Clinical pharmacist practitioners prescribing of buprenorphine for opioid use disorder.

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Published in final edited form as: Drug Alcohol Depend. 2025 Mar 26;271:112663. doi: 10.1016/j.drugalcdep.2025.112663 Clinical pharmacist practitioners prescribing of buprenorphine for opioid use disorder Jacob D Baylis a, b , Terri L Jorgenson c , Haley E Pals d , Catherine S Hwang e, f , Michelle D Colvard g , Veldana Alliu c , Tera Moore c , Lewei A Lin h, i , Jessica Wyse j, k , Eric J Hawkins l, m, n , Hildi J Hagedorn l, o, p , Adam J Gordon a, b, * Author information Article notes Copyright and License information a Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA b Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA c Clinical Pharmacy Practice Office, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs, USA d Tomah VA Medical Center, Tomah, WI, USA e Division of General Internal Medicine and Geriatrics, Oregon Health and Science University, Portland, OR, USA f Section of General Internal Medicine, VA Portland Health Care System, Portland, OR, USA g VA Tennessee Valley Healthcare System, Nashville, TN, USA h Center for Clinical Management Research, VA Ann Arbor Healthcare System, USA i Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA j Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA k School of Public Health, Oregon Health & Science University, Portland, OR, USA l Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA m Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA n Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA o Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA p Department of Psychiatry & Behavioral Sciences, University of Minnesota, Minneapolis, MN, USA * Correspondence to: 295 Chipeta Way, Salt Lake City, Utah 84108, USA. adam.gordon@hsc.utah.edu (A.J. Gordon). Issue date 2025 Jun 1. PMC Copyright notice PMCID: PMC12491063  NIHMSID: NIHMS2097478  PMID: 40228325 The publisher's version of this article is available at Drug Alcohol Depend Abstract Background: Clinical Pharmacist Practitioners (CPPs) have a long history of collaborating with other prescribers for the provision of buprenorphine medication treatment for opioid use disorder (B-MOUD). In January 2023, with the removal of the DATA 2000 X-waiver process, CPPs were allowed to prescribe B-MOUD in states that allow CPP prescriptive authority of controlled substances. We sought to examine CPP prescribing patterns of B-MOUD in a large heath care system in 2023. Methods: We conducted a retrospective cohort study of patients with opioid use disorder (OUD) who received B-MOUD care in 2023 within the Veterans Health Administration (VHA). B-MOUD was defined as a formulation of buprenorphine indicated for OUD. We characterized Veterans who were prescribed B-MOUD by CPPs and examined the characteristics of these prescriptions and the episodes of care (EOC). Results: In 2023, 22,863 Veterans received B-MOUD; 1090 (4.8 %) from a CPP. Veterans prescribed B-MOUD by CPPs were primarily 36–50 years old (n = 419, 38.4 %), male (n = 987, 90.6 %), white (n = 987, 90.6%), non-Hispanic/Latino (n = 1043, 95.7%), and in urban areas (n = 648, 59.4%). 110 CPPs prescribed B-MOUD in 36 states representing 1.9% of all B-MOUD prescribers in 2023. CPPs prescribed 5258 B-MOUD prescriptions, conducted 339 (2.7%) initiations, were involved in 1162 (4.2%) of all EOC throughout the year, and were the sole prescriber for 16.6% of EOC. CPP-involved EOC had 86.9% (n = 867) 90-day retention. Conclusion: When they were able to, VHA CPPs were early adopters in prescribing B-MOUD. B-MOUD prescribing by CPPs is an emerging opportunity to further expand access to B-MOUD. Keywords: Pharmacists, Clinical, Buprenorphine, Opioid-related disorders, Veterans, Veterans health services 1. Introduction Increasing access to buprenorphine medication treatment for opioid use disorder (B-MOUD) is a crucial intervention to confront the US opioid epidemic. In 2002, the Drug Addiction Treatment Act of 2000 (DATA 2000) authorized certified physicians to prescribe B-MOUD in office-based settings outside of opioid treatment programs. Subsequent amendments to DATA 2000 expanded the list of eligible prescribers to advanced practice clinicians, including physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified midwives. These clinicians, who had US Drug Enforcement Administration (DEA) prescriptive authority to prescribe DEA Schedule 3 medications (thus including formulations of B-MOUD) and received requisite training to prescribe under DATA 2000, could subsequently receive an X-waiver for B-MOUD prescribing and thus were allowed to prescribe B-MOUD (subject to any additional state requirements to prescribe) ( Andraka-Christou et al., 2022 ). Until 2023, clinical pharmacists who were licensed in states allowing them to prescribe Schedule 3 medications were not part of the workforce allowed to prescribe B-MOUD under DATA 2000 and its amendments ( Adams et al., 2023 ). In December 2022, the US passed the Mainstreaming Addiction Treatment (MAT) Act, which removed the requirement for an X-waiver to prescribe B-MOUD. With this removal—essentially removing DATA 2000 prescriber eligibility requirements—all practitioners authorized to prescribe DEA Schedule 3 medications were able to prescribe B-MOUD ( Adams et al., 2023 ; Ostrach et al., 2023 ; Saloner et al., 2023 ). Thus, for the first time after the MAT Act was enacted (January 2023), pharmacists had the legal authority to prescribe B-MOUD if they had a DEA license in a state that allowed pharmacists to prescribe in collaborative practice or independent practice frameworks and were not otherwise restricted by their state of licensure ( Adams et al., 2023 ). A clinical pharmacist is a member of the interprofessional care team with advanced education and training with a focus on delivering comprehensive medication management. Pharmacists improve access to care, ( Bradshaw and Doucette, 1998 ) patient outcomes, ( Bunting and Cranor, 2006 ; Chisholm-Burns et al., 2010 ) and cost-effective care ( Giberson et al., 2011 ; Isetts et al., 2008 ). With their training, clinical pharmacists provide specialized medication knowledge, expertise, and support for complex treatments, such as B-MOUD ( Bond and Raehl, 2007 ; Mohammad et al., 2024 ; Percy et al., 2023 ). Prior to 2023, clinical pharmacists had a long history of collaborating with other prescribers to improve care for patients receiving B-MOUD ( Cheetham et al., 2024 ; DeRonne et al., 2021 ; Grgas, 2013 ; Jarrett et al., 2023 ; Rao et al., 2024 ). This included assisting with B-MOUD initiations, suggesting dose and frequency adjustments of B-MOUD, discontinuing B-MOUD, monitoring B-MOUD outcomes, providing naloxone education and distribution, and providing non-pharmacological treatments (Codell et al., 2020; DeRonne et al., 2021 ; Percy et al., 2023 ). Thus, their skill and expertise are ideal for improving the ease of management of B-MOUD among existing prescribers. Pharmacists in all 50 states may have prescriptive authority through collaborative practice models ( Smith et al., 2024 ), but only 10 states in 2023 authorize controlled substance prescriptive authority for pharmacists ( Drug Enforcement Administration, 2024 ). Within the Department of Veterans Affairs, Veterans Health Administration (VHA), clinical pharmacists with a scope of practice, termed Clinical Pharmacist Practitioners (CPP), have prescriptive authority pursuant to their scope of practice (i.e., collaborative practice agreement) which allows the provision of comprehensive medication management. CPPs provide direct patient care, with independent decision-making within the parameters of their scope of practice ( Department of Veteran Affairs, 2024 ). CPPs may have controlled substance prescriptive authority when licensed in a state that allows it. The VHA is the largest single provider of addiction care in the US ( Wyse et al., 2018 ). With the passing of the MAT Act, we sought to quantify and characterize CPP prescribing of B-MOUD within VHA. We aimed to characterize B-MOUD prescriptions and patients receiving B-MOUD from a CPP, examine whether CPPs initiated B-MOUD episodes of care (EOC), and analyze CPPs contribution to prescribing within a B-MOUD EOC. 2. Materials and methods 2.1. General study design and timeframe We report on a National Institute on Drug Abuse (NIDA) Clinical Trials Network Study – NIDA CTN-0087—a retrospective cohort study of Veteran patients receiving B-MOUD care in the VHA—a study previously described ( Gordon et al., 2023 ). Briefly, this cohort study included Veterans with OUD who received B-MOUD from 2006 (the calendar year when B-MOUD became formulary in the VHA) to 2023. Prescription data from January 1, 2023 (the month that the MAT Act was enacted) to December 31, 2023 were examined. Reporting of the results is done consistent with the STROBE reporting guidelines of observational studies ( von Elm et al., 2007 ). This study is approved by the University of Utah and VHA Salt Lake City Health Care System Institutional Review Board. 2.2. Data source Data was extracted from the VHA’s Corporate Data Warehouse (CDW), which contains all the electronic health record data for care provided by the VHA, including clinical, pharmacy, and administrative data. To evaluate VHA prescribing of B-MOUD, only VHA services were included. Data included patient (e.g., demographics), VHA pharmacy B-MOUD prescriptions and encounter location, and provider characteristics (e.g., provider type). 2.3. Study population and inclusion and exclusion criteria Veterans were included if they had an OUD diagnosis documented in the VHA electronic medical record between January 1, 2006 and December 31, 2023, and subsequently received B-MOUD between January 1 and December 31, 2023. An OUD diagnosis was defined as an inpatient or outpatient International Classification of Disease (ICD) 9 or 10 diagnosis codes of opioid abuse or dependence ( Appendix 1.a ). Buprenorphine formulations for B-MOUD excluded those indicated solely for pain to focus on prescriptions of buprenorphine indicated for OUD ( Appendix 1.b ). CPP providers were identified using a unique provider identifier (ProviderSID) given to all VHA providers and their provider type listed in the CDW. 2.4. Measures We recorded all prescriptions of B-MOUD and defined a prescription where a medication was dispensed. Veteran demographic information including age, sex, race, ethnicity, and urban/rural status were obtained at time of first B-MOUD prescription from a CPP during 2023 (missingness imputed as “other”). Telehealth prescriptions were identified through the VHA encounter location identifier (i.e., stopcodes) and were categorized as telephone, VHA video connect (VVC), and clinical video telehealth (CVT), consistent with prior reports (U.S. Department of Veterans Affairs; Wicker, 2022 ). Telephone encounters are visits occurring over a telephone call. VVC involves a video interface between providers and Veterans over a secure platform. CVT is an encounter where the Veteran is at a VHA clinic and has a live interaction with a provider at a different location. Geographic locations of states and VHA facilities (i.e., Sta3ns) were recorded to identify locations of dispensation of CPP prescriptions; VHA CDW does not have information regarding the state of CPP licensure. 2.5. Outcomes The main outcome of this study was B-MOUD dispensation based on prescriptions from CPPs. However, all B-MOUD prescriptions in 2023 were recorded to obtain the proportion of CPP-prescribed B-MOUD among all unique Veterans receiving B-MOUD care. A B-MOUD EOC is defined as the initial B-MOUD prescription and all subsequent pre-scriptions without a 30+ day gap in coverage, or until the end of 2023, consistent with our prior work ( Gordon et al., 2023 ; Hayes et al., 2024 ; Olfson et al., 2020 ). For these analyses, EOC that began prior to 2023 but extended into the year were included. However, only prescriptions received during 2023 were considered in the analysis. For example, if a patient was initiated on B-MOUD treatment in July of 2022 and continued treatment with no gaps in coverage of 30+ days into 2023, all the 2023 B-MOUD prescriptions were included in the analysis. The full duration of all EOCs was not measured due to data collection being terminated on December 31, 2023. Retention in B-MOUD care was recorded and defined as > 90 days of B-MOUD coverage for those initiated in 2023 to examine retention among CPP-initiations. To account for the cross-sectional nature of the data, only EOCs that began before October 1, 2023, were analyzed for retention, ensuring the possibility of assessing 90-day retention. 3. Results During 2023, a total of 22,863 Veterans with an OUD diagnosis received B-MOUD within the VHA. Among these Veterans, 1090 (4.8%) Veterans received at least one B-MOUD prescription from one of 110 CPPs who had prescribed B-MOUD. Of Veterans receiving one or more B-MOUD prescriptions from a CPP, the majority were 36–50 years old (n= 419, 38.4%), male (n = 987, 90.6%), white (n= 943, 90.6%), non-Hispanic/Latino (n= 1043, 95.7%), and lived in urban areas (n= 648, 59.4%) ( Table 1 ). Of the Veterans receiving one or more B-MOUD prescriptions from a CPP, 36.6% received less than a quarter of all their B-MOUD prescriptions from a CPP while 16.6% exclusively received their B-MOUD prescriptions from a CPP ( Table 2 ). Table 1. Characteristics of Veterans who have received buprenorphine for opioid use disorder from a Clinical Pharmacist Practitioner in 2023 (N= 1090). n % Age 18–35 117 10.7 36–50 419 38.4 51–65 308 28.3 65+ 246 22.6 Sex Male 987 90.6 Female 103 9.4 Race White 943 86.5 African American 61 5.6 American Indian or Alaska Native 13 6.8 Other (Asian, Native Hawaiian or Pacific Islander, or missing) 73 6.7 Ethnicity Hispanic/Latino 47 4.3 Rurality (of patient) Urban 648 59.4 Rural 442 40.6 Open in a new tab Table 2. Characteristics of Clinical Pharmacy Practitioner prescriptions of buprenorphine for opioid use disorder in 2023. n % Total number of prescriptions by CPPs 5258 100 Number of telehealth prescriptions by CPPs 2778 52.8 Telephone 1081 38.9 Virtual video connect 1607 57.8 Clinical video telehealth 90 3.2 Episodes of care with the following proportion of B-MOUD prescriptions from a CPP 1161 100 > 0–25% 425 36.6 > 25%–50% 217 18.7 > 50%–75% 162 14.0 > 75%–100% 164 14.1 100% 193 16.6 Veterans with > 90 days of coverage during EOC involving a CPP Formulations of B-MOUD prescriptions by CPPs 867 86.9 Buprenorphine/Naloxone sublingual tab 3571 67.9 Buprenorphine/Naloxone sublingual film 969 18.4 Buprenorphine injectable 395 7.5 Buprenorphine sublingual tab 323 6.1 Open in a new tab CPPs prescribed 5258 B-MOUD prescriptions throughout the year with the majority via telehealth encounter (n= 2778, 52.4%). In 31 states, Veterans received B-MOUD prescriptions from CPPs, with California, Wisconsin, and Michigan having the highest numbers of prescribing CPPs (n= 12, 8, 7, respectively). The most common formulation of B-MOUD prescribed was buprenorphine/naloxone sublingual tablets (n= 3571, 67.6%) ( Table 2 ). Long-acting injectable buprenorphine was prescribed 395 (7.5%) times by 22 unique CPPs. A total of 27,852 EOC and 12,749 B-MOUD initiations (first prescriptions of the episode) occurred during 2023. 1162 (4.2%) EOCs included at least one CPP-involved prescription, and 339 (2.7%) initiations were conducted by CPPs. Among the EOCs eligible for 90-day retention analyses, CPP-involved EOCs had 86.9% (n= 867) 90-day retention. 4. Discussion Our findings suggest CPPs have played a measurable role in prescribing B-MOUD in VHA during 2023, the first year CPPs could prescribe B-MOUD. Prior to 2023, the evidence of CPP management of B-MOUD in VHA and non-VHA environments has been robust, showing CPPs are uniquely positioned to enhance and manage B-MOUD and have been involved in medication management of B-MOUD for several years ( Cleary et al., 2022 ; Pals and Bratberg, 2022 ; Wu et al., 2021 ). With the adoption of the MAT Act and in the states that allow controlled substance prescriptive authority for pharmacists (including buprenorphine), CPPs have gained prescriptive opportunities in B-MOUD EOC. Our study indicates that VHA CPPs implemented this clinical opportunity quickly, so much so that over 4% of all B-MOUD prescriptions were prescribed by VHA CPPs in 2023. It is also important to note that CPP-prescribed B-MOUD EOC had retention rates of almost 87%, better than the 30–50% rates reported in most settings ( Chan et al., 2021 ; Hammerslag et al., 2023 ). The VHA, like many insurers and health care systems, is striving to increase access to MOUD, including B-MOUD ( Gordon et al., 2020 ; Perry et al., 2022 ). CPPs with controlled substance prescriptive authority could improve access to B-MOUD among patient populations ( American Society of Addiction Medicine, 2024 ). The use of telehealth in the majority of CPP B-MOUD prescribing displays how CPPs may be uniquely positioned to provide and expand B-MOUD care to people in rural communities, which often lack B-MOUD prescribers. Further, CPPs could provide bridge prescriptions when patients’ primary B-MOUD prescribers are unavailable (e.g., rural settings) or when patients are transferring from one setting to another (e.g., emergency room to addiction specialty care services) ( Wyse et al., 2024 ). The literature highlights the positive impact of CPPs in collaborative medication therapy management services, which have led to improved health outcomes and patient satisfaction ( Strand et al., 2020 ). Within the VHA, the Pharmacy Benefits Management, Clinical Pharmacy Practice Office, and the Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative ( Gordon et al., 2020 ) are providing resources, webinars, and consultations to expand CPPs role in B-MOUD medication management across specialty and general care settings. The integration of CPPs in additional settings where B-MOUD care is, or can be, offered may further increase access for patients, improve retention rates, and provide additional medication management support for over-burdened providers ( Henderson et al., 2011 ; Ma et al., 2010 ; Saberi et al., 2012 ). There are limitations to this study, including the use of only prescription-level data related to a VHA setting. The specific settings where CPPs prescribe, such as primary care, were not analyzed and could offer additional insights into CPP prescribing trends and the settings where they are most likely to prescribe. Outcomes explored in this analysis were limited to access and treatment retention. CPP in VHA often evaluate more complex patients with diabetes, schizophrenia, bipolar disorder, and major depressive disorder than other providers ( Jasuja et al., 2024 ; Miller et al., 2023 ). Future work should compare CPP vs. other prescribers B-MOUD prescribing practices based on patient characteristics, characteristics of the EOC, and outcomes. 5. Conclusion CPPs within VHA were early adopters in prescribing B-MOUD. In 2023, 110 CPPs prescribed B-MOUD to over 1000 Veterans. These CPP B-MOUD EOC were more often prescribed via telehealth, and in over 16%, the CPP was the sole prescriber. The involvement of CPPs prescribing B-MOUD underscores the increasing role of CPPs and telehealth in expanding access to B-MOUD. The high level of treatment retention among Veterans receiving B-MOUD care from CPPs underscores their potential to enhance the quality of care for patients with OUD. Supplementary Material Supplemental Appendix NIHMS2097478-supplement-Supplemental_Appendix.docx (14KB, docx) Supplementary data associated with this article can be found in the online version at doi: 10.1016/j.drugalcdep.2025.112663 . Acknowledgements We thank the staff of the Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network and the Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA) at the University of Utah, specifically Sophie Huebler and Andrea Stofko for their involvement in curating and maintaining the dataset of Veterans with OUD utilized for this study. Funding resources Research reported in this publication was supported by Helping to End Addiction Long-term ® Initiative or NIH HEAL Initiative ® under award numbers 3UG1DA040316–04S3 and 1UG1DA049444–01 from the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Institutional support for this work occurred from the VA Salt Lake City Health Care System’s Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation (CIN 13–414); Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA) at the University of Utah; and the Vulnerable Veteran Innovative PACT (VIP) Initiative at the VA Salt Lake City Health Care System. Staff of the Center for the Clinical Trials Network in the National Institute on Drug Abuse Clinical Trials Network had an advisory role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation; review of the manuscript; and decision to submit the manuscript for publication. Supporting organizations including the NIH, VHA, and academic institutions, had no further role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The authors are solely responsible for the content of this article. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Federal Government, including the Veterans Health Administration, the National Institute of Health, National Institute on Drug Abuse, or any of the authors’ academic affiliates. Glossary/Abbreviations B-MOUD Buprenorphine Medication Treatment for Opioid Use Disorder CDW Corporate Data Warehouse CPP Clinical Pharmacist Practitioner CVT Clinical Video Telehealth DATA 2000 Drug Addiction Treatment Act of 2000 DEA US Drug Enforcement Agency EOC Episode of Care ICD International Classification of Disease MAT Act Mainstreaming Addiction Treatment Act MOUD Medication Treatment for Opioid Use Disorder OUD Opioid Use Disorder VHA Department of Veterans Affairs, Veterans Health Administration VVC Virtual Video Connect Footnotes Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: TLJ is on the Board of Directors for the Maryland Society of Health System Pharmacists and is a member of the House of Delegates for the American Society of Health System Pharmacists and receives no renumeration for either role. AJG reports an honorarium from the medical online resource UpToDate, Inc, for an authored chapter unrelated to this work. AJG has served, in the last three years, on the board of directors for the American Society of Addiction Medicine (ASAM), the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA), and the International Society of Addiction Journal Editors (ISAJE), all not-for-profit organizations that he received no remuneration. AJG receives remuneration from AMERSA for his Editor-in-Chief role of the organization’s peer reviewed journal. CRediT authorship contribution statement Alliu Veldana: Writing – review & editing. Moore Tera: Writing – review & editing. Lin Lewei A.: Writing – review & editing. Wyse Jessica: Writing – review & editing. Hawkins Eric J.: Writing – review & editing. Hagedorn Hildi J.: Writing – review & editing. 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