Addressing buprenorphine bottlenecks in the context of MAT Act implementation: A shared responsibility

Medications for opioid use disorder (OUD) such as buprenorphine reduce overdose mortality and other opioid related acute health events but have historically been highly regulated. The recent Mainstreaming Addiction Treatment (MAT) Act ended the requirement clinicians complete a specified training and apply for a DATA 2000 ("X") waiver on their Drug Enforcement Administration (DEA) number, to prescribe buprenorphine. With the MAT Act, any practitioner with Schedule III prescribing authority (a regular DEA number) can now prescribe buprenorphine for OUD. While this has potential to improve OUD treatment access, the impact will depend on implementation. Though the MAT Act may facilitate increased buprenorphine prescribing, ensuring adequate buprenorphine dispensing is also critical to improving Medications for opioid use disorder. Recognized buprenorphine bottlenecks arise from a complex convergence of factors in community pharmacies, threatening to undercut the benefits of the MAT Act. If prescribing increases but is not matched by increased dispensing, bottlenecks may worsen. Any worsening of buprenorphine bottlenecks could have a disproportionate impact in rural areas where residents may rely on fewer pharmacies to fill prescriptions for people in larger geographic area and where larger prescribing-dispensing gaps already exist such as in Southern states. Rigorous research will be needed to document the overall impact of the MAT Act on community pharmacists and their patients. At the federal level, pharmacists and their professional organizations should lobby the DEA to de-schedule or re-schedule buprenorphine. The DEA should announce a moratorium on enforcement actions against wholesalers and pharmacies related to buprenorphine distribution and dispensing. More supports should be offered to community pharmacies by state pharmacy boards and associations including continuing pharmacy education and technical assistance for advocating with wholesalers to increase buprenorphine order sizes, and to more effectively communicate with prescribers. Pharmacies should not have to face these challenges alone. Regulators, wholesalers, and researchers must join together with community pharmacies to further reduce regulatory barriers to dispensing, provide evidence-based interventions where needed to support pharmacy dispensing efforts, conduct rigorous implementation research, and be constantly vigilant in identifying and addressing multi-level buprenorphine bottlenecks in the wake of the MAT Act.