Rural community pharmacist willingness to dispense Suboxone® - A secret shopper investigation in South-Central Appalachia.

Background: Buprenorphine access is limited for patients with opioid use disorder, especially in rural areas. Telephone audits have identified pharmacist limitations to the dispensing of buprenorphine particularly in independent pharmacies in comparison to chain pharmacies and in rural areas. The objective of this study was to assess rural community pharmacists' stated willingness to dispense buprenorphine-naloxone, and document potential bias and or stigma that the shopper experiences when asking about buprenorphine- naloxone. Methods: To assess pharmacist willingness, a telephone audit of 15 rural Appalachian North Carolina pharmacies was conducted. Three secret shopper scenarios were utilized including one shopper posing as a new patient, one shopper posing as an out of state patient, and one shopper first asking about buying syringes. Encounters were noted by willingness to dispense buprenorphine, and shoppers were to note any potential stigma and or bias that they experienced while asking for Suboxone®. Results: Overall, 60% of pharmacies audited indicated willingness to dispense buprenorphine without reservation, and 31% indicated willingness to dispense only under certain circumstances. Pharmacies tended to add more conditions to dispensing to the out of state patient (46%), such as only dispensing if the practitioner was from in state in comparison to the other shopper scenarios. Potential stigma and bias were encountered in 40% of the 45 encounters. Conclusion: Although pharmacies overall seemed willing to dispense, nuances regarding who pharmacies are most likely to dispense are felt in rural areas. Buprenorphine access limitations were more common in independent pharmacies and more often placed on patients from out of state. Pharmacy- directed education is necessary to reduce stigma and bias and increase patient access to buprenorphine.