The Troubling Trend of Pharmacies Refusing to fill a lifesaving Addiction Treatment Medication

I sat on the phone yesterday consoling a single mother in Ohio. She was scared and tearful. She was going through acute withdrawal from heroin. In between bouts of vomiting and dry heaving, she pleaded, “When will I be able to pick up the medication you ordered that stops all of this?” This mother had already overcome the significant barriers Americans face when seeking addiction treatment, including stigma associated with treatment, affordability of treatment, and finding high quality, highly trained Addiction Specialists. I had prescribed an FDA approved life-saving addiction treatment medication that reduces her chance of death from addiction by over fifty percent. Seems like it should be a happy ending. Instead, we found her local Kroger pharmacy refusing to fill this lifesaving prescription.

The Ohio Kroger pharmacy response is just one example of a troubling, growing trend. Pharmacies across the country are refusing to fill the life-saving addiction treatment medication called Suboxone. Suboxone is one of only a handful of FDA approved medications that treats opioid use disorder and reduces fatalities from addiction by over fifty percent. As a multi-state licensed Addiction Psychiatrist, I find myself in daily debates across the country with major retail pharmacy chains Walgreens, Walmart, CVS Pharmacy, and Kroger among many others who refuse to fill this life-saving medication. The largest number of pharmacy refusals come from Florida. The Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration (SAMHSA) have both issued recent policy statements urging healthcare providers and pharmacies alike to increase access to this life-saving medication with fully telehealth treatment of substance use disorders.

Why are so many pharmacies refusing to fill valid, legal, physician issued prescriptions for the single most important, effective medication used to treat addiction? The answer, ironically, lies in recent well-meaning landmark court proceedings designed to decrease the opioid epidemic: court decisions that are now having opposite, unintended consequences of increasing untreated opioid addiction and preventing access to life-saving treatment.

In late 2022, CVS Pharmacy, Walgreens, and Walmart were forced to pay an eye-popping $10.7 billion to settle allegations that the pharmacy chains failed to adequately oversee opioid painkiller prescriptions, thus contributing to America’s opioid addiction crisis. CVS Pharmacy alone paid $4.9 billion while Walgreens paid $4.95 billion in fines. With this decision, the pharmacy chains also agreed to implement robust “controlled substance compliance programs” that required additional layers of opioid prescription reviews, mandatory state prescription pharmacy data-base checks, and new employee training programs on prescription monitoring oversight. The Connecticut Attorney General William Tong remarked, “One by one, we are holding every player accountable for the millions of lives lost or devastated by the opioid epidemic. The companies that helped to create and fuel this crisis must commit to changing their business practices, and to providing the resources needed for treatment, prevention, and recovery.”

This well-meaning legislation was designed to rightfully reduce access to dangerous and addictive prescription opioid drugs like Oxycontin, Percocet, and Vicodin among others-drugs which are gateways to opioid addiction and are often involved in opioid overdose deaths. Suboxone is also a controlled substance. Because Suboxone contains a very low, weakened amount of opioid to treat withdrawal, some pharmacists mistakenly lump it into the same category of traditional, dangerous opioids that are subject to this new regulatory oversight. But Suboxone has a very different chemical make-up than traditional opioids. Suboxone’s chemical makeup is designed to prevent people from getting high on it. It also contains the opioid overdose agent Naloxone or NARCAN® Nasal Spray Canada which further reduces abuse potential. These importance differences make Suboxone a safe, effective, FDA approved medication designed to treat addiction, not cause, or worsen it. (For a more in-depth explanation on crucial distinctions between Suboxone and opioid drugs, click here.) Despite all of these important differences, some pharmacies continue to lump Suboxone in with other opioid medications. Ironically, the very measures designed to curb addiction are now resulting in less access to our most important medications used to fight addiction.

As an Addiction Psychiatrist who is passionate about addiction treatment, I spend a significant portion of my days talking to pharmacists who refuse to fill Suboxone prescriptions. My goal is always to try and find a way for my patients to obtain this life-saving medication. The most common reasons pharmacists give for Suboxone refusal include “the patient lives too far away from your treatment facility,” “you did not see the patient in person,” “There is no previous prescription for Suboxone on file for this patient,” or “I think the Suboxone dose is too high.” All of these reasons defy logic. The Drug Enforcement Administration, The National Institute on Drug Abuse (NIDA), Substance Abuse and Mental Health Services Administration (SAMHSA), and American Society of Addiction Medicine – ASAM all agree that in-person appointments for this prescription are not medically necessary and unnecessarily hinder access to treatment. Pharmacists concerned with no previous prescription for Suboxone is equally puzzling. Luckily, due to increased addiction treatment access, many patients are starting Suboxone to treat opioid use disorder for the first time- and this is a good thing. It means we are broadening treatment access to more folks who need it most. Finally, the “too high dose” argument also does not make sense. Suboxone, unlike most other medications, has a “ceiling effect,” which means that the medication effects cap off somewhere between 16-24 milligrams, thus making a 24-milligram dose as safe as a 16-milligram dose. Unlike its opioid cousins, higher doses of Suboxone do NOT result in higher addiction or abuse potential.

I’m successful in convincing the pharmacist to ultimately dispense the Suboxone about half of the time. After an hour on the phone with the Kroger pharmacist, I was able to convince her to dispense the Suboxone prescription to the single mom who was waiting outside in the grocery store parking lot in acute opioid withdrawal. Many other times, our patients are forced to pharmacy hop until we find an understanding and well-informed pharmacist. It is tiring and exhausting.

What is the solution? We desperately need advocacy help from our high-profile medical stakeholders. It would be helpful if the Drug Enforcement Administration, American Medical Association, American Society of Addiction Medicine – ASAM, and Substance Abuse and Mental Health Services Administration (SAMHSA) released specific policy statements encouraging all pharmacies to fill Suboxone prescriptions without geographic, mileage, or in-person requirements.

The best way to quickly curb the Opioid Epidemic is increased access to effective treatment. Suboxone is one of the very few life-saving addiction treatments in our medicine arsenal. It reduces mortality rates from overdose by over fifty percent. This means that your loved one suffering from Opioid Use Disorder is more than twice as likely to survive with this medication. We need help reducing well-meaning but misinformed pharmacy red tape to Suboxone access. We owe this to the American public. We owe this to our friends, family members, and loved ones whose lives are jeopardized by addiction. We owe this to the more than 500,000 people we’ve lost in the United States in the past two decades due to overdose. We owe this to our children. Martin Luther King Jr. famously said, “The ultimate tragedy is not the oppression and cruelty by bad people but the silence over that by the good people.” Now more than ever, we need loud, passionate battle cries from our good people.

At Aware Recovery Care, we recognize that everyone’s journey towards recovery is unique. We strive to provide personalized treatment options to meet our clients’ specific needs. Whether individuals require a flexible outpatient treatment approach, intensive medical support, or a comprehensive long-term program, our dedicated team is here to provide guidance and support throughout the recovery process and beyond. Remember, you don’t have to face addiction alone – we are here to help you take the first step towards a healthier and happier future. Contact us today to get started.