Study Finds Pharmacies Are Under-Prescribing Buprenorphine in Rural Kentucky

By Kelly Jordan

Hannah L. F. Cooper, ScD, Rollins Chair in Substance Use Disorders, is lead author on a paper published in the International Journal of Drug Policy that looks at buprenorphine dispensing behaviors in rural Kentucky. David Cloud, JD, MPH; Monica Fadanelli; and Stephanie Beane, PhD; also from Emory, contributed to the paper. Drs. April Young and Patricia Rippetoe Freeman from the University of Kentucky also contributed to the paper.

Buprenorphine is the first medication for treating opioid disorders (MOUD) that U.S. pharmacists have been charged with dispensing widely. This medication is vital to curbing overdoses, hepatitis C, HIV, and other drug-related harms. Given concerns that harmful drug use may increase vulnerability to COVID-related morbidity and mortality, access to buprenorphine and other MOUD may help reduce community-level burdens of the current pandemic. However, emerging evidence suggests that pharmacists in rural areas are refusing to do so. To investigate this trend, the researchers conducted a qualitative analysis that examined the buprenorphine dispensing behaviors of pharmacists in 12 rural Kentucky counties that are at an epicenter of the U.S. opioid epidemic.

The researchers conducted interviews with 14 pharmacists in 15 different pharmacies across these counties to understand their harm reduction attitudes and practices, then reviewed state policy, media coverage, and grey papers to get a sense of area perceptions that may have affected prescribing behaviors.

“Federal, state, and local governments are scaling up access to buprenorphine to end the opioid epidemic in the US. Unfortunately, these initiatives focus almost exclusively on increasing buprenorphine prescribing,” says Cooper. “Our findings identify pharmacy-level barriers to dispensing buprenorphine.”

Findings suggest that most pharmacists developed buprenorphine dispensing practices that rejected some or all patients with legitimate buprenorphine prescriptions due to varying influences including:

• Fears over exceeding a Drug Enforcement Administration cap;
• A history of fraudulent marketing of opioid analgesics (OA) by pharmaceutical companies;
• Wariness over physician OA overprescribing practices; and/or
• Concerns over the local war on drugs.

The authors suggest that any buprenorphine prescription initiatives should incorporate pharmacists in the future, and should include policy changes to increase dispensing. Specifically, the authors recommend that, “buprenorphine be removed from opioid monitoring systems; efforts to de-escalate the war on drugs be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing be strengthened; and efforts to re-build pharmacist trust in physicians are needed.”