I haven’t written here for a long time. I’m reminded of an old joke my dad would tell (over and over!) about the mom who took her kid to the doctor over and over because he wouldn’t talk. Finally, on his 15th birthday, he yelled out “I hate angelfood cake!” His mom had tears of joy, and asked him “why haven’t you said anything?!” He answered “before now everything was good.”
In the same spirit, I’m writing now out of anger at the pharmacies run by Kroger, AKA Pick N Save. I’ve had a couple encounters with their pharmacists over the past few months when patients have taken prescriptions there for buprenorphine, calling to ask whether the patient is pregnant, or whether the patient has an allergy to naloxone. A couple days ago a patient told me that her Pick N Save pharmacist said he wouldn’t fill buprenorphine going forward.
Yesterday I received a questionnaire about a patient that was accompanied by a statement from the Kroger/Pick n Save pharmacy in Oshkosh, WI. The statement was on the local store letterhead, so I don’t know if the issue springs from local ignorance or from something larger. The questionnaire asked whether the patient was pregnant, had addiction problems, had an allergy to naloxone, or had chronic pain — things that are supposed to be protected health information, not discussed by fax, and not the pharmacist’s business.
The statement was worse. It was an interpretation of ASAM’s 2020 updated guidelines for buprenorphine treatment — guidelines that include one paragraph that says that treatment should ‘generally’ use the combination product (buprenorphine/naloxone) rather than the solo product to reduce diversion. The bottom line is that Kroger/Pick n Save is using the guidelines to micro-manage the choice of medication used by patients, a decision that is left to doctors and patients in fields other than addiction.
I recognize that companies have the right to control what they sell. But as I wrote back to the pharmacy, guidelines put out by professional associations are just that – guides, not rules. I remember a poster session at the last AATOD meeting that described the result of surveys of practice patterns. ASAM guidelines recommend giving out only one week of medication at the first visit, and initially seeing patients weekly. In a perfect world (where nobody has to work, and money grows on trees that reach to the sky) weekly appointments make sense. Heck, let’s make it daily – then patients won’t even have time to use drugs!! Yes, that’s sarcasm…. in the real world we have to make compromises.
Buprenorphine is FDA-indicated for ‘maintenance treatment’ of opioid use disorder. The FDA places no requirements on prescribing the medication beyond the waiver, that applies to all buprenorphine products used for opioid use disorder. My state has no laws that restrict the use of buprenorphine (unlike the idiots in charge of Tennessee). But the solo product has been under siege for years, ever since Reckitt Benckiser stopped producing Subutex. According to rumor, plain buprenorphine is more trouble than good.
The anti-mono crowd claim that plain buprenorphine is easier to divert and abuse. They often make claims that are simply untrue — for example that plain buprenorphine creates more euphoria than buprenorphine/naloxone. The Kroger/Pick n Save statement claims that ‘snorted’ buprenorphine can create euphoria that is blocked by the naloxone in the combo product — which is not accurate. There have been studies showing less diversion of the combination product, but those studies are confounded by other variables. For example, the people who I’m most-likely to prescribe the mono product to are those who do not have health insurance, sometimes because they are unemployed – something that also impacts diversion.
I’ve always wondered whether naloxone has any benefit other than allowing a new patent by Reckitt Benckiser back in 2000 when the drug was first being proposed. Studies showing the impact of naloxone on IV use of buprenorphine showed that naloxone reduced ‘liking scores’, and didn’t cause withdrawal. I would discharge any patient who sells any medication that I’ve prescribed, so I’m no fan of diversion. But is buprenorphine a huge diversion risk? Deaths from buprenorphine are rare. And many of the patients I’ve accepted for treatment came to me after ‘abusing’ buprenorphine purchased on the street, sometimes for years. Those people usually tell me that they stopped heroin and changed to buprenorphine on their own because they were ‘sick and tired’ of using. Their ‘diversion’ was a form of self-treatment; misguided, but not a huge threat to public health.
The biggest issue, though, is that this is the area of the prescriber. If they don’t like it, lobby to change the law. Don’t tinker with medicine.