As a young pharmacy intern, Daniel Ventricelli received an unforgettable lesson in how pharmacies can sometimes pose barriers to accessing potentially life-saving buprenorphine for patients with opioid use disorder (OUD).
A woman had arrived at the pharmacy around 5 p.m. to pick up her buprenorphine prescription, but the script she thought had been sent from her clinic wasn't on file. Ventricelli's repeated calls to the clinic weren't being answered. As the patient grew increasingly anxious about what she would face without immediate access to the medication, the pharmacist whispered in Ventricelli's ear, “Get her out of here. She's crazy.”
Fortunately, the story had a positive ending. Ventricelli pressed on and kept calling the clinic. Someone finally answered, and an error on the fax of the prescription was corrected. The patient's script was delivered.
“I wonder what could have happened if she was brushed away,” Ventricelli said Wednesday at a breakout session during the virtual Rx Drug Abuse & Heroin Summit. “I wonder how frequent or common this must be.”
Ventricelli, PharmD, assistant professor of clinical pharmacy at the Philadelphia College of Pharmacy, University of the Sciences, and Alysson Light, PhD, assistant professor of psychology at the University of the Sciences, co-presented a session on issues of access to buprenorphine at community pharmacies. While much research has examined issues around provider capacity to prescribe buprenorphine, there is comparatively little data on access issues once the patient has a prescription and seeks to fill it, they said.
Ventricelli and Light presented unpublished results of a survey of Pennsylvania community pharmacists, conducted with the help of the state pharmacists association. Combining all of the many factors that might affect a pharmacist's decision on whether to dispense buprenorphine, the survey concluded that community pharmacists were only “mildly” in favor of dispensing the partial agonist medication for OUD.
Helpful factors, such as the perception of doing something positive for patients, were offset to some degree by concerns about barriers, such as dealing with insurance obstacles or addressing mixed messages from regulators.
“The results suggest there is some ambivalence underlying this,” Light said.
Around 70% of the survey's 130 respondents were independent pharmacists (the final sample size for the results that will be peer-reviewed is 64). The researchers found that pressures from outside entities have a potentially strong effect on pharmacists' decision-making around buprenorphine.
“Pharmacists do not feel completely in control in being able to dispense buprenorphine when they want to,” Light said. Multiple factors can contribute to this. Ventricelli said that when asked in the survey about the most important factor considered in the decision-making process, community pharmacists most frequently cited data in the prescription drug monitoring program (PDMP), followed by prescriber location and patient insurance coverage.
There are many opportunities for prescribers and pharmacists to collaborate more closely, but each group's roles and responsibilities need to be more clearly defined, Ventricelli suggested. Some prescribers have reported that they can't always trust community pharmacists to fill buprenorphine prescriptions, leaving them in some cases to resort to ordering medication from mail-order pharmacies for their clinics.
Results of the pharmacist survey also indicated a rural divide in responses, with rural pharmacists having a considerably more negative attitude about dispensing buprenorphine. Much of this concern stemmed from worries over staff safety and possible theft or diversion of medication, Light said. She believes much of this can be addressed with proper messaging delivered by leaders who understand rural communities.