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Overcoming Barriers

Several statements about the barriers facing patients with opioid use disorder are listed below. Decide whether each statement is true or false, and then click the button that corresponds with your response. Feedback is provided in the right column.

StatementTrue or FalseFeedback
Opioid use disorder patients who cannot get their buprenorphine prescription filled have an increased likelihood of obtaining a new opioid prescription.

This statement is true. OUD patients who lose access to buprenorphine are more likely to obtain a new opioid prescription.13

Opioid use disorder patients who cannot get their buprenorphine prescription filled are at increased risk of discontinuing treatment. 

This statement is true. Pharmacists can encourage patients to stay engaged in treatment.

Opioid use disorder patients who cannot get their buprenorphine prescription filled are at increased risk of using non-prescribed substances.

This statement is true. When unable to obtain medications for opioid use disorder, OUD patients are more likely to return to use.18,19

Opioid use disorder patients who cannot get their buprenorphine prescription filled are at increased risk of an emergency department visit.

This statement is true. When OUD patients lose access to buprenorphine, they are at greater risk for needing care in an emergency room.17

Opioid use disorder patients who cannot get their buprenorphine prescription filled are at increased risk of overdose.

This statement is true. Access to MOUD reduces overdose death risk. Overdose death rates are measurably higher in counties where residents have less access to buprenorphine.2,20

Opioid use disorder patients who cannot get their buprenorphine prescription filled are at increased risk of all-cause mortality.

This statement is true. OUD patients unable to access medications for opioid use disorder have higher rates of all-cause mortality.21

  1. Strickland DM, Burson JK. Sublingual absorption of naloxone in a large clinical population. J Drug Metab Toxicol. 2018;9(02):240.

  1. Williams AR, Samples H, Crystal S, Olfson M. Acute care, prescription opioid use, and overdose following discontinuation of long-term buprenorphine treatment for opioid use disorder. American Journal of Psychiatry. 2020;177(2):117-124.

  1. Davoli M, Perucci CA, Forastiere F, et al. Risk factors for overdose mortality: a case-control study within a cohort of intravenous drug users. International Journal of Epidemiology. 1993;22(2):273-277.
  2. O’Halloran C, Cullen K, Njoroge J, et al. The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland. International Journal of Drug Policy. 2017;46:34-40. doi:10.1016/j.drugpo.2017.05.017

  1. Strickland DM, Burson JK. Sublingual absorption of naloxone in a large clinical population. J Drug Metab Toxicol. 2018;9(02):240.

  1. Carroll J, Green T, Noonan R. Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018. Centers for Disease Control; 2018:40. Accessed December 2, 2019. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
  2. Flavin L, Malowney M, Patel N, et al. Availability of Buprenorphine Treatment in the 10 States With the Highest Drug Overdose Death Rates in the United States. Journal of Psychiatric Practice. 2020;26(1):17-22.

  1. Ma J, Bao YP, Wang RJ, et al. Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry. 2019;24(12):1868-1883. doi:10.1038/s41380-018-0094-5

Endorsement of the American Pharmacists Association

The American Pharmacists Association (2020) endorses pharmacists’ role in increasing access to and advocacy for medications for opioid use disorder.

APhA supports the use of evidence-based medication as first-line treatment for opioid use disorder for patients… for as long as needed to treat their disease… APhA encourages pharmacies to maintain an inventory of medications of public health importance, particularly medications for opioid use disorder, to ensure access for patients. APhA encourages pharmacists and payers [to] ensure patients have equitable access to and coverage for at least one medication from each class of medications used in the treatment of opioid use disorder, [for example by] making medications available on the payer’s lowest cost-sharing tier.”22APhA 2020

 

  1. American Pharmacists Association. Increasing Access to and Advocacy for Medications for Opioid Use Disorder (MOUD).; 2020. Accessed August 10, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7440871/

“Red flags” – when not to worry

Some pharmacists report reluctance to dispense buprenorphine in specific scenarios, citing “red flags.” However, in many cases legislation and other guidance on controlled substance dispensing, for example, the NC STOP Act, outlines verification procedures for each scenario rather than directing pharmacists not to dispense.

Detailed guidance from the NC Stop Act for each of these scenarios is shown below.23 Click each scenario to learn more.

Guidance for Targeted Controlled Substances (including buprenorphine)

✅The STOP Act does not require checking CSRS for a newly prescribed patient/new script. You may choose to do so and document if you wish.

  • Scripts from new patients will increase as eligible prescribers increase.

Guidance for Targeted Controlled Substances (including buprenorphine)

✅Review the CSRS and document.

  • Scripts from new patients will increase as eligible prescribers increase.
  • Telehealth prescribing may lead to increased access, particularly in rural areas.
  • Many patients must travel outside their local community to fill their prescription when local pharmacies encounter wholesaler thresholds on buprenorphine ordering.
  • Some patients may cross a state border due to state-specific restrictions on a particular formulation (e.g. mono product restrictions in TN).

Guidance for Targeted Controlled Substances (including buprenorphine)

✅ Review CSRS and document

  • Patients with OUD commonly express that buprenorphine makes them feel like they can function and have a normal life. Consequently, the thought that they could run out of their medication can result in considerable anxiety and concern about experiencing withdrawal from buprenorphine, which can cause them to seek a refill early so they know that they will have their buprenorphine on hand.
  • Patients prescribed buprenorphine may request an early fill when anticipating travel or anticipate difficulty getting to the pharmacy (transportation issues), to avoid experiencing withdrawal due to dispensing delays.

Guidance for Targeted Controlled Substances (including buprenorphine)

✅ Review CSRS and document

  • Scripts will increase with the increase in eligible prescribers.
  • Many patients must travel outside their local community to fill their prescription when local pharmacies encounter wholesaler thresholds on buprenorphine ordering.

Guidance for Targeted Controlled Substances (including buprenorphine)

✅ The STOP Act predates the ruling that allows prescribers to prescribe buprenorphine via telehealth. Therefore, there is no distinct requirement to check the CSRS; however, pharmacists may review the CSRS prior to dispensing.

  • The Substance Abuse and Mental Health Services Administration issued a final rule (add date) that permanently allows patients to be prescribed buprenorphine via telehealth.
  • Starting buprenorphine treatment for OUD through telehealth was associated with an increased likelihood of staying in treatment compared to starting treatment in a non-telehealth setting.25
  • Telehealth providers are licensed providers qualified to care for patients with opioid use disorder. If there are concerns about the legitimacy of the script, pharmacists are welcome to reach out to the prescriber, as they would any other medication, and document this on the script.

Guidance for Targeted Controlled Substances (including buprenorphine)

✅ There is no requirement for pharmacists to review the CSRS based on length of buprenorphine prescription.

  • Buprenorphine scripts, similar to all other C III medications may be filled no more than 6 months after the date written date or refilled more than 5 times. Patients on stable doses of buprenorphine may have refills on their scripts, similar to other C III medications.
  • Evidence-based guidelines recommend OUD treatment with buprenorphine for as long as beneficial. Some clinical guidelines state one year minimum and longer in pregnancy/postpartum.

Guidance for Targeted Controlled Substances (including buprenorphine)

✅ Review CSRS and document

Patients may request a specific formulation for any of the following reasons:

  • Insurance may only cover one formulation
  • Patient assistance may only be available for a certain formulation
  • Patient is more familiar and comfortable with a specific product
  • Patient prefers to continue on a medication that they used in the past

Guidance for Targeted Controlled Substances (including buprenorphine)

There is no requirement for pharmacists to review the CSRS based on buprenorphine formulation prescribed.

Providers may prescribe mono vs. combo product for any of the following reasons:

  • Prescribers determine the best option for a given patient’s circumstances, for example, allergy/intolerance, insurance limitation, et cetera.
  • Insurance may only cover a certain formulation
  • Patient assistance may only be available for a certain formulation
  • As of late 2021, the DEA and the Department of Justice demonstrated a preference for pharmacies to document a reason for dispensing mono-product buprenorphine. The prescriber can provide rationale with the script, such as ‘Patient reported adverse reaction to naloxone.’ If not, a pharmacist can inquire and document the response.

References: NC Legislature. STOP Act.; 2017. http://www.ncbop.org/PDF/NCDHHSImplementationofCSRSSTOPActJuly2021.pdf

and NC Board of Pharmacy. 2017. http://www.ncbop.org/PDF/GuidanceImplementationSTOPACTJuly2017.pdf

 

 

Did you know…

A district court judge ruling on a DEA enforcement action recently acknowledged that patients “may go out of their way… because there aren’t enough nearby doctors who prescribe it or pharmacies that stock it… they might pay cash because they’re uninsured or Medicaid won’t cover prescriptions written by an out-of-network doctor… they might prefer [mono product] because it’s often cheaper than [combo product].”16


  1. Williams AR, Samples H, Crystal S, Olfson M. Acute care, prescription opioid use, and overdose following discontinuation of long-term buprenorphine treatment for opioid use disorder. American Journal of Psychiatry. 2020;177(2):117-124.