Buprenorphine for Opioid Use Disorder (OUD)

In this episode, TRC Healthcare editor, Vickie Danaher, PharmD, discusses how pharmacists and pharmacy technicians play a vital role in ensuring access to buprenorphine for opioid use disorder treatment. She’ll explore approaches to addressing dispensing barriers, inventory management strategies, and the importance of recognizing opioid use disorder as a chronic condition requiring appropriate long-term care. 

This is an excerpt from our March 2025 Pharmacy Essential Updates continuing education webinar series.

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CE Information:

TRC Healthcare offers CE credit for this podcast for pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers. Log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose.

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The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Break Down Barriers to Dispensing Buprenorphine for OUD
• FAQ: Management of Opioid Use Disorder
• Graphic: Opioid Reversal Agents Quick Start Guide
• Course: Substance Use Disorders and Pain Management: MATE Act Training

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Transcript

This transcript is automatically generated. 

00:00:04 Narrator

Welcome to Clinical Capsules from TRC Healthcare, your go-to podcast for fast, evidence-based insights. 

00:00:11 Narrator

On this episode, Associate Editor and Clinical Pharmacist Vickie Danaher examines the use of buprenorphine for treating opioid use disorder, or OUD in an excerpt from our popular Pharmacy Essential Updates webinar series.  

00:00:25 Narrator

TRC has been a trusted resource for healthcare professionals for over 40 years—and now we’re bringing that expertise straight to your ears every 2nd and 4th Tuesday, in bite-sized, actionable episodes…right here on Clinical Capsules.

00:00:40 Narrator

And new starting this month… this podcast offers Continuing Education credit for pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers.

00:00:50 Narrator

Please log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.

00:00:58 Narrator

None of the speakers have anything to disclose.  With that, let’s get started…

00:01:09 Vickie Danaher

And we're highlighting this topic today since we, as pharmacists and pharmacy technicians play a crucial role in ensuring patients have access to buprenorphine products such as generic Suboxone, which are first line treatments for OUD.

00:01:23 Vickie Danaher

And we know that in the last few years there's been some big changes with buprenorphine prescriptions for OUD to help overcome some of the barriers that patients may face with getting treatment.

00:01:35 Vickie Danaher

And although many of these changes were initially introduced during the COVID-19 pandemic, they've since been extended and made permanent in some cases.

00:01:44 Vickie Danaher

For example, we know that prescribers don't need a special X DEA number to write prescriptions for buprenorphine for OUD anymore.

00:01:53 Vickie Danaher

These prescriptions now only require a standard DEA number, so we no longer need to check for an X DEA number on these prescriptions.

00:02:03 Vickie Danaher

Also in the past there was a maximum number of patients that prescribers were allowed to prescribe buprenorphine for.

00:02:11 Vickie Danaher

But now there's no limit to the number of patients that prescribers can treat.

00:02:17 Vickie Danaher

In addition, federal rules have been extended to allow prescriptions for buprenorphine to be issued via telehealth or telemedicine under specific regulations.

00:02:28 Vickie Danaher

And this may be particularly beneficial for patients in rural or underserved areas.

00:02:33 Vickie Danaher

Who may face barriers to in person care, such as transportation challenges or financial constraints.

00:02:41 Vickie Danaher

But despite these efforts to help expand access, many patients who want or need treatment for opioid use disorder still aren't getting it.

00:02:51 Vickie Danaher

And there's many possible reasons for this, but one that relates to us in the pharmacy has to do with medication availability.

00:02:58 Vickie Danaher

Recent data indicates that over half of US pharmacies report not having buprenorphine for OUD in stock.

00:03:05 Vickie Danaher

Which composes significant barrier to treatment.

00:03:10 Vickie Danaher

Plus, we know when dispensing these prescriptions, questions often pop up about regulations or liability or there may be concerns about misuse or diversion.

00:03:20 Vickie Danaher

So today we're going to spend a few minutes talking about how we as pharmacists and techs can help extend access to treatment by working together to overcome challenges with dispensing buprenorphine for OUD.

00:03:31 Vickie Danaher

And understanding how we can best support patients and recovery.

00:03:37 Vickie Danaher

A key part of this is also being ready to help new patients starting buprenorphine because it may be the last stop for that patient before they get started. We want to make every effort to ensure patients have access.

00:03:51 Vickie Danaher

This is especially important because patients who can't get buprenorphine products for opioid use disorder are at risk for withdrawal relapse or return to use overdose and death.

00:04:03 Vickie Danaher

Medications to treat OUD also decrease illicit opioid use, reduce criminal activity and improve social functioning and increase treatment retention.

00:04:13 Vickie Danaher 

And when we discuss this topic with experts in the past, they pointed out that patients can change the course of their whole life by starting treatment, and we can help with those efforts.

00:04:25 Vickie Danaher

Now in terms of which buprenorphine products can be used for opioid use disorder, we know that there's combo products with buprenorphine and naloxone, including sublingual tabs or films or single ingredient products. With buprenorphine alone.

00:04:44 Vickie Danaher

There's also long acting buprenorphine injections, which can last up to about a month or so depending on the product.

00:04:51 Vickie Danaher

But these injections will usually be reserved for patients if there's concerns about adherence, abuse or diversion.

00:04:58 Vickie Danaher

They're only available through certified prescribers, must be administered, by a healthcare provider and they cost about $2000 per month. 

00:05:08 Vickie Danaher

So of all these options, anticipate that the combo products with buprenorphine and naloxone are still the go to treatments.

00:05:18 Vickie Danaher

Buprenorphine is a partial opioid agonist, which is how it helps prevent withdrawal symptoms.

00:05:24 Vickie Danaher

And the naloxone in these sublingual products is an opioid antagonist or blocker.

00:05:30 Vickie Danaher

And is included in an effort to help deter misuse.

00:05:35 Vickie Danaher

And that's because when the combos are taken, sublingually naloxone has low bioavailability.

00:05:42 Vickie Danaher

But if the combo product is misused by injection, then naloxone may block the effects of buprenorphine or precipitate opioid withdrawal, in someone taking opioids.

00:05:53 Vickie Danaher

So that's one reason why the combo sublingual tabs are films are generally preferred over sublingual buprenorphine tabs alone.

00:06:03 Vickie Danaher

Be aware that any formulation of the combo buprenorphine naloxone products can be used and sublingual tablets or films are similarly effective.

00:06:13 Vickie Danaher

In terms of dosing, patients may start buprenorphine in a prescriber's office, hospital or at home and they’ll need to be having withdrawal symptoms before starting to prevent precipitating withdrawal.

00:06:26 Vickie Danaher

But after this induction phase, we can recommend titrating to a usual maintenance buprenorphine dose of about 16 to 24 milligrams a day for the sublingual tabs or films.

00:06:38 Vickie Danaher

This dose may be more effective than lower doses for preventing illicit opioid use.

00:06:45 Vickie Danaher

But the dose does need to be individualized and can vary widely.

00:06:50 Vickie Danaher

For example, doses may range from lower doses up to about 24 milligrams per day or more of buprenorphine.

00:06:59 Vickie Danaher

And keep in mind that even higher doses may be needed in some cases.

00:07:03 Vickie Danaher

Such as those with a history of fentanyl, misuse or to help manage uncontrolled cravings.

00:07:09 Vickie Danaher

Also be aware that there's no maximum duration of treatment for continuing buprenorphine for OUD.

00:07:16 Vickie Danaher

Opioid use disorder is a chronic condition similar to high blood pressure, cardiovascular disease or diabetes.

00:07:24 Vickie Danaher

So just like you wouldn't stop a patient's Med after a heart attack or for diabetes, patients with opioid use disorder can also use treatment long term and for as long as they see benefit.

00:07:37 Vickie Danaher

And the longer that patients stay on treatment, the lower their risk of illicit use, relapse, and death.

00:07:44 Vickie Danaher

So considering that many patients who take buprenorphine products for OUD will be on them long term and we also want to have buprenorphine available for patients just starting therapy, we want to make sure to maintain adequate inventory.

00:07:59 Vickie Danaher

So this is a good reminder for us to regularly review our stock levels, anticipate demand to prevent shortages and collaborate with distributors to ensure a steady supply.

00:08:11 Vickie Danaher

Now one worry that pharmacies may have with ordering buprenorphine. Is that because it's a controlled substance? Distributors have limits and thresholds on how much can be purchased.

00:08:22 Vickie Danaher

And there are concerns about exceeding these thresholds.

00:08:26 Vickie Danaher

But be aware that DEA has stated that distributors or wholesalers should carefully examine any established purchase limits in light of the expected increase in buprenorphine prescribing.

00:08:38 Vickie Danaher

And they want to ensure that pharmacies are able to dispense legitimate prescriptions for buprenorphine for OUD without undue delay.

00:08:46 Vickie Danaher

So consider contacting your distributor if you have any problems ordering buprenorphine due to their controlled substance purchase limits.

00:08:54 Vickie Danaher

Distributors can provide info on submitting A threshold change request to start the process of getting those limits adjusted if needed.

00:09:03 Vickie Danaher

If you don’t  have, buprenorphine in stock, offer to help patients find another pharmacy that does and also work as a team to reduce other barriers that patients may face, such as by expediting any insurance issues.

00:09:17 Vickie Danaher

Continue to use your states prescription drug monitoring program or PDMP as a tool to support appropriate dispensing, but not as the final word.

00:09:28 Vickie Danaher

We know PDMP's are valuable for monitoring prescriptions, but they should not be the sole determinant in dispensing decisions.

00:09:37 Vickie Danaher

For example, don't automatically deny prescriptions with a potential red flag, such as paying cash or living a certain distance from the pharmacy or prescriber?

00:09:48 Vickie Danaher

Instead, think of these as prompts to look into further, such as through open discussions with the prescriber or patient.

00:09:56 Vickie Danaher

And again, remember that data from the PDMP is just one part of the bigger picture. But think about other important factors too.

00:10:04 Vickie Danaher

Have an open discussion with the prescriber and patient to clarify any concerns and carefully document the discussion and outcome.

00:10:12 Vickie Danaher

Continue to rely on your clinical judgment and prioritize patient care.

00:10:17 Vickie Danaher

Another way we can help improve access to buprenorphine is by minimizing stigma.

00:10:22 Vickie Danaher

And helping to clear up misconceptions about the management of opioid use disorder. Since these things remain a significant barrier to treatment.

00:10:32 Vickie Danaher

So one simple strategy we can take is using person first language when talking to or about patients getting buprenorphine for OUD.

00:10:42 Vickie Danaher

For example, we can say patient with a substance use disorder or a patient with opioid use disorder. Instead of calling that person an addict or a drug abuser.

00:10:55 Vickie Danaher

This approach offers a more supportive and respectful environment and helps to encourage patients to seek and continue treatment.

00:11:04 Vickie Danaher

Also educate that use of meds for OUD is not trading one addiction for another. Rather, it's a tool to help patients improve daily function.

00:11:13 Vickie Danaher

For example, like I mentioned, treatment helps reduce the risk of illicit opioid use, limit withdrawal symptoms, and reduces the risk of overdose and death.

00:11:24 Vickie Danaher

And then there are other things we can do to support these patients in recovery.

00:11:28 Vickie Danaher

So we can continue to recommend or provide rescue naloxone or nalmefene for patients taking buprenorphine.

00:11:36 Vickie Danaher

And this serves as a safety measure in case of opioid overdose, since these patients may still be at risk of a relapse.

00:11:44 Vickie Danaher

You want to educate patients and their families about how to use these medications and to also have them readily available and also refer patients for non drug strategies or services if needed, such as behavioral therapy to help change thought patterns and habits or to help with stress or cravings.

00:12:03 Vickie Danaher

And recommend treating any comorbidities such as anxiety or depression if needed.

00:12:10 Vickie Danaher

When patients get buprenorphine products, it's also important to promote proper administration.

00:12:16 Vickie Danaher

You might remember that in the last year or two, an FDA warning came out and labels for sublingual buprenorphine products were updated to question about the risk of dental problems such as cavities, abscesses or tooth loss.

00:12:32 Vickie Danaher

So as pharmacists, we want to counsel to dissolve sublingual buprenorphine completely.

00:12:37 Vickie Danaher

Take a large sip of water and then swish and swallow.

00:12:42 Vickie Danaher

Patients should also see a dentist when starting buprenorphine and at least twice a year and report any sensitivity to tooth pain or other dental problems.

00:12:55 Vickie Danaher

Let's close out with a few practice pearls.

00:12:58 Vickie Danaher

So keep in mind that although buprenorphine prescriptions do not need that X DEA number anymore, buprenorphine is still a C-III controlled substance.

00:13:08 Vickie Danaher

So follow the usual policies with this Med in terms of counting, storing and dispensing.

00:13:14 Vickie Danaher

And also encourage patients to store buprenorphine in a safer locked place.

00:13:20 Vickie Danaher

Remember to double check that you're dispensing the right dosage form and strength. For example, the generic buprenorphine naloxone sublingual tabs come in two strengths, but the sublingual films come in 4 strengths.

00:13:34 Vickie Danaher

So to find out more about the various buprenorphine products available and to get answers to frequently asked questions including how to treat acute pain in patients taking buprenorphine for opioid use disorder, you can see our FAQ called management of opioid use disorder.

00:13:52 Vickie Danaher

And if you're in a practice or state where you may get involved with prescribing buprenorphine for OUD or you just want to learn more, you can use our eight-hour MATE Act training course to learn or refresh your knowledge of the options for treating substance use disorder.

00:14:11 Narrator

We hope you enjoyed and gained practical insights from listening to this episode! 

00:14:15 Narrator

Now that you’ve listened, pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers can receive CE credit. 

00:14:23 Narrator

Just log into your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.

00:14:32 Narrator

We’ve linked the resources we mentioned—and more on today’s topic—right in the show notes. Those links will take you straight to our websites, where you’ll find even more concise, evidence-based charts, articles, and tools.

00:14:45 Narrator 

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00:14:54 Narrator

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00:15:02 Narrator

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00:15:10 Narrator

Thanks for listening… stay sharp, stay current—and we’ll catch you next time on Clinical Capsules!