Pharmacist-managed buprenorphine care across diverse practice settings: A qualitative study of implementation patterns, collaborative practice agreement design, and scalability conditions

Pharmacists managing medications for opioid use disorder (MOUD) under collaborative pharmacy practice agreements (CPPAs) could scalably address national buprenorphine capacity gaps, yet practice models, implementation conditions, and barriers to scale remain inadequately characterized.

To characterize how pharmacist-managed MOUD operates across diverse practice settings, the structures that support implementation, and the systemic barriers to scale in the United States.

We conducted a qualitative study nested within NIDA Clinical Trials Network Study (CTN-0151/PharmValue). Forty-four key informant interviews were completed using purposive and snowball sampling across seven stakeholder groups spanning 15 U.S. states. Interviews were guided by the Consolidated Framework for Implementation Research and analyzed using a deductive-then-inductive thematic approach; reporting followed the COREQ checklist.

Thirteen themes were identified across five domains. Treatment demand exceeded prescriber capacity, with broad multi-stakeholder support for pharmacist involvement. State scope-of-practice authority was the upstream determinant of feasibility, while billing infrastructure emerged as the most proximate barrier to scale. Functioning models span a continuum from independent prescribing to advisory roles, enabled by team integration, electronic health record access, and workflow separation from dispensing. CPPA design requires balancing protocol explicitness with clinical flexibility. Pharmacy settings offer structural destigmatization, and retention rather than abstinence was endorsed as the quality metric.

Pharmacist-managed MOUD is operationally established across diverse U.S. practice settings, with comparable clinical competence reported regardless of practice model. What differentiates these models is structural position: prescribing authority determines whether pharmacist-led care is legally possible, while payer-recognized billing infrastructure and adaptable CPPA templates determine whether it can be sustained and scaled nationally.