Commentary on Hill et al.: Breaking down barriers-increasing access to lifesaving opioid use disorder medications to save lives

Concise Statement:

Numerous barriers exist for patients attempting to access treatment for opioid-use disorder and/or naloxone, with geographical, racial, and age-related differences exacerbating these hardships.

Commentary:

With drug-related deaths in the United States (US) increasing again after a brief reprieve in 2018, much work has focused on identifying real-world barriers to lifesaving medications for individuals with opioid-use disorder (OUD). In a recent issue of Addiction, Hill et al. examined the availability of buprenorphine/naloxone films and naloxone nasal spray (NNS) in commercial and independent pharmacies in Texas.(1) Using a ‘secret shopper’ approach, researchers phoned a random sample of pharmacies and asked about their availability of a 1-week supply of generic buprenorphine/naloxone (BUP/NX) films and of naloxone nasal spray (NNS). Only approximately one-third of pharmacies were able to fill both prescriptions; 40% could fill the BUP/NX alone, while NNS was available in 60% of pharmacies. Availability varied by pharmacy type (commercial v. independent), as did willingness to order the desired medications.

As this well executed study shows, real-world barriers to critical OUD medications are widespread. Buprenorphine is a standard-of-care treatment of OUD, and expanded access to naloxone is associated with reductions in opioid-related mortality.(2-5) But for these interventions to be effective, individuals with OUD need to be able to easily access them. Access varies by geography given the heterogeneity of the opioid-overdose epidemic as well as regional social (e.g., stigma and pervasive inaccurate beliefs about OUD and treatment), political (e.g., state and local laws facilitating or obstructing access), and healthcare-sector (e.g., density of OUD treatment providers) differences.

Findings similar to those of Hill et al. have been shown throughout the US. A recent study of naloxone availability in Pennsylvania found that only 45% of pharmacies stocked it.(6) After California passed legislation in 2016 allowing patients to obtain naloxone without a prescription, fewer than one-quarter of pharmacies reported distributing naloxone to patients without a prescription.(7) Naloxone distribution in the US remains heavily dependent on a patchwork of community and public health department distribution programs with diverse and variable funding streams. Naloxone distribution is more progressive in some settings outside the US, with federal governments funding take-home naloxone kits in Scotland, and countries like Italy and Australia allowing naloxone to be purchased over-the-counter.(8,9)

OUD medication access gaps in the US are exacerbated by longstanding racial inequities. Across settings and populations, studies consistently demonstrate poorer access to buprenorphine for Black and Latinx compared to non-Hispanic white individuals.(10-14) Historically, access to MOUD has been fragmented according to race with highly segregated predominantly Black and Latino communities having relatively greater access to methadone as compared to buprenorphine, while predominantly white communities have easier (though still inadequate) access to buprenorphine.(15) Ongoing and future interventions need to incorporate clear antiracist strategies to reduce disparities by race.

It is also important to highlight the barriers that adolescents and young adults face when accessing OUD medications, with less than one-quarter of US youth aged 13-22 receiving timely addiction treatment after an opioid overdose and far fewer receiving an evidence-based medication like buprenorphine.(16) Access to naloxone can be difficult for adolescents to obtain as pharmacies often incorrectly restrict dispensing to youth based on age.(17) Expanded youth access to naloxone needs to be a focus of future policy interventions, not only because youth may themselves have an OUD diagnosis, but also because they are often the family member of someone with OUD.(18)

Policymakers, clinicians, the pharmaceutical industry, and retail and independent pharmacies can implement several solutions to overcome the many access barriers to lifesaving medications for OUD. Given the safety margin of naloxone, the US Food & Drug Administration could make naloxone an over-the-counter purchase. Such a policy change would need to be bolstered by a fully funded national strategy (e.g., through partnerships between government and drug companies) to ensure an adequate, affordable supply of naloxone to retail and independent pharmacies; such a strategy, which should also be pursued for buprenorphine, should have the dual goals of maximizing naloxone availability and minimizing pharmacies’ and patients’ financial burden. The US Drug Enforcement Agency should eliminate the “X-waiver” (the federal requirement in the US that prescribers complete mandatory training and registration to provide buprenorphine for OUD treatment) to increase the number of buprenorphine prescribers and dismantle the inherent stigma towards people with addiction that the X-waiver legislation was built upon.(19) In doing so, federal agencies should allow and incentivize pharmacists, who have enormous expertise in medication management, to offer OUD treatment, directly dispensing buprenorphine and naloxone. Until the barriers that prevent equitable access to OUD treatment and overdose interventions are undone, we will continue to see needless harm and death that is disproportionally experience by marginalized communities.