Physician-Pharmacist Partnerships May Help Expand Access to Opioid Addiction Treatment

People withopioiduse disorder who get prescribed the anti-addiction medicationbuprenorphineby a physician may be able to continue this treatment regimen without repeat doctor visits if their local pharmacist can step in to manage their care, a new pilot study suggests.

Even though community pharmacists in most U.S. states can administervaccinesand prescribe a variety of medicines to patients who don’t see a doctor first, buprenorphine isn’t one of these drugs.Buprenorphineis highly regulated, and clinicians who prescribe it are required to go through training and receive waivers from the federal government.

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For the pilot study, pharmacists took over care management for 71 patients who had already been prescribed buprenorphine by a physician. For six months, patients made monthly visits to the pharmacy for prescription refills, drug testing, and counseling as well as any needed referrals to see specialists or get their dose of buprenorphine adjusted by a physician.

Overall, 95 percent of the participants in this pilot study stuck with their daily medication regimen after care was transferred to a pharmacist, according toresults published in January 2021 in the journalAddiction. During the study, less than 5 percent of the patients had positive drug screens, and none of them had opioid-related emergencies or hospitalizations, outcomes suggesting that this may be a safe way to deliver care to some people with opioid use disorder.

“只有少量的初级保健医生the United States have a waiver to prescribe buprenorphine, and many do not take new patients,” saysBrendan Saloner, PhD, an associate professor of health policy and management at Johns Hopkins Bloomberg School of Public Health in Baltimore.

“Providing a new source of care for patients can help to address this low availability of treatment,” says Dr. Saloner, who wasn’t involved in the pilot study.

Why Better Access to Buprenorphine Is Needed

Buprenorphine is considered the gold standard for阿片use disorder treatmentbecause it can reduce cravings and also help curb withdrawal symptoms. But less than 1 in 10 primary care physicians have waivers from the U.S. government allowing them to prescribe the drug, according to astudy published in April 2020 in theAnnals of Internal Medicine.

Exacerbating the scarcity of physicians prescribing buprenorphine, most who do this treat only a limited number of patients. Nearly 3 in 4 providers with waivers to prescribe buprenorphine can treat no more than 30 patients at time with this drug, this study found.

“There are few clinicians who are licensed and willing to prescribe the medication, and access can be further limited by geographic proximity to providers,” saysPooja Lagisetty, MD, a health services researcher and general internist at the University of Michigan Medical School and the Ann Arbor VA Hospital.

Beyond these hurdles, patients often have toovercome additional barriers to buprenorphine treatmentsuch as multiple checkups, regular urine drug screenings, repeat visits to the pharmacy to pick up the medication, and sometimes required drug counseling, says Dr. Lagisetty, who wasn’t involved in the buprenorphine pilot project.

“As you can imagine, this can be hard to accommodate with work and personal responsibilities,” Lagisetty says.

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How Pharmacists Can Help

Having pharmacists help manage care for patients who need buprenorphine could make it easier for people to stick with treatment by potentially limiting the number of repeat trips they need to make to different places for checkups, drug testing, and prescription refills, Lagisetty says.

While the current pilot project was small in scope, it isn’t the first time the idea of using pharmacists to expand access toopioid addiction treatmenthas been tested out. Astudy published in May 2020 in theAmerican Journal of Health-System Pharmacyfound that pharmacists working inside primary care clinics could help manage patients with chronic pain, tapering opioid usage and steering those with opioid use disorder toward therapy with buprenorphine.

“The bottom line is that pharmacists are extremely well qualified in assisting with medication management, and often do this more effectively than physicians,” says Lagisetty, lead author of this study.

Some Open Questions

While all of the physicians and pharmacists in the latest pilot study expressed satisfaction with the collaboration, it’s hard to tell from a small pilot study how widely accepted this type of arrangement might be or how many patients might ultimately get treatment who would otherwise fall through the cracks.

Some pharmacists might not have the training or education necessary to manage patients with opioid use disorder, and some physicians might not be to have their patients’ care managed at a drugstore, saysRyan McBain, PhD, MPH, a health policy researcher at RAND in Boston and professor of policy analysis at Pardee RAND Graduate School in Santa Monica, California.

“It may be the case that physicians and others would really need to be convinced of the safety and benefits before they bought in,” says Dr. McBain, who wasn’t involved in the pilot study.

Pharmacists also might struggle to manage some of the complex social issues that can accompany addiction like housing insecurity, criminal activity, and mental illness, Saloner says.

None of the patients in the pilot study were getting buprenorphine for the first time, Saloner notes. Instead, they all had seen a physician several times to start a prescription and follow up to make sure it was working well for them.

“It may be that this model works well for more stable patients,” Saloner says. Other patients might be able to have buprenorphine treatment managed by a pharmacist if they got extra support from other providers like counselors or peer support specialists, Saloner suggests.

There are also potential privacy concerns because addiction is a very stigmatized illness and people need to be able to interact with their pharmacist in a confidential way, not in front of other customers at the drugstore, saysMichael L. Barnett, MD, an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health in Boston.

But privacy concerns have been raised, and overcome, for pharmacists to prescribe a wide variety of medicines directly to patients without the need for a checkup with a doctor first, Dr. Barnett notes.

“There is strong evidence for the benefit of physician-pharmacy collaborations in a variety of settings beyond opioid use disorder, such as chronic pain,diabetes, andhigh blood pressuremanagement,” Barnett says. “There is no reason why opioid use disorder management should be more challenging than these.”