Let pharmacists prescribe addiction medicine
In early 2022, a woman we’re calling Joan was about to lose her temporary COVID-19 housing at a hotel in Warwick, R.I., and she had no reliable transportation or cell phone. Worse, she was no longer receiving buprenorphine, a medication she took for her opioid use disorder. Having felt regularly stigmatized by the health care system, she had little hope she could find a doctor willing to treat her.
Joan turned to street fentanyl for relief from feeling sick. Then she was approached by a research study team at Rhode Island Hospital, who offered her an opportunity to try something new: sameday treatment at a pharmacy in her community.
Following a brief assessment, the specially trained pharmacist called an addiction medicine physician at the Lifespan Recovery Center to collaborate on Joan’s care. The pharmacist then educated Joan on how to safely take buprenorphine on her own and gave her a week’s supply until her next visit — all in about an hour.
Although medications like buprenorphine and methadone are safe and effective at treating addiction and preventing overdose and death, regulatory hurdles have prevented these treatments from being widely utilized. A recent national study estimated that 87 percent of people with opioid use disorder never receive any medication treatment.
Those who do receive treatment often have to manage long-distance travel, inconvenient hours, stigma, and strict rules that can seem impossible to follow. Joan had lost hope that she would get the care she deserved.
She was able to get help at a neighborhood pharmacy because of a study we conducted in which pharmacists in Rhode Island got special training to directly provide patients with buprenorphine. That meant patients could walk in and ask to start treatment, and the pharmacist could initiate the process. The pharmacist did this in consultation with a physician, but the patient did not have to see the physician first. We wrote about this research, the MATPharm Study, last week in the New England Journal of Medicine.
We found that pharmacies offer a safe and accessible starting point for treatment and keep patients engaged better than is typical. Of 100 people who started buprenorphine treatment at a pharmacy, 58 stabilized and were randomly split into two groups. Twenty-eight of them continued to receive their addiction care at a pharmacy, while the other 30 had the usual follow-up care with a doctor or an opioid treatment program. One month later, 25 of the 28 patients in the pharmacy group were still proceeding with their assigned treatment. Only five of the 30 patients in the doctor-treatment group were doing so.
A third of the patients in our study identified as Black, Indigenous, or persons of color; almost half were homeless.
Pharmacies are especially well suited to deliver medications for opioid use disorder because they have convenient locations and hours and often employ a staff that is more diverse and representative of the community than physicians’ offices. Their convenience is a major reason why several other countries, including Canada and Australia, allow pharmacists to write some prescriptions. In designing this study, we followed the example of Scotland, which pioneered the delivery of addiction care and other public health interventions in pharmacies.
We can do this more broadly in the United States and help far more people like Joan, but only if several things change.
Our pilot program was legal in Rhode Island through what is called a collaborative practice agreement, in which a physician and pharmacist agree to cooperate on providing care and certain activities — like starting treatment, delivering screening exams, performing toxicological assessments, and carrying out follow-up visits — can be delegated to the pharmacist.
Thirty-nine other states, including Massachusetts, also allow such agreements. We think all of these states should add buprenorphine to the list of drugs that pharmacists can offer patients in their collaborations with physicians.
In 10 states (California, Idaho, Massachusetts, Montana, New Mexico, North Carolina, Ohio, Tennessee, Utah, and Washington) pharmacists are already allowed to prescribe controlled substances, although in Massachusetts this extends only to pharmacists in hospitals and other health care institutions. We think that all states should allow pharmacists to prescribe buprenorphine, with or without physician involvement.
The federal government has eased the way for states to make such changes. Last month President Biden signed a law that eliminated the “X waiver” previously required to prescribe buprenorphine.
Creating multiple avenues to addiction care is crucial for vulnerable groups whom the system often misses or overlooks. For people like Joan, finding a doctor and maintaining scheduled appointments may be especially challenging. But a pharmacy literally “meets people where they’re at.” We need pharmacists’ help now.
Traci Green is adjunct associate professor of emergency medicine and epidemiology at Brown University and director of the Opioid Policy Research Collaborative at the Heller School for Social Policy and Management at Brandeis University. Jeffrey Bratberg is clinical professor of pharmacy practice and clinical research at the University of Rhode Island College of Pharmacy. Josiah “Jody” Rich is an attending physician at the Miriam and Rhode Island hospitals and professor of medicine and epidemiology at Brown.