioid overdose crisis

Background: The opioid overdose crisis remains of critical concern after historic increases in overdose mortality in the United States between 2020 and 2021. Improving access to buprenorphine —a partial opioid agonist and one of three FDA-approved medications for opioid use disorder (OUD) treatment— and reducing inappropriate opioid prescriptions may help curb mortality. Here, we examined the impact of Medicaid expansion and pain management clinic laws on opioid prescription rates and buprenorphine availability. Methods: We examined both retail opioid prescriptions per 100 persons in the state population using data from the Centers for Disease Control and Prevention and data on buprenorphine distributions in kilograms per 100,000 persons in the state population from the Automated Reports and Consolidated Ordering System database. We employed difference-in-difference frameworks to estimate the impact of Medicaid expansion on buprenorphine access and retail opioid prescription rates. Models considered three separate treatment variables: Medicaid expansion, pain management clinic (“pill mill”) laws, and the interaction of Medicaid expansion and pain management clinic laws. Results: Findings showed that Medicaid expansion was associated with increased access to buprenorphine in expansion states that also employed more stringent supply-side policies, including pain management clinic laws, relative to states that did not implement policies targeting the over-supply of prescription opioids over the same time period. Conclusions. Together, Medicaid expansion and policies limiting inappropriate opioid prescriptions show promise for improving the accessibility of buprenorphine treatment for OUD.

Individual and Health Policy Factors Associated With Positive Heroin and Opioid Treatment Response: United States, 2018.

Objectives. To identify client- and state-level factors associated with positive treatment response among heroin and opioid treatment episodes in the United States. Methods. We used national data from 46 states using the Treatment Episode Dataset‒Discharges (2018) to identify heroin and opioid treatment episodes (n = 162 846). We defined positive treatment response as a decrease in use between admission and discharge. We used multivariable regression, stratified by race/ethnicity, to identify demographic, pain-related, and state-level factors associated with positive treatment response. Results. Lower community distress was the strongest predictor of better treatment outcomes across all racial/ethnic groups, particularly among White and American Indian/Alaska Native episodes. A primary opioid of heroin was associated with worse outcomes among White and Hispanic episodes. Legislation limiting opioid dispensing was associated with better outcomes among Hispanic episodes. Buprenorphine availability was strongly associated with better outcomes among Black episodes. Conclusions. State-level variables, particularly community distress, had greater associations with positive treatment outcomes than client-level variables. Public Health Implications. Changes in state-level policies and increased resources directed toward areas of high community distress have the potential to improve opioid use disorder treatment and reduce racial/ethnic disparities in treatment outcomes. (Am J Public Health. 2022;112(S1):S66-S76. https://doi.org/10.2105/AJPH.2021.306503).

Rural and urban differences in undersupply of buprenorphine provider availability in the United States, 2018

BackgroundMedications to treat opioid use disorder (OUD) including buprenorphine products are evidence-based and cost-effective tools for combating the opioid crisis. However, limited availability to buprenorphine is pervasive in the United States (US) and may serve to exacerbate the deadly epidemic. Although prior research points to rural counties as especially needy of strategies that improve buprenorphine availability, it is important to investigate the availability of waivered providers according to treatment need as defined by the county-level rate of opioid-overdose deaths (OOD). This study examined differences in buprenorphine provider availability relative to treatment need among rural and urban counties in the US.MethodsBuprenorphine provider availability relative to need in each county was defined as the number of waivered providers divided by the rate of OODs (i.e., number of OODs/100,000 population), according to 2018 data. Counties with ratios in the bottom tertile of their state were classified as buprenorphine undersupplied. We estimated logit models to statistically test the association of rurality and state main effects and their interaction terms (independent variables) and the county classified as buprenorphine undersupplied (dependent variable).ResultsA total of 38 states and 2595 counties had sufficient non-suppressed data to remain in the analysis. A larger percent of urban counties (36.43%) than rural counties (32.01%) were classified as buprenorphine undersupplied (p = 0.001). The likelihood of a rural county being undersupplied varied considerably by state (Chi Square = 82.88, p = 0.000). All states with significant (p < 0.05 or p < 0.10) interaction terms showed lower likelihood of buprenorphine undersupply in rural counties.ConclusionsThe rural–urban distribution in undersupply of waivered buprenorphine providers relative to need varied markedly by state. Strategies for improving access to buprenorphine-waivered providers should be state-centric and informed by county-specific indicators of need.

“I wanted something that was more flexible”: A qualitative study of patient preferences on choosing buprenorphine over methadone in a large, safety-net hospital opioid treatment program

Background: Buprenorphine availability for the treatment of opioid use disorders (OUD) has expanded in the United States. Programs that previously offered only methadone treatment to patients with OUD now offer an equal choice between buprenorphine and methadone at the same location, yet little is known about patient preferences for buprenorphine over methadone in these settings. We sought to understand the decision-making factors and motivations underlying why patients opt for buprenorphine over methadone for the treatment of OUD when both are offered in a safety-net hospital-based opioid treatment program (OTP). Methods: We conducted semi-structured, qualitative interviews with patients receiving buprenorphine, in which we asked about substance use and treatment history, reasons for choosing buprenorphine, advantages, and disadvantages of choosing buprenorphine, and what they would like to change in their treatment experience. Results: Participants had varied exposure to buprenorphine prior to their current treatment, ranging from none to years of experience in multiple settings. Increased flexibility with take-home doses was a widespread motivation for choosing buprenorphine over methadone. Participants described decreased sedation and greater effectiveness in preventing opioid use compared to methadone as advantages during their treatment with buprenorphine. Difficulty with the transition to buprenorphine was a noteworthy challenge for many. Conclusions: Overall, patients maintained on buprenorphine at an urban safety-net hospital OTP viewed their treatment favorably compared to methadone. Increased autonomy in light of federal regulation differences and an improved physical profile were significant decision-making factors, although the number of patients choosing buprenorphine at the OTP remained low. Targeted patient education about induction and focus on improving structural barriers such as dosing efficiency may enhance patient experiences.

Socio-ecological and pharmacy-level factors associated with buprenorphine stocking at pharmacies in New York City.

Research is lacking on community and pharmacy-level factors that are associated with stocking buprenorphine. To address these gaps, this study applied a socio-ecological framework to estimate the association between community- and pharmacy-level factors and buprenorphine stocking among a sample of pharmacies in New York City. A telephone survey recruitment strategy was used to administer surveys to 662 pharmacies on the New York City Naloxone Standing Order Pharmacy list in 2018. The survey assessed pharmacy-level factors of private spaces to consult with pharmacists, type of pharmacy (chain/independent), size of pharmacy, having buprenorphine in stock and being open on nights and weekends. Socio-ecological variables drawn from census tract and public health data consisted of racial and ethnic composition, rates of poverty, rates of people without insurance, and rates of overdose. Mixed effects logistic regression estimated odds ratios (OR) of carrying buprenorphine in stock after adjusting for socio-ecological and pharmacy-level factors. Fewer than half of the pharmacies reported having buprenorphine in stock (43.81% n=290). Logistic regression analyses indicate that several pharmacy-level factors - the number of private spaces (aOR=1.67 95% CI=1.20, 2.32 p=.002), large size of the pharmacy (aOR=1.52 95% CI=1.04, 2.22, p=.032), having naloxone in stock (aOR=1.54, 95%CI=1.03, 2.32 p=.037), as well as neighborhood-level factors of higher rates of poverty (aOR=2.07 95%CI=1.07, 4.02 p<.001) and higher rates of uninsured residents were associated with carrying buprenorphine (aOR=0.23 95%CI=0.14,.38). Using a socio-ecological framework, this study identified inequities in pharmacy stocking of buprenorphine by neighborhood rates of health insurance. At the pharmacy level, increasing private spaces for consultation and encouraging co-stocking of naloxone with buprenorphine stocking may reduce inequalities in buprenorphine availability.

Pharmacy-related buprenorphine access barriers: An audit of pharmacies in counties with a high opioid overdose burden

BackgroundPharmacies sometimes restrict access to buprenorphine-naloxone (buprenorphine) for individuals with opioid use disorder. The objective of this study was to quantify the frequency of barriers encountered by patients seeking to fill buprenorphine prescriptions from pharmacies in United States (US) counties with high opioid-related mortality. MethodsTo characterize buprenorphine availability, we conducted a telephone audit ("secret shopper") study using a standardized script in two randomly selected pharmacies (one chain, one independent) in US counties reporting higher than average opioid overdose rates. Availability across pharmacy type (chain versus independent), county characteristics (rurality, region, overdose rate), and day of week were analyzed using univariate tests of categorical data. Independent predictors of buprenorphine availability were then identified using a multivariable binomial regression model. ResultsAmong 921 pharmacies contacted (467 chain, 454 independent), 73 % were in urban counties and 42 % were in Southern states. Of these pharmacies, 675 (73 %) reported being able to dispense buprenorphine. There were 183 (20 %) pharmacies that indicated they would not dispense buprenorphine. Independent pharmacies (adjusted prevalence ratio [aPR], 1.59; 95 % CI 1.21–2.08) and pharmacies in Southern states (aPR 2.06; 95 % CI 1.43–2.97) were significantly more likely to restrict buprenorphine. ConclusionsIn US counties with high overdose mortality rates, one in five pharmacies indicated they would not dispense buprenorphine. Buprenorphine access limitations were more common among independent pharmacies and those in Southern states. Pharmacy-directed interventions may be necessary to ensure timely buprenorphine access for patients with opioid use disorder.

The Pharmacology of Buprenorphine Microinduction for Opioid Use Disorder.

Although expanding the availability of buprenorphine—a first-line pharmacotherapy for opioid-use disorder (OUD)—has increased the capacity of healthcare systems to offer treatment, starting this medication is fraught with significant barriers. Standard induction regimens require persons with OUD to taper and discontinue full opioid agonists and experience opioid withdrawal prior to the first dose of buprenorphine. Further, emerging evidence indicates that precipitated withdrawal during induction may impact long-term treatment outcomes. Microinduction is a novel approach that, by harnessing buprenorphine’s unique pharmacological profile, may allow circumventing the needed for prolonged opioid tapers, and reduce the risk of precipitated withdrawal—holding promise to enhance treatment access. In this review, we examine the pharmacological basis for microinduction and appraise the evidence of this approach to improve clinical outcomes among persons with OUD. First, we highlight the potential dose-dependent effects of buprenorphine on two key neuroadaptations at the mu-opioid receptor (MOR)—resensitization and upregulation. We then focus on how microinduction may reverse these chronic MOR neuroadaptations, allowing the maintenance of an adequate opioid tone, and thereby potentially circumventing opioid withdrawal. Second, we describe the clinical evidence available, derived from observational reports and open-label studies, examining the potential efficacy of microinduction. Despite significant heterogeneity—exemplified by variable buprenorphine formulations, daily doses, and schedules of administration—these data provide preliminary support for the feasibility of microinduction. Finally, we provide new mechanistic, methodological, and clinical insights to guide future translational research, as well as randomized, placebo-controlled clinical trials in this compelling agenda of pharmacotherapy development.

Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose?

BackgroundUnintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period. MethodsParticipants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use. ResultsAlmost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis. DiscussionThe findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed.