I sat on the phone yesterday consoling a single mother going through heroin withdrawal. In between bouts of vomiting and dry heaving, she pleaded, “When will I be able to pick up the medication you ordered that stops all of this?” This mother had already overcome significant barriers Americans face when seeking addiction treatment, including stigma associated with treatment, affordability of treatment, and finding high quality, highly trained addiction specialists. I had prescribed an FDA-approved addiction treatment medication that reduced her chance of death from addiction by more than 50%. Seemed like it should be a happy ending. Instead, she found her local pharmacy refusing to fill the prescription.
That pharmacy’s response is just one example of a troubling, growing trend. Pharmacies across the country are refusing to fill the life-saving addiction treatment medication buprenorphine/naloxone. As a multi-state licensed addiction psychiatrist, I find myself in daily debates across the country with major retail pharmacy chains who refuse to fill this medication. The DEA and the federal Substance Abuse and Mental Health Services Administration (SAHMSA) have both issued recent policy statements urging health care practitioners and pharmacies alike to increase access to this medication with fully telehealth treatment of substance use disorders.
Why are so many pharmacies refusing to fill valid, legal, physician-issued prescriptions for the single most important and effective medication used to treat addiction? The answer, ironically, lies in recent well-meaning landmark court proceedings designed to decrease the opioid epidemic.
In late 2022, CVS, Walgreens, and Walmart were forced to pay an eye-popping $10.7 billion to settle allegations that the pharmacy chains failed to adequately oversee opioid painkiller prescriptions, thus contributing to America’s opioid addiction crisis. CVS alone agreed to pay nearly $5 billion in fines over 10 years, while Walgreens would pay $5.7 billion over 15 years. With this decision, the pharmacy chains also agreed to implement robust “controlled substance compliance programs” that required additional layers of opioid prescription reviews, mandatory state prescription pharmacy database checks, and new employee training programs on prescription monitoring oversight.
This well-meaning legislation was designed to rightfully reduce access to dangerous and addictive prescription opioid drugs like Oxycontin, Percocet, and Vicodin, among others — drugs which are gateways to opioid addiction and are often involved in opioid overdose deaths. Buprenorphine is also a controlled substance, although it contains a very low, weakened amount of a “partial” opioid to treat withdrawal and ultimately has a very different, safer chemical make up than traditional opioids. The chemical makeup is designed to prevent people from getting high on it. It also contains the opioid overdose agent Naloxone or “Narcan,” which further reduces abuse potential. These important differences make it a safe, effective, FDA-approved medication designed to treat addiction, not cause or worsen it. Despite all of these important differences, some pharmacies continue to lump it in with other opioid medications. Ironically, the very measures designed to curb addiction are now resulting in less access to our most important medications used to fight addiction.
I spend a significant portion of my days trying to convince pharmacists to fill these prescriptions. Pharmacists’ objections to refilling the meds include: “The patient lives too far away from your treatment facility,” “You did not see the patient in person,” or “There is no previous prescription for buprenorphine on file for this patient.” Pharmacists concerned with no previous prescription is puzzling. Luckily, due to increased addiction treatment access, many patients are starting to treat their opioid use disorder for the first time — and this is a good thing! It means we are broadening treatment access to more folks who need it most and saving more lives.
I’m successful in convincing the pharmacist to ultimately dispense the drug about half of the time. After an hour on the phone with the pharmacist, I addressed all of her questions and she dispensed the prescription to the single mother waiting outside in the grocery store parking lot. Many other times, my patients are forced to pharmacy hop until we find an understanding and well-informed pharmacist. It is tiring and exhausting.
What is the solution? We desperately need advocacy help from our high-profile medical stakeholders, as well as more pharmacist education and training on buprenorphine. It would be helpful if the DEA, the American Medical Society, and SAMHSA released specific policy statements encouraging all pharmacies to fill these prescriptions without geographic, mileage, or in-person requirements. If you are a pharmacist reading this article right now, please share it with as many of your colleagues as possible to spread the word: we need your help!
The best way to quickly curb the opioid epidemic is increased access to effective treatment. This is one of very few life-saving addiction treatments in our medicine arsenal. Its effects on mortality rates mean that your loved one suffering from opioid use disorder is more than twice as likely to survive with this medication. We need help reducing well-meaning but misinformed pharmacy red tape to its access. We owe this to the American public. We owe this to our friends, family members, and loved ones whose lives are jeopardized by addiction. We owe this to our children. We owe this to the more than 500,000 people we’ve lost in the U.S. in the past two decades due to overdose. Martin Luther King Jr. famously said, “The ultimate tragedy is not the oppression and cruelty by bad people but the silence over that by the good people.” Now more than ever, we need loud, passionate advocacy from you: our good people.
Dr. Lauren Grawert is a double board certified addiction psychiatrist. She received her medical degree from Medical University of South Carolina College of Medicine and has been in practice 15 years. She speaks multiple languages, including Spanish. She was Chief of Psychiatry at Kaiser Permanente of the Mid-Atlantic from 2018-2022. She is currently the Chief Medical Officer at Aware Recovery Care. She enjoys working with the media in her spare time to reduce stigma around mental illness and addiction. She has been interviewed by SAMHSA on Co-Occurring Disorders and most recently published articles in Capital Psychiatry and Northern Virginia Magazine.
Image by Irina Strelnikova / Shutterstock
