A Secret Shopper Study Reveals Obstacles to Getting Suboxone in Appalachia

rural town appalachia
This entry was posted in Blogs, Opioid Use Disorder on .

It’s no secret that the opioid crisis is a serious public health problem in the United States. The last thing we want to see are obstacles to getting treatment, yet, in many parts of Appalachia in can be challenging to get Suboxone / buprenorphine. 

Since the 1999, over a million people died of drug overdose in the U.S. Data shows that around 70 percent of those deaths are related to opioid misuse and people diagnosed with opioid use disorder (OUD).

The Centers for Disease Control (CDC) reports that in the year 2021, a staggering 107,622 people died of fatal drug overdose, with 80,816 of those fatalities involving opioids.

That’s a serious crisis.

When we see those numbers, we’re galvanized into action, because we know through both firsthand experience and decades of evidence that there’s a way to reduce these deaths and offer lifesaving treatment and support to people with OUD.

That specific type of support is called medication-assisted treatment (MAT) with the use of three medications, called medications for opioid use disorder (MOUD):

  • Buprenorphine, which is often recognized by the brand name Suboxone.
  • Methadone, which is known by that name: methadone.
  • Naltrexone, which is often recognized by the brand name Vivitrol

Treatment professionals use buprenorphine and methadone to treat OUD, and naltrexone to treat alcohol use disorder (AUD) in addition to OUD.

This article will focus on buprenorphine. As the title suggests, we’ll discuss obstacles to access to buprenorphine that may exist in pharmacies in rural areas. This information is important to examine because MAT with buprenorphine or methadone is recognized around the world as the gold standard treatment for people with opioid use disorder.

To learn the details about MAT for OUD, please visit our MAT page:

Medication-Assisted Treatment

In short, treatment with MAT significantly reduces the harm caused by opioid use disorder: it improves lives for individuals, families, and communities, and saves lives for people with opioid addiction. That’s why understanding barriers to access is critical: if we can identify them, we can reduce them.

Secret Shopper Study in Rural North Carolina: Is There Stigma Against Dispensing Suboxone?

The study we discuss here – “Rural Community Pharmacist Willingness to Dispense Suboxone® – A Secret Shopper Investigation in South-Central Appalachia” – examined whether the same type of barriers to MOUD access exists in pharmacies in rural Appalachia, specifically in a region of North Carolina.

This research is relevant to our work at our  facility in Appalachia, where we operate a facility that offers MAT with MOUD for individuals diagnosed with opioid use disorder (OUD) in Williamson, West Virginia.

Previous publications on pharmacy-related barriers to access to treatment or MOUD include a study of over 700 pharmacies in Texas published in 2020, which shows that less than half –  42.2% – were willing to dispense a 1-week supply of generic Suboxone.

This study enlisted secret shoppers to search, via telephone, for pharmacies willing to dispense buprenorphine. Researchers coached shoppers to inquire about acquiring buprenorphine in three scenarios:

  1. A patient with a new prescription. Their question: “I was wondering, if a doctor sent you a prescription for Suboxone®, could you fill it?”
  2. An out-of-state, but just over the border patient. Their question: “I live in [specific nearby town across the border], and I was wondering, if a doctor sent you a prescription for Suboxone®, could you fill it?”
  3. An individual who first asked about buying syringes, then followed up with a question about Suboxone. Their question(s): “Do you sell syringes?” followed by “I have another question, if a doctor sent you a prescription for Suboxone®, could you fill it?”

Researchers designed the first question to gauge overall willingness to dispense Suboxone, the second to gauge willingness to dispense Suboxone in a typical, but sometimes problematic circumstance, and the third to gauge willingness to dispense Suboxone to a patient who may appear to engage in the intravenous injection and/or use of illicit substances.

The Results: Willing or Not? The Role of Stigma in Dispensing Medication for Opioid Use Disorder (MOUD)

The shopper graded each inquiry call on two areas: willingness to dispense, and the detectable presence of stigma or bias in the manner, tone, or content of pharmacist responses.

They graded willingness to dispense on a three-point scale:

  • (-)1: not willing
  • 0: willing, with conditions
  • 1: willing

They graded stigma on a similar, but not identical, three-point scale:

  • 0: no stigma detected
  • 1: possible stigma detected
  • 2: stigma detected

Shoppers made a total of 45 contacts with 6 local, independent pharmacies and 9 commercial chain pharmacies.

Here’s what they found.

Willingness to dispense, totals:

  • 80% of pharmacies showed willingness to dispense buprenorphine
  • 20% of pharmacies showed willingness to dispense, with conditions
  • No pharmacies shows total unwillingness to dispense Suboxone

Presence of stigma, totals:

  • 60% of shoppers detected possible stigma
  • 40% of shoppers detected no stigma

Now let’s look at the results by scenario and type of pharmacy.

First Scenario: New Patient

  • Independent Pharmacies:
    • No stigma: 83%
    • Possible stigma: 17%
  • Chain Pharmacies:
    • No stigma: 78%
    • Possible stigma: 12%

Second Scenario, Out of State Patient

  • Independent Pharmacies:
    • No stigma: 50%
    • Possible stigma: 50%
  • Chain Pharmacies:
    • No stigma: 67%
    • Possible stigma: 33%

Third Scenario, Asking About Syringes Before Asking About Suboxone

  • Independent Pharmacies:
    • No stigma: 33%
    • Possible stigma: 67%
  • Chain Pharmacies:
    • No stigma: 44%
    • Possible stigma: 56%

Overall, those results are encouraging, with the exception of the last scenario. Those data points reveal the stigma against people who may engage in intravenous use of illicit substances is still strong. They reveal a bias against people who need treatment and support the most: those who may have a severe opioid use disorder and are in the process of exploring various avenues of treatment and support.

Why First Contact Stigma Can Cause Harm

This data reveals the nuance of this situation.

No pharmacy was totally unwilling to dispense buprenorphine: that’s a good sign.

However, in the second and third scenarios, pharmacists attached strings that were not necessarily associated with federal or state rules and regulations. In the second scenario, the out-of-state conditions seem surmountable and so present a concern. Ultimately, that barrier is understandable – not ideal, of course – but from a pharmacist’s point of view, we understand the reluctance with regards to a prescription written by an out-of-state provider

The real concern this this data causes is the impact of hesitation or judgment perceived by the shoppers who asked about syringes first. Were they actual intravenous drug users seeking to complete the details of a treatment and support strategy, the sense of unwillingness or feeling of bias might cause to hang up the phone and stop their search. That could ultimately result in ongoing harm in many forms, including continued opioid use, which is associated with increased risk of overdose and/or fatal overdose.

We don’t place a burden that heavy on a pharmacist who fields phone calls from potential patients, it’s important for anyone even peripherally involved in the life of a person with OUD who seeks support that their words and behavior have an impact, and that impact can be positive or negative. In the case of this study, researchers identified a potentially negative impact on those seeking support, based on perceived attitude resulting from a question about syringes, as compared to asking only about medication.

That’s something we can change.


Public officials, policymakers, and employers can ensure pharmacists understand the value of all aspects of harm reduction – including the sale of syringes, which reduces risk communicable disease transmission – in mitigating the negative effects of the ongoing opioid crisis.