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The Community Pharmacist’s Role In Office-Based Treatment of Opiate Addiction

Columns - Opinion

Tuesday, 30 September 2003

As an addiction specialist, I am excited about the possibilities of expanding opiate addiction treatment with the passage of the Drug Abuse Treatment Act of 2000 (DATA 2000), and the recent FDA approval of buprenorphine and buprenorphine/naloxone. However, as a pharmacist, I am concerned about the lack of discussion involving the pharmacist's role in office-based treatment of addiction. Admittedly, many pharmacists are ill trained in issues related to treating substance abuse, an irony I struggle with, given pharmacists’ recognition as drug therapy experts. This still does not explain why there has been little inclusion of the pharmacist in the development of office-based treatment of opiate addiction.

Historically, buprenorphine has been available only as an injectable drug and had been dispensed only in the hospital setting. As such, many community pharmacists may not be aware of buprenorphine's unique pharmacological properties, which make it an excellent choice for opiate-replacement therapy. For example, buprenorphine is partial mu receptor agonist/antagonist with high affinity for and slow dissociation of the mu receptor. In other words, it doesn't produce as good a high as a full mu agonist and can displace a weaker pure mu agonist; increasing the dose does not produce a corresponding increase in the high; and it has a long duration of action. In short, it’s a better drug with a lower abuse potential for opiate replacement than methadone or other pure mu agonist drugs. Important to note is that since it is a partial antagonist, it can actually induce a withdrawal syndrome, requiring the patient to be tapered from their pure mu agonist onto buprenorphine.

While pharmacists may lack addiction education, their training and skills in addressing drug interactions and contraindications is unmatched by any other licensed health professional. The fact that there is a potentially fatal interaction between benzodiazepines and buprenorphine underscores the importance of the pharmacist being involved in the dispensing of buprenorphine. In regards to training, while the DATA 2000 requires physicians to have at least eight hours of CME, or to be a member of a qualifying organization, there are currently no education requirements for pharmacists electing to fill buprenorphine prescriptions for use in opiate-replacement therapy.

There appears to be the assumption that most physicians will simply choose to dispense buprenorphine out of their office, rather than write prescriptions to be filled by the pharmacist. While this may be true in some cases, many states have laws that restrict physician dispensing of medications, and most require at least that the physician dispenser be registered with their state’s Board of Pharmacy. In North Carolina, only 2 percent of licensed physicians are registered to dispense medications. There is also concern that some physicians will simply become buprenorphine pill factories, but these concerns are adequately addressed by the 30-patient-per-practice requirement in the law.

In those cases where the physician chooses to write a prescription, little information has been provided to the community pharmacist on how to recognize which physicians are approved to write for buprenorphine. Most pharmacists are not even aware of the passage of DATA 2000, the role of the DEA suffix, and the implications it may have on their pharmacy. The most serious implication (which I am embarrassed to mention) is that some pharmacists will be unwilling to stock the medication because they don’t want addicts in their pharmacy. Overcoming these barriers will require many pharmacists to change their opinions of drug addicts, a population that most pharmacists do not want in their pharmacies due to fears of theft and robbery.

Of utmost importance is that all pharmacists in the retail community environment become aware of:

A) buprenorphine and buprenophine/naloxone’s FDA approval

B) the requirements for physicians to legally write prescriptions

C) buprenorphine’s unique role in the office-based treatment of addiction

D) drug addiction, and the negative effects that untreated addiction has on our families, communities, and society at large.

It appears to me that the success or failure of this program relies heavily on either: a) qualifying physicians being willing to stock the medication, register with the Board of Pharmacy, and comply with storage and labeling requirements; or b) for those physicians who want to treat these patients and not deal with the administrative issues, having a pharmacist willing to stock and dispense the medication.

I would encourage all the major players involved in the implementation of buprenorphine’s use in office-based treatment of opiate addiction, SAMHSA, CSAT, NAADAC, NIDA, and the manufacturer, to immediately begin an intensive dialogue with the national community pharmacy organizations such as the American Pharmaceutical Association (APhA), the National Association of Chain Drug Stores (NACDS), the National Com-munity Pharmacists Association (NCPA), and the National Association of Boards of Pharmacy (NABP). Equally important will be the dissemination of information at the community level, since only about one third of all pharmacists are members of a national pharmacy association.

Pharmaceutical advancements in the treatment of addiction will only continue. The addictions and pharmacy professions would do well to work together as this field continues to emerge. One national pharmacy organization, APhA, has within its structure the Addiction Pharmacist Practitioner Interest Group that is already looking to develop more comprehensive education programs for pharmacists involved in the treatment of addiction. For more information, visit www.aphanet.org.

David Marley, PharmD, RAS, is the founder and recently retired executive director of the North Carolina Pharmacist Recovery Network, and has recently opened his own pharmacy, Marley Drug, Inc. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

This article is published in Counselor,The Magazine for Addiction Professionals, October 2003, v.4, n.5, pp. 30-31.