Barriers to Buprenorphine Dispensing by Medicaid-Participating Community Retail Pharmacies

Abstract

Importance: Controlled substances have regulatory requirements under the US Federal Controlled Substance Act that must be met before pharmacies can stock and dispense them. However, emerging evidence suggests there are pharmacy-level barriers in access to buprenorphine for treatment for opioid use disorder even among pharmacies that dispense other opioids.

Objective: To estimate the proportion of Medicaid-participating community retail pharmacies that dispense buprenorphine, out of Medicaid-participating community retail pharmacies that dispense other opioids and assess if the proportion dispensing buprenorphine varies by Medicaid patient volume or rural-urban location.

Design, setting, and participants: This serial cross-sectional study included Medicaid pharmacy claims (2016-2019) data from 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, West Virginia) participating in the Medicaid Outcomes Distributed Research Network (MODRN). Community retail pharmacies serving Medicaid-enrolled patients were included, mail-order pharmacies were excluded. Analyses were conducted from September 2022 to August 2023.

Main outcomes and measures: The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder among pharmacies dispensing an opioid analgesic or buprenorphine prescription to at least 1 Medicaid enrollee in each state. Pharmacies were categorized by median Medicaid patient volume (by state and year) and rurality (urban vs rural location according to zip code).

Results: In 2016, 72.0% (95% CI, 70.9%-73.0%) of the 7038 pharmacies that dispensed opioids also dispensed buprenorphine to Medicaid enrollees, increasing to 80.4% (95% CI, 79.5%-81.3%) of 7437 pharmacies in 2019. States varied in the percent of pharmacies dispensing buprenorphine in Medicaid (range, 73.8%-96.4%), with significant differences between several states found in 2019 (χ2 P < .05), when states were most similar in the percent of pharmacies dispensing buprenorphine. A lower percent of pharmacies with Medicaid patient volume below the median dispensed buprenorphine (69.1% vs 91.7% in 2019), compared with pharmacies with above-median patient volume (χ2 P < .001).

Conclusions and relevance: In this serial cross-sectional study of Medicaid-participating pharmacies, buprenorphine was not accessible in up to 20% of community retail pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment. That some pharmacies dispensed opioid analgesics but not buprenorphine suggests that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.

Figure 1.. Trends in the Proportion of Pharmacies Dispensing Buprenorphine by State, 2016 to 2019

The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder treatment was calculated using the number of pharmacies dispensing at least 1 opioid analgesic or buprenorphine prescription as the denominator. Any pharmacy National Provider Identifier number that had at least 1 Medicaid claim for a product was considered to have dispensed that product. Shaded areas represent the exact binomial 95% CIs. The letters in the key represent state pseudonyms assigned and reported in prior Medicaid Outcomes Distributed Research Network publications.

Figure 2.. Trends in the Proportion of Pharmacies Dispensing Buprenorphine by State, and Medicaid Patient Volume and Urbanization, 2016 to 2019

Medicaid patient volume was determined using a median split of the total number of unique Medicaid enrollees with dispensed prescriptions associated with each pharmacy National Provider Identifier number, within each state and each year. Urbanization was determined using the zip code for the pharmacy location. Zip codes with primary Rural-Urban Commuting Area (RUCA) codes of 1 to 3 were classified as urban and pharmacies with RUCA codes of 4 to 10 were classified as rural. The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder treatment was calculated using the number of pharmacies dispensing opioid analgesics or buprenorphine as the denominator. Any pharmacy National Provider Identifier number that had at least 1 Medicaid claim for a product was considered to have dispensed that product. Shaded areas represent the exact binomial 95% CIs. The letters in the key represent state pseudonyms assigned and reported in prior Medicaid Outcomes Distributed Research Network publications.