(64) Availability of Buprenorphine-Naloxone in Outpatient Pharmacies in South Florida

Introduction: Medications for opioid use disorder (MOUD) have been shown to reduce mortality among people with opioid use disorder (OUD), yet patients continue to face multilevel barriers to treatment. One important element of access to MOUD is their availability in community pharmacies. Once a patient has a prescription for buprenorphine-naloxone, delays in obtaining the medication can lead to further illicit opioid use and its associated risks – such as overdose and injection-related infections. Therefore, whether pharmacies maintain a supply of buprenorphine-naloxone is an important facilitator across the OUD continuum of care. Previous studies from other states have illustrated gaps in availability of these medications via telephone audits to local pharmacies1, 2. As a response to the “Pill Mills'' of the early 2000s, Florida placed heavy restrictions on dispensing opioids from outpatient pharmacies, which may have impacts on a pharmacy’s willingness to provide buprenorphine-naloxone. We performed a telephone audit of local pharmacies to describe availability of buprenorphine-naloxone in South Florida pharmacies.


Methods: A list of all outpatient pharmacies in the South Florida tri-county area (Miami-Dade, Broward, and Palm Beach Counties) was compiled using a Florida Pharmacy association database. The list was randomized, and pharmacies were called sequentially until 200 successful surveys had been completed. Medical students used a “secret shopper” audit approach using a standardized script. Students called the pharmacies and asked to speak with the pharmacist. Students reported they were working for an attending physician planning to prescribe buprenorphine-naloxone for a patient and were wanting to confirm availability before sending the prescription. The primary outcome was availability of any buprenorphine-naloxone. Secondary outcomes included whether a full two-week supply was available and differences in availability by pharmacy type and county. If unavailable, pharmacists were asked whether the medication could be ordered, and we estimated the delay in delivery.


Results: Overall, 1,374 registered outpatient pharmacies were identified in the tri-county area. 378 randomly selected pharmacies were contacted to accrue 200 successfully completed interviews (53% success rate). Of the total pharmacies contacted, 80% were national chains and 20% were independent pharmacies. In total, 62% of pharmacies reported having no buprenorphine-naloxone currently available. Chain pharmacies had a significantly higher rate of carrying buprenorphine-naloxone when compared to independent pharmacies (41% vs. 25%, p < 0.05). There was a significant difference in availability of buprenorphine-naloxone by county (p < 0.05). Of the 38% that did have buprenorphine-naloxone available, 82% (31% of all surveyed pharmacies) had enough available for a two-week supply of 8-2 mg sublingual twice daily (28 films or tablets). Of the pharmacies that did not have buprenorphine, 49% would be willing to have it ordered with a median estimated time to receive an order being 2 days (interquartile range 1.25-3).


Conclusions: Our study demonstrated that less than 40% of pharmacies in South Florida stocked buprenorphine-naloxone and only half without any supply were willing to have it ordered. Lack of pharmacy MOUD availability is one of many community-level barriers to OUD treatment access in South Florida in addition to a shortage of providers and low access for funding for treatment.

Diversity, Equity, and Inclusion: With the recent removal of required training and certification to treat OUD with buprenorphine products, this project sought to uncover barriers outside the scope of physician restrictions that could prevent patients from obtaining life-saving medications for OUD. By demonstrating a shortage of buprenorphine products at both independent and chain outpatient pharmacies, it has become evident that there are greater measures that must be taken to provide this patient population -- one that faces extreme bias from society and providers alike -- with optimal care. Despite there being a greater number of providers able to prescribe buprenorphine, decreased supply inhibits many from obtaining and complying with medication regimens. Further, through comparing three separate counties in South Florida, this study aimed to emphasize disparities that may be faced regionally. Each county studied represents its own diverse community and, when compared, broadens the ability to understand healthcare differences amongst regions and which communities have the least access to these lifesaving medications.

References: 1. Koehl JL, Zimmerman DE, Bridgeman PJ. Medications for management of opioid use disorder. Am J Health Syst Pharm. 2019 Jul 18;76(15):1097-1103. doi: 10.1093/ajhp/zxz105. PMID: 31361869.
2. Pham S, Haigh A, Barrett E. Statewide Availability of Buprenorphine/Naloxone in Acute Care Hospitals. J Addict Med. 2021 Mar 16. doi: 10.1097/ADM.0000000000000833. Epub ahead of print. PMID: 33758118.
3. Strang J, Volkow ND, Degenhardt L, Hickman M, Johnson K, Koob GF, Marshall BDL, Tyndall M, Walsh SL. Opioid use disorder. Nat Rev Dis Primers. 2020 Jan 9;6(1):3. doi: 10.1038/s41572-019-0137-5. PMID: 31919349.
4. Hill LG, Loera LJ, Evoy KE, Renfro ML, Torrez SB, Zagorski CM, Perez JC, Jones SM, Reveles KR. Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in Texas, USA. Addiction. 2021 Jun;116(6):1505-1511. doi: 10.1111/add.15314. Epub 2020 Nov 22. PMID: 33140519.