Buprenorphine Access Still Lags, Even After Major Federal Policy Changes

The overdose crisis has been a pressing public health issue for many decades now and has claimed the lives of over 1,000,000 people in the United States. Specifically, opioids have been responsible for a staggering 72% of these deaths. Especially at the start of the pandemic, there was a significant uptick in the number of overdose deaths, but many efforts were undertaken on the part of federal and local agencies, hospitals and clinics, and community organizations in response to this, and in 2023, the United States witnessed a drop in the number of drug overdose deaths for the first time since 2018.

In the past couple of years, the federal government has made significant strides in increasing access to buprenorphine, one of the three medications used to treat opioid use disorder (OUD). Firstly, during the pandemic, the Drug Enforcement Agency announced that buprenorphine could be prescribed via telemedicine, instead of requiring an in-person visit, which significantly increased access for people who lived far from a healthcare facility or were unable to visit a clinic due to lockdown restrictions. Additionally, the federal government made it easier for physicians to prescribe buprenorphine by first relaxing the X-waiver training requirements in April 2021 and then getting rid of it altogether in December 2022. 

However, despite these policy changes, a recent study has demonstrated that access to buprenorphine has not increased as much as anticipated. In their research, Dr. Gery Guy Jr. and his team at the Center for Disease Control and Prevention and Substance Abuse and Mental Health Services Administration explored changes in buprenorphine dispensing patterns at pharmacies before and after the described federal policy changes. The researchers sourced data from the IQVIA Total Patient Tracker, analyzing buprenorphine dispensing data for OUD from over 56,000 US pharmacies between January 2018 to December 2023. They looked at changes in dispensing patterns at three time points: March 2020 (telehealth expansion), April 2021 (relaxed training requirements for providers), and December 2022 (the removal of prescribing waivers). They utilized time-series analysis to analyze changes in monthly dispensing rates, finding that even though the overall rate of buprenorphine dispensing increased from 2018 to 2023, the growth rate of dispensing slowed after each consecutive policy change and the rate of increase was less pronounced with each new policy implementation. 

The authors of the study suggested that this could indicate that while all these federal policy changes are important and significant, their effects are diminishing over time and there are other barriers that need to be addressed to solve the problem of buprenorphine access. First, there is still a resounding stigma surrounding OUD which often prevents people from seeking out treatment in the first place. Addressing this stigma through strategies such as community education programs is crucial in fostering conversations around this topic and ensuring that people are aware of the resources for treatment that exist in their community. 

Second, many clinicians themselves have demonstrated reluctance in using buprenorphine to treat OUD, describing challenges in the reimbursement process, concerns about medication misuse, and lack of institutional support. These barriers need to be addressed, through developing physician training programs that address physician concerns with buprenorphine and also by streamlining the reimbursement process and tackling the administrative burden that may be involved in the buprenorphine prescription process. Widespread integration of buprenorphine treatment into primary care could also greatly increase its accessibility and has been demonstrated to increase treatment retention in pilot studies. 

Third, even if a person has access to a provider who can prescribe buprenorphine, many patients face additional barriers when their local pharmacies don’t adequately or consistently stock the medication, which is especially challenging for individuals living in areas where there are less pharmacies to begin with. Ensuring that pharmacies in all regions of the country are consistently stocked with buprenorphine is key in maintaining access to the medication. 

These are just some of the many barriers that exist at various levels – patient, physician, and pharmacy — that are preventing people from accessing buprenorphine. The federal government has taken powerful steps towards increasing access to buprenorphine treatment, but now communities, hospitals, and pharmacies must do their part. While the drop in drug overdose deaths in 2023 is promising, and could potentially be partially attributed to the efforts of the federal government, we must remain cognizant about the sheer number of lives we continue to lose every year to overdose. The problem is far from being solved and it is imperative that we address the other barriers that currently exist surrounding buprenorphine treatment to ensure that people get access to the care they need.

Photo: sorbetto, Getty Images

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