Common Barriers To Treatment For Suboxone Patients

January 6, 2021

Patients struggling with addiction to opiates (prescription opioids like oxycodone, percocet, and vicodin AND illicit opioids like heroin and fentanyl) often face numerous barriers in obtaining treatment. In fact, only 10-20% of patients with an opioid addiction actually receive evidence-based medication treatment with medications such as buprenorphine/naloxone (Suboxone), methadone, or naltrexone (AKA “vivitrol”).1

And, for many, the barriers they encounter when they bring their prescription to the pharmacy may be the last and most frustrating step.

R.T., a 35 year old man, who became addicted to oxycodone after a motor vehicle accident left him with severe back pain, recalls his journey.  “It took me about 6 months after I realized I had a problem to seek out help. I was ashamed and scared to admit it. Once I did, I had a hard time finding a doctor who would prescribe me Suboxone. When I finally got a prescription and was looking forward to getting back to feeling like my old self, I showed up at the pharmacy only to be told that the Suboxone was on backorder. I came back 2 weeks later and told it was still not available. I had to go to 5 pharmacies before I could get my prescription filled.”

R.T. is not alone. Patients across the country report pharmacy-level barriers to obtaining medications to treat their addiction, such as drug shortages, pharmacies refusing their insurance and instead making patients pay out of pocket, or the converse--pharmacies refusing to allow patients to pay out of pocket temporarily in order to obtain their medications while waiting for authorizations to be processed. Many patients also report feeling highly scrutinized, judged and “given the third degree,” leading them to avoid going to certain pharmacies.

Buprenorphine/naloxone (Suboxone) is considered a first-line medication to treat opioid addiction. Dr. Brian Clear, Chief Medical Officer at Bicycle Health, a telehealth group that helps patients struggling with opiate addiction explains that, “When taken as prescribed, Buprenorphine is safe and very effective.” 

He elaborates, “It helps patients avoid feelings of cravings and withdrawal so they can take back control of their lives and engage in activities that are important to them-- like going to work, reconnecting with friends, taking care of their kids, and putting money back into their bank account.”

So, if buprenorphine/naloxone (Suboxone) is such a beneficial treatment option for patients struggling with addiction, why are some pharmacies putting up barriers that make it difficult for patients to fill prescriptions?

Common Barriers To Treatment

Unfortunately, barriers exist for several reasons:

Suboxone Supply Limitations

First, there is the supply side at the wholesaler level. Current Drug Enforcement Administration (DEA) regulations require wholesalers to detect and report suspicious orders of ALL opioids (including buprenorphine) at the pharmacy level. Wholesalers have thus created systems that monitor individual pharmacy’s ordering patterns and have established ordering thresholds.1

How have pharmacies interpreted this? T.J., a pharmacist based in Boston, MA, explains, “A lot of pharmacists see this as a “DEA cap” on the amount of buprenorphine/naloxone (Suboxone) they can order and dispense. There really is no actual cap, but pharmacists worry that if the amount they order is more than the DEA will allow, they will be investigated, their licenses will be jeopardized, or the pharmacy might be subject to large fines.”

These concerns have led pharmacists to develop rationing systems and set arbitrary dispensing limits.2,3 T.J. explains “Since pharmacists worry about exceeding their dispensing limits, they might only fill existing customers’ prescriptions and turn away new customers who come in with a buprenorphine prescription. Or, they may simply refuse to fill all buprenorphine prescriptions.”

Why does this DEA create these regulations? While the DEA’s intent is to pick up concerning prescribing patterns and avoid patients misusing opioids, it unfortunately lumps buprenorphine/naloxone (Suboxone) -- that is used as an effective treatment for opioid addiction -- into the same category opioids (like oxycodone or percocet) that contribute to the risk of developing an opioid addiction.

Dr. Clear further explains the effects of these regulations, “The DEA treats buprenorphine in exactly the same way as it does the higher risk opioids that cause opioid use disorder, and this has the nonsensical effect of trying to control a disease by restricting the treatment for it. If anything, too little buprenorphine prescribing should be a warning sign that the healthcare system in a region isn’t doing enough to identify and address problems with opioid use.”

Patients' Distrust of Physicians

A second barrier to pharmacies dispensing buprenorphine/naloxone (Suboxone) is a distrust of physicians. Over the past several decades, physicians have prescribed too many opioids (like oxycodone and vicodin) that have contributed to the opioid crisis. Misinformed pharmacists may thus look at buprenorphine/naloxone (Suboxone) like other opioids thinking that it may contribute to the opioid epidemic rather than combatting it.

Pharmacists also harbor concerns about physicians’ motivations. Pharmacist T.J. explains, “I’m lucky that I know a lot of physicians who truly want to help their patients. They offer individual appointments and support groups and really care that their patients do better. It makes me want to help out too.”

He continues, “But, not all pharmacists have seen this view point and many pharmacists may worry that physicians prescribing Buprenorphine/naloxone (Suboxone) are just doing it for the money, so they don’t want to be part of that.”

Pharmacists' Stigma Towards Suboxone

Another barrier to pharmacies prescribing Buprenorphine/naloxone (Suboxone) is the stigma. Rather than viewing buprenorphine/naloxone (Suboxone) as evidence-based treatment for a chronic medical condition, they may view it as another drug and think that patients are taking it to get high or selling it for personal gain.

T.J. explains “A lot of pharmacists see Suboxone as a temporary hold over for patients until they can get more drugs. Many also wonder, ‘why is this patient STILL on this after so many years?”

Dr. Clear counters these misconceptions, “We know that, when taken appropriately, buprenorphine should help patients feel NORMAL-- not high and not sedated. Patients seeking treatment with buprenorphine/naloxone (Suboxone) are usually quite motivated to reclaim their lives before drug addiction took over."

He adds, “And, since we are treating a chronic medical condition, patients should take it as long as they need to, which may be many years or even lifelong. If it helps them stay in recovery, there is certainly no rush or need to come off it.”

Finally, patients often run into barriers at the pharmacy due to hoops created by insurance companies, which may require special prior authorizations to get buprenorphine/naloxone (Suboxone) or formulations not prescribed by the physician.

Pharmacist T.J. explains “If we get a prior authorization request from an insurance company, that means we have to get a physician to complete paperwork and then this has to be processed by the insurance company. Other times, we have to have the doctor change the prescription from buprenorphine tabs to films or vice-versa. All this takes time and can delay patients getting refills.”

While all these obstacles may seem daunting, future changes in DEA regulations and continued efforts to decrease stigma and encourage pharmacists and physicians to work together to provide life-saving medication treatment may help patients avoid these barriers.

Bicycle Health 

At Bicycle Health, we recognize the barriers our patients may face at the pharmacy level and aim to reduce them. 

As Bicycle Health CEO Ankit Gupta explains “We have a dedicated team at Bicycle Health focused on making sure our patients get timely access to their medications. Patients are able to reach out to us through our smartphone app if they encounter barriers at the pharmacy, and we will work to quickly address them.”

To learn more about the success rates and safety of Bicycle Health’s telemedicine buprenorphine/naloxone (Suboxone) treatment in comparison to other common treatment options, call us at (844) 943-2514 or schedule an appointment.

For more information on buprenorphine/naloxone (Suboxone), opioid dependence, and our telehealth treatment model, please visit our FAQ.

Header Photo by National Cancer Institute on Unsplash

About the Author

Randi Sokol, MD, MPH, MMedEd

Randi Sokol, MD, MPH, MMedEd, is an Assistant Professor at the Tufts Family Medicine Residency Program and Instructor at Harvard Medical School. She is Board Certified in both Family Medicine and Addiction Medicine. She earned her B.A. at the University of Pennsylvania, her Medical Degree and Masters in Public Health from Tulane University, completed Family Medicine Residency at UC-Davis, and earned a Masters in Medical Education through the University of Dundee.

Citations

1Cooper HLF, Cloud DH, Young AM, Freeman PR. When Prescribing Isn’t Enough-- Pharmacy-Level Barriers to Buprenorphine Access. New England Journal of Medicine. (383)8:703-705.

2Cooper HL, Cloud DH, Freeman PR, et al. Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: a case study of the rural risk environment in Appalachian Ken- tucky. Int J Drug Policy 2020 March 26 (Epub ahead of print).

3Ventricelli DJ, Mathis SM, Foster KN, Pack RP, Tudiver F, Hagemeier NE. Com- munication experiences of DATA-waivered physicians with community pharmacists: a qualitative study. Subst Use Misuse 2020; 55:349-57.

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