Overcoming Barriers

Several statements about the barriers facing patients with opioid use disorder (OUD) are listed below. Decide whether each statement is true or false, and then click the button that corresponds with your response. Feedback is provided in the right column.

Statement	True or False		Result
People with OUD who cannot get their buprenorphine prescription filled have an increased likelihood of obtaining a new opioid prescription.
People with OUD who cannot get their buprenorphine prescription filled are at increased risk of discontinuing treatment.
People with OUD who cannot get their buprenorphine prescription filled are at increased risk of using non-prescribed substances.
People with OUD who cannot get their buprenorphine prescription filled are at increased risk of an emergency department visit.
People with OUD who cannot get their buprenorphine prescription filled are at increased risk of overdose.
People with OUD who cannot get their buprenorphine prescription filled are at increased risk of all-cause mortality.

Endorsement by the American Pharmacists Association

The American Pharmacists Association (APhA) endorses pharmacists’ role in increasing access to and advocacy for medications for opioid use disorder. ²⁶

"APhA supports the use of evidence-based medication as first-line treatment for opioid use disorder for patients… for as long as needed to treat their disease… APhA encourages pharmacies to maintain an inventory of medications of public health importance, particularly medications for opioid use disorder, to ensure access for patients. APhA encourages pharmacists and payers [to] ensure patients have equitable access to and coverage for at least one medication from each class of medications used in the treatment of opioid use disorder, [for example by] making medications available on the payer’s lowest cost-sharing tier."

"Red Flags" – when not to worry

Some pharmacists report reluctance to dispense buprenorphine in specific scenarios, citing "red flags." However, in many cases legislation and other guidance on controlled substance dispensing, for example, the NC STOP Act, outlines verification procedures for each scenario rather than directing pharmacists not to dispense. ²⁷

Statement	Myth or Fact		Result
I can’t fill scripts from telehealth prescribers.
I cannot fill a script from a prescriber from outside of my geographic area.
When patients request buprenorphine by color or imprint, they are just trying to find the product with a higher street value.

Detailed guidance from the NC Stop Act for each of these scenarios is shown below. Click each scenario to learn more.

NEW PATIENT

You CAN fill scripts for new patients.

The STOP Act does not require checking CSRS for a newly prescribed patient/new script. You may choose to do so and document if you wish.

Scripts from new patients will increase as the number of eligible prescribers increase.

NEW OR OUT-OF-AREA PRESCRIBER

You CAN fill scripts for new or out of area prescribers.

The STOP ACT does require review of the CSRS for new prescribers or prescribers from outside of the usual geographic area served.

Make sure to document why you are filling the buprenorphine prescription from an out of area prescriber. Strong rationales include: Telehealth prescriber servicing patients in the area; lack of other prescribers in area.

The number of new prescribers may increase with new legislation changes.
Telehealth prescribing may lead to new prescribers, or prescribers from outside your area, particularly in rural areas.

PATIENT OUT OF USUAL GEOGRAPHIC AREA SERVED BY PHARMACY

You CAN fill scripts for patients outside of the usual geographic area served by the pharmacy.

The STOP ACT does require review of the CSRS for patients that reside outside of the usual geographic area served by the pharmacy.

Make sure to document why you are filling the buprenorphine prescription from an out of area patient. Strong rationales include: Pharmacy closures in the area; pharmacy closest to where the patient works; previous pharmacy unable to fill due to thresholds etc.

Scripts will increase with the increase in eligible prescribers.
Many patients must travel outside their local community to fill prescriptions when local pharmacies encounter wholesaler thresholds on buprenorphine ordering, or close.
Some patients may cross a state border due to state-specific restrictions on a particular formulation, for example, monoproduct restrictions in TN.

TELEHEALTH PROVIDER

You CAN fill scripts for patients seen by telehealth providers.

The STOP Act predates the ruling that allows prescribers to prescribe buprenorphine via telehealth. However, if the telehealth prescriber is located outside of the usual geographic area served by the pharmacy, it is still required to check the CSRS and document.

The DEA final rule: Expansion of Buprenorphine Treatment via Telemedicine Encounter authorizes providers to prescribe buprenorphine via telemedicine, without requiring an in-patient visit for the treatment of OUD.
Starting buprenorphine treatment for OUD through telehealth is associated with an increased likelihood of staying in treatment compared to starting treatment in a non-telehealth setting. ²⁹
Telehealth providers are licensed prescribers qualified to care for patients with OUD. If there are concerns about the legitimacy of the script, pharmacists are welcome to reach out to the prescriber, as they would any other medication, and document this on the script.

PRESCRIPTION DURATION

You CAN fill scripts for patients that have been on buprenorphine for years.

The STOP Act does not require checking CSRS based on the prescription duration of buprenorphine. You may choose to do so and document if you wish.

Buprenorphine scripts, similar to all other C III medications may be filled no more than 6 months after the date written date or refilled more than 5 times. Patients on stable doses of buprenorphine may have refills on their scripts, similar to other C III medications.
Evidence-based guidelines recommend OUD treatment with buprenorphine for as long as beneficial. Some clinical guidelines state one year minimum and longer in pregnancy/postpartum. ^{30, 31}

MEDICATION REQUESTED BY NAME, IMPRINT, OR DESCRIPTION

You CAN fill scripts for patients who request buprenorphine by specific name, imprint, or description.

The STOP ACT does require review of the CSRS for patients that ask for a medication by name, imprint or description, and document.

Patients may request a specific formulation for any of the following reasons

Known adverse reaction to one formulation
Insurance may only cover one formulation
Patient assistance may only be available for a certain formulation
Patient is more familiar and comfortable with a specific product
Patient prefers to continue on a medication that they used in the past

REQUEST EARLY FILLS

The STOP ACT does require review of the CSRS for patients that requests early fills.

Patients with OUD commonly express that buprenorphine makes them feel like they can function and have a normal life. Consequently, the thought that they could run out of their medication can result in considerable anxiety and concern about experiencing withdrawal from buprenorphine, which can cause them to seek a refill early so they know that they will have their buprenorphine on hand.
Patients prescribed buprenorphine may request an early fill when anticipating travel or anticipate difficulty getting to the pharmacy, such as transportation issues, to avoid experiencing withdrawal due to dispensing delays.

MONO VS COMBO PRODUCT

You CAN fill buprenorphine monoproduct OR combination product with naloxone.

The STOP ACT does not require review of the CSRS for patients based on buprenorphine formulation prescribed. However, the DEA demonstrated a preference for pharmacies to document a reason for dispensing monoproduct buprenorphine. We recommend checking the CSRS and documenting this review for monoproduct buprenorphine.

Patients may be prescribed monoproduct buprenorphine for a variety of reasons such as intolerance to naloxone, or due to the cost associated with the combination product.
The prescriber should provide rationale with the script, such as patient reported intolerance, nausea/vomiting, to naloxone. If not, the pharmacist should inquire for rationale of the mono-product use and document the response.
Understanding that wholesalers are closely monitoring mono product buprenorphine, if one prescriber is consistently prescribing monoproduct and you are concerned; reach out to the prescriber to see if a switch to combination product could be appropriate for the patient.

References: NC Legislature, STOP Act.; 2017 (PDF) and NC Board of Pharmacy. 2017 (PDF).

Filling Bridge Scripts

In some pharmacies you may be able to fill for a specific minimum number of days to ensure that the patient does not have a gap in continuity of care while you initiate a validation process. Examples of how some pharmacists determine length of fill while verifying the prescriber are described in the table below. Remember: A positive experience with filling can encourage a patient to continue in treatment.

How to Determine Length of Fill While Verifying Prescriber

Circumstance	If You Can’t Reach Prescriber, Consider Filling For:	Next Steps
Patient brings in new script or script from unknown prescriber on a Friday	3 days minimum – prevent treatment gap through weekend	Ask patient to call prescriber on Monday and ask them to contact the pharmacy Contact prescriber on Monday to verify Document reasons why you filled a bridge script in the patient’s record. Example: Checked CSRS. Attempted to contact patient’s provider and could not reach them. Left a message. In order to reduce overdose risk, provided 3 days of rx so they did not experience a treatment gap over the weekend.
New patient brings in one-week script, or patient brings in one-week script from unknown prescriber	7 days – prevent a treatment gap until patient’s next appointment	Ask patient to have the prescriber get in touch with the pharmacy at their next appointment Clarify that pharmacy won’t fill again until prescriber contacts pharmacy Document reasons why you filled 1-week script in the patient’s record. Example: Checked CSRS. Attempted to contact patient’s provider and could not reach them. Left a message. In order to reduce overdose risk, provided 7 days of rx so they did not experience a treatment gap before their next scheduled appointment. Stated that we would not fill another script until their prescriber contacts the pharmacy.
Patient missed or needed to reschedule an appointment with prescriber, for example, childcare or transportation fell through; work schedule changed, et cetera.	Dispense bridge script until patient’s rescheduled appointment	Encourage patient to ask provider to prescribe a few days of extra medication to prevent a treatment gap until rescheduled appointment Document reasons why you filled bridge script in the patient’s record. Example: Checked CSRS. Attempted to contact patient’s provider and could not reach them. Left a message. Patient had transportation issues and missed scheduled appointment. Filled one-time emergency fill according to Board Rule 21 NCAC 46.1809, this medication is essential to the continuation or therapy in a chronic condition, and interruption of therapy might reasonably produce an undesirable health consequence, that is, overdose. Provided X days of rx so they did not experience a treatment gap before their next rescheduled appointment. Notified prescriber of emergency dispensing within 72 hours via fax. Stated that we would not fill another script until their prescriber contacts the pharmacy. ³²