Maryland pharmacies aren’t stocking enough of the addiction treatment drug buprenorphine, threatening efforts to stem the growing number of overdose deaths from opioids like fentanyl.
The drug, also known by the brand name Suboxone, has been proven to reduce cravings and withdrawal symptoms that can send people to buy untrustworthy street drugs. It’s among three types of opioid treatment drugs but favored because patients can pick up a month’s worth at a pharmacy and take it daily at home. Many people take it long-term.
But locally and around the country, retail pharmacies’ reluctance to stock buprenorphine may be limiting the number of new patients accessing lifesaving treatment and threaten gaps for those already on it, advocates, clinicians and federal health program administrators say.
“We get in a good place with supply and then we get in a bad spot again, and when we have that there isn’t a lot we can do,” said Deborah Agus, executive director of the Behavioral Health Leadership Institute, a nonprofit that operates treatment clinics in Baltimore.
“People have to take it every day or they have cravings and could easily overdose,” she said. “We worry they will buy drugs on the street, so we jump on it and make sure they don’t miss more than a day.”
A just-released federal report offers some reasons for the shortfalls and recommendations to boost supply.
The Substance Abuse and Mental Health Services Administration, or SAMHSA, found that a general stigma and bias against people with substance use disorders is likely contributing to the low stock, but there are also practical issues, such as low reimbursement for the drug and inflexible rules on the types and doses of buprenorphine they can dispense.
Pharmacies also fear the U.S. Drug Enforcement Administration could come after them for filling too many prescriptions or scripts outside its geographic area, sometimes made through telehealth appointments allowed since the coronavirus pandemic.
Providers like Agus point to studies showing buprenorphine is safe. She has met herself with pharmacies and the DEA, which categorizes drugs based on the threat they pose. Agus plans more meetings soon, “building bridges to increase supply,” she said.
The major chain pharmacies Walgreens and CVS did not respond to requests for comment. The National Association of Chain Drug Stores declined to comment.
The shortages come as demand for the medication has been on the rise, nearly doubling since 2009, according to a study by Brown University researchers published earlier this year. Much is due to rule changes allowing prescribers to each take on far more patients in person and remotely.
More than 2,580 people in Maryland died from overdoses in the 12 months ending in July, the majority from fentanyl, according to the latest state health department figures. Fatal overdoses nationally have been trending up for the most part for the past two decades, exceeding 100,000 for the first time in 2021, according to the National Institute on Drug Abuse.
An estimated 1.6 million Americans have an opioid use disorder.
Buprenorphine is often dispensed as a pill but increasingly in the form of a film that dissolves in the mouth. It’s now often mixed with naloxone, which reverses overdoses, to keep the medication from producing the euphoric and addictive sensation of opioids.
A study of nearly 5,300 pharmacies published in JAMA Network Open earlier this year found only about 58% reported stock of buprenorphine, and there was variation among stores and states. Florida reported the least stocked at about 37%, and Washington had the most, at 84%.
In Maryland, 42.7% of pharmacies stocked buprenorphine.
The SAMHSA report also found availability limited, with less stock in Southern and rural states and in areas with lower health insurance coverage.
Dr. Michael Fingerhood sees patients in a clinic in the Amazing Grace Church in East Baltimore and finds some have a hard time getting their prescriptions filled in retail pharmacies. Sometimes returning patients can’t get refills.
Prescribers shared daily inventories from one drug store chain with The Banner, showing several Baltimore pharmacies can sometimes can fill no more than a dozen prescriptions. One store recently showed enough to fill just three prescriptions.
Another issue is the limit on the version of buprenorphine that can be prescribed under Medicaid, the federal-state health plan for low-income residents that covers a disproportionate number of people with substance use disorders. The Maryland program covers Suboxone, but if pharmacies run out, prior authorization is needed to fill the script with a generic version.
That causes delays, said Fingerhood, also chief of the Division of Addiction Medicine at Johns Hopkins Bayview Medical Center. His Bayview patients can fill their prescriptions in Hopkins pharmacies, which have not had shortages.
Several other clinics that have in-house pharmacies, and do not rely on retail pharmacies, also told The Banner that they do not have shortages.
“Luckily, I have not had patients relapse,” Fingerhood said. “They quickly contact me and I find a same-day solution, that obviously may present an inconvenience to patients as they need transportation to a different pharmacy.”
The SAMHSA report had several recommendations for easing the shortage, many centering on communications with pharmacies about the importance of the treatment medication. It said government regulators should be directly available to answer questions.
The report also said, “DEA could offer clear and written documentation to address fears and clarify points of misunderstanding regarding buprenorphine policy and investigations.”
Longer term, the report suggested federal health officials study higher reimbursements for buprenorphine through Medicaid, easing prior authorization requirements, allowing different doses and types, and expanding the places where buprenorphine could be dispensed.
