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Abstract

Background:

Implementing buprenorphine medication treatment for opioid use disorder (B-MOUD) in office-based, non-addiction specialty care settings is challenging. Clinical pharmacist practitioners (CPPs) can facilitate this care. The Veterans Health Administration’s (VHA) Stepped Care for Opioid Use Disorder Train the Trainer Initiative (SCOUTT) implemented B-MOUD in primary care, mental health, and pain clinics across 37 VHA facilities. B-MOUD activities provided by CPPs within SCOUTT are not well known.

Objectives:

We sought to examine CPPs’ roles, typical activities, and opportunities to provide B-MOUD.

Design:

We performed a cross-sectional survey of CPPs within SCOUTT facilities.

Methods:

In March 2023, known CPPs in SCOUTT clinics were invited via email to participate in an online survey. We also emailed local SCOUTT leaders to forward the invitation to CPPs not initially invited. The anonymous survey gathered information on clinic settings, CPP roles in 25 B-MOUD related tasks (eg, patient intake, risk assessment, initiation), state licensure, and whether they had or desired controlled substance prescriptive authority for B-MOUD.

Results:

Twenty-two CPPs responded to the survey working in pain (40.9%), primary care (27.3%), mental health (22.7%), and primary care mental health integrated (22.7%) settings. Nearly all (95.5%) reported involvement in naloxone education and distribution and patient management after B-MOUD initiation. Additionally, 90.9% reviewed and interpreted urine drug test results, 90.9% conducted B-MOUD follow-up (assessing side effects or treatment outcomes) and 72.7% assisted in B-MOUD initiation. Most CPPs (95.5%) indicated they work in a team-based environment often acting as a medication expert, were prescribing B-MOUD (27.3%), or desired to do so (86.4%).

Conclusion:

In the VHA’s SCOUTT Initiative, CPPs play a significant role in leading and collaboratively facilitating B-MOUD. The VHA’s SCOUTT approach to CPP management and B-MOUD prescribing efforts may be a model to emulate in other health systems to improve access to and management of B-MOUD care.

Keywords

pharmacists clinical buprenorphine opioid-related disorders Veterans Veterans Health Services

Highlights

This evaluation surveyed clinical pharmacist practitioners querying their roles, responsibilities, and views of providing medication treatment for opioid use disorder.

Clinical pharmacist practitioners’ unique roles and responsibilities can facilitate Veteran access to buprenorphine treatment for opioid use disorder outside of addiction specialty care settings.

Many clinical pharmacist practitioners are prescribing buprenorphine for opioid use disorder or wish to do so.

Background

A clinical pharmacist practitioner (CPP) is an interprofessional care team provider who is a licensed practitioner with advanced education and training with a focus on delivering comprehensive medication management within a collaborative, team-based practice. CPP practice has been shown to improve patient outcomes,^1,2 enhance access to care,³ provide cost-effective care,^4,5 provide specialized knowledge and expertise,⁶ and provide support for complex treatments,^7,8 including opioid use disorder (OUD).^9-13

CPP practice is common in the Department of Veterans Affairs, Veterans Health Administration (VHA). In July 2025, 53.4% (n = 6263) of all pharmacists in the VHA were CPPs. CPPs are distinct from other pharmacists within the VHA. CPPs within the VHA have independent prescriptive authority under a scope of practice (ie, collaborative practice agreement) which allows them to provide comprehensive medication management (CMM) as part of the care team within their given practice setting (eg, primary care, pain management, mental health).¹⁴ A scope of practice is obtained through review of the pharmacist’s qualifications and competencies as part of the facility’s credentialing and privileging process with oversight by the executive committee of the individual facilities’ medical staff. Evidence of expertise could include post-graduate pharmacy residency training; Board of Pharmacy Specialties certification such as BCPP (Board Certified Psychiatric Pharmacist), BCPS (Board Certified Pharmacotherapy Specialist), and BCPMP (Board Certified Pain Management Pharmacist); or other clinical experience such as mentorship.¹⁵ CPP competency is assessed through professional practice evaluations upon initial appointment and periodically thereafter in line with Joint Commission Standards and VHA policies related to credentialling of healthcare providers.^14,16

Collaborative practice settings where CPPs practice are ubiquitous in the clinical environments of the VHA. For example, patient-aligned-care-teams (PACTs) are the VHA’s primary care medical home model where prescribers are teamed with nurse care managers, pharmacists, social workers, and other professionals to provide primary care and wrap around care to Veterans.^17,18 Similar collaborative care models exist with the VHA’s outpatient mental health and pain clinic environments, among other specialty and acute practice areas. These environments enable Veteran patients to be served by teams of clinicians in a longitudinal approach to address chronic health conditions, such as OUD. Within these environments, CPPs have been known to work collaboratively with a controlled substance prescriber to initiate medication treatment for opioid use disorder (MOUD), adjust dose and frequency of MOUD, and/or discontinue MOUD along with more traditional roles of monitoring MOUD outcomes, provide naloxone education and distribution, and provide non-pharmacological treatments.^8,12,19

With the passing of the US’ 2022 Mainstreaming Addiction Treatment Act as part of the US Consolidated Appropriations Act of 2023, the DATA-2000 Waiver program was eliminated, including qualifying practitioner restrictions.²⁰ With this legislative change, DEA-registered CPPs could now prescribe formulations of buprenorphine for MOUD (B-MOUD) in the states that allowed CPPs to prescribe Schedule 3 medications in collaborative practice settings.^21-23 As of this writing, while all 50 states authorize dependent, collaborative, or autonomous pharmacist prescribing, only 14 states authorize CPPs to obtain DEA registration and more states are considering expanding controlled substance prescribing authority by CPPs, with a particular emphasis on improving access to B-MOUD.^24,25 VHA CPPs have been early adopters of B-MOUD prescribing: in 2023, over 1090 Veterans were prescribed B-MOUD by 110 CPPs in over 30 states.²⁶ VHA CPPs may be licensed in any state across the US and, if licensed in a state with prescriptive authority, are able to provide B-MOUD care in any VHA location.

The VHA’s Stepped Care for Opioid Use Disorder Train the Trainer Initiative (SCOUTT) began in 2018 with a goal of facilitating access to MOUD, primarily B-MOUD, in non-substance use disorder specialty settings, namely primary care, mental health, and pain clinic settings.²⁷ The impetus for SCOUTT was that, historically, MOUD treatment had been relegated to substance used disorder (SUD) specialty care environments. These environments could reduce access to MOUD care as patients may be averse to attending SUD specialty care or engaging in OUD treatment in an episodic way.^28,29

Through the first 4 years of SCOUTT, 37 facilities implemented MOUD in over 70 non-SUD-specialty clinic settings, improving access and retention to B-MOUD. This occurrence wasn’t limited to SCOUTT clinics and was observed in non-SCOUTT intervened facilities as well.^30-33 Further, notable outcomes of SCOUTT included positive perspectives of providers,^34-36 and improved health care utilization.^37,38 Originally funded as a quality improvement project, SCOUTT continues today with VHA operational funding.

In expanding this B-MOUD access, several different clinic models developed, including OUD collaborative non-prescriber care. In the initial SCOUTT training in 2018, the first collaborative care model taught to SCOUTT teams was the nurse care manager collaborative care model.^27,39-41 CPP collaborative care was not an original target intervention in SCOUTT; CPPs were not required to participate in SCOUTT clinics, although the original SCOUTT trainings had an unknown number of CPPs who attended. In these collaborative models of care, we observed that non-prescribing health care providers (eg, CPPs, nurse care managers, social workers) were the point of care contacts for patients to receive B-MOUD care and its care management. To date, the VHA employs 6263 CPPs, although not all facilities in the VHA have a CPP involved in providing B-MOUD; over 20 SCOUTT facilities were known to have engaged with CPPs. While there are some descriptions of how CPPs may manage MOUD within the VHA,^8,12 the specific roles and responsibilities that CPPs had regarding patient intake, initiation, monitoring and risk assessment, follow-up activities, and quality assurance/outcomes were unknown.

To further understand how CPPs were integrated within SCOUTT, we sought to examine CPPs’ roles, typical activities, and opportunities to provide MOUD within SCOUTT. We sought to examine whether CPPs affiliated with SCOUTT wished to prescribe (or were prescribing) B-MOUD to Veterans. Finally, we wished to explore opportunities to expand CPP practices within SCOUTT and across the VHA to continue to further expand access to B-MOUD.

Methods

We performed a cross-sectional study of CPPs affiliated with SCOUTT to examine their roles, responsibilities, and opportunities for B-MOUD care and care management. We used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in reporting our study and results.⁴² To be eligible for our study, the respondent affirmed that they were a CPP within a SCOUTT-intervened facility (n = 49 within 29 US States at the time of the survey). The VA Salt Lake City Health Care System and University of Utah Institutional Review Board confirmed that this quality improvement evaluation did not require approval as human subject research.

In March 2023, we emailed known CPPs affiliated with VHA SCOUTT clinics (n = 21) to participate in an online Research Electronic Data Capture (REDCap) survey regarding their practices within SCOUTT related to B-MOUD. The email indicated the purpose of the survey and included basic instructions to complete it through a link that would be sent directly to their email. Two days after the initial email, we employed a snowball sampling method and emailed SCOUTT leaders with instructions to forward the invitation to CPPs not initially invited. To help expand our list of CPPs, we also advertised this survey opportunity in several monthly national SCOUTT webinar community of practice calls. We requested survey completion within 16 days of the initial invitation and sent an email reminder to complete the survey 14 days later. Responses to this questionnaire were anonymous and to preserve anonymity, we did not inquire about demographic or practice characteristics. Respondents provided implicit consent to participate in this evaluation and could have terminated their participation at any time. The survey indicated the purpose of the study and the voluntary nature of the subjects’ participation. The VA Salt Lake City Health Care System and University of Utah Institutional Review Board did not require an informed consent document to be signed for this anonymous survey.

The survey structure and content were pilot tested by the authors, which included CPPs, and iteratively modified prior to execution. The survey content (see Supplemental Appendix for the complete survey) included information on clinic settings, CPP roles in 25 B-MOUD related tasks (eg, patient intake, initiation, monitoring and risk assessment, follow-up activities, quality assurance/outcomes), state licensure (specifically whether they had prescriptive authority for buprenorphine), and whether they desired (or had) controlled substance prescriptive authority for B-MOUD. The survey was developed by the authors, including VA Pharmacy Benefits Management Clinical Pharmacy Practice Office program managers, VA clinical investigators, and staff and based on typical CPP roles, responsibilities, authority, and standards of care.⁵ We inquired whether each of the B-MOUD related tasks were typically conducted by the CPP and/or other members of the clinical team. The survey also included 3 yes/no questions that provided opportunity for comments that inquired (1) whether the respondent believes they are providing care formally as a CPP; (2) whether they function as a “primary conduit” for the OUD patient to the health care team; and (3) whether the CPPs do or would prescribe B-MOUD if their state license would allow it. Our a priori intentions were not to analyze these results through any qualitative methodology and subsequently did not.

Study data were collected and managed using REDCap electronic data capture tools hosted at the VA Information Resource Center.^43,44 Data was collected and analyzed using descriptive statistics; we did not need to adjust for any missing data.

Results

Twenty-two CPPs responded to the survey. Respondents indicated they were licensed to practice in 17 different states and reported practicing in 15 states. Respondents worked in pain clinics (40.9%), primary care (27.3%), mental health (22.7%), and mental health-primary care integrated clinics (22.7%; multiple settings could be chosen).

Table 1 indicates 25 patient tasks associated with intake, initiation, monitoring and risk assessment, follow-up, and quality assurance/outcome activities typical for CPPs which were specific for B-MOUD episodes of care. The highest CPP reported tasks involved naloxone education and distribution (n = 21, 95.5%), follow up management (n = 21, 95.5%), SUD medication review (n = 20, 90.9%), general medication review (n = 19, 86.4%), relapse prevention (n = 19, 86.4%), and opioid/B-MOUD tapering (n = 18, 81.8%). Conversely, prescribing controlled substances (n = 5, 22.7%) and initiating MOUD by prescribing (n = 6, 27.3%) were the lowest reported activities by CPPs.

Table 1.

Buprenorphine Medication Treatment for Opioid Use Disorder Tasks (n = 22 Respondents).

Activities	CPPs^a n (%)	Other team member^a n (%)
Intake activities
Medication Review: Reviews medication the patient is prescribed and what the patient is taking; assesses for side effects and/or outcomes of the medications.	19 (86.4%)	5 (22.7%)
History: Performs a targeted or extensive history on the patient; assesses and documents chief complaint, history of present illness, past medical/mental health/substance use disorder history, allergies, medications, prior treatments, social history, family history, reviews chart.	16 (72.7%)	11 (50.0%)
Initial Assessment: Assesses the appropriateness to provide OUD treatment; reviews chart; may talk to the patient.	15 (68.2%)	12 (54.5%)
Triage: Receives and triages consults for care from another provider outside of the clinic.	13 (59.1%)	10 (45.5%)
Physical Exam: Performs a physical exam; performs a comprehensive or targeted physical exam.	1 (4.5%)	22 (95.5%)
Initiation activities
SUD Medication Review: Reviews medication treatment for substance use disorder; assesses for side effects and/or outcomes of the medications.	20 (90.9%)	5 (22.7%)
Opioid withdrawal management: Monitors for opioid withdrawal symptoms and manages as needed.	17 (77.3%)	9 (40.9%)
Prescribes (non-controlled) Medications for Medical and Mental Health Conditions: Prescribes medication for patient, details follow up and expected outcomes.	16 (72.7%)	5 (40.9%)
Initiation of MOUD (not prescribing): Instructs patient on MOUD initiation process for buprenorphine or naltrexone, monitors and assesses need for dose adjustments, instructs patients on any needed medication dose changes.	16 (72.7%)	10 (45.5%)
Initiation of MOUD (prescribing): Instructs patient on MOUD initiation process for buprenorphine or naltrexone, monitors and assesses need for dose adjustments, instructs patients on any needed medication dose changes.	6 (27.3%)	17 (77.3%)
Prescribes (controlled substances) Medications for Medical and Mental Health Conditions: Prescribes medication for patient, details follow up and expected outcomes.	5 (22.7%)	18 (81.8%)
Monitoring and risk assessment activities
Naloxone Education/Distribution: Reviews whether patient has been provided overdose education and naloxone education and prescription; provides overdose and naloxone education and prescribes naloxone.	21 (95.5%)	6 (27.3%)
PDMP (Prescription Drug Monitoring Program) Review: Queries and reviews available PDMP data.	20 (90.9%)	6 (27.3%)
Substance Use Laboratory Assessment and Review: Assess and document substance use laboratories (eg, urine drug tests, confirmation testing).	20 (90.9%)	5 (22.7%)
Laboratory Assessment and Review: Assesses and documents important laboratories (eg, liver function tests, pregnancy); orders new laboratory testing appropriate to the patient.	18 (81.8%)	7 (31.8%)
Database Risk Review (Patient specific): Reviews pertinent VA tools	17 (77.3%)	8 (36.4%)
Screening Laboratories Assessment and Review: Assesses and documents important age- or substance use- appropriate screening laboratories (eg, HIV, hepatitis, tuberculosis); orders new laboratory testing appropriate to the patient.	14 (63.6%)	10 (45.5%)
Harm Reduction Services: Reviews harm reduction services provided to patient; provides services to patient.	13 (59.1%)	8 (36.4%)
Follow-up and maintenance activities
Follow-Up Management: Assesses patient after initiation of buprenorphine for effects and side effects; contacts patient to see “how is it going”; suggests to provider or adjusts care plan based on outcomes.	21 (95.5%)	4 (18.2%)
Relapse Prevention: Assesses patients for need for other treatments (eg, 12-step facilitation; counseling; group treatment; mindfulness).	19 (86.4%)	7 (31.8%)
Tapering: Assess patient needs after discontinuation (either planned or abrupt) of medication treatment or those lost to follow-up.	18 (81.8%)	6 (27.3%)
Other Service Coordination: Orders consults; discusses care with other service providers.	17 (77.3%)	9 (40.9%)
Wellness and prevention activities
Follow-Up Triage: Assess patient needs after discontinuation (either planned or abrupt) of medication treatment or those lost to follow-up.	16 (72.7%)	8 (36.4%)
Population Health Management: Reviews dashboards for proactive opportunities to engage patients in care and acts on identified patients.	16 (72.7%)	5 (22.7%)
Patient Related Outcome Measures (PROMS): Identifies veteran-specific goals and tracks progress on PROMS.	7 (31.8%)	12 (54.5%)

Participants were allowed to select more than 1 person with primary responsibility so columns can exceed 100%.

CPPs overwhelmingly agreed that activities and tasks they work on meet a formal definition of a CPP providing B-MOUD care (n = 21, 95.5%). In addition, many reported functioning as the “primary conduit” for the OUD patient to the health care team (n = 17, 77.3%) and would prescribe B-MOUD if their state license allowed it (n = 17, 77.3%).

Table 2 indicates corresponding free text responses under each of the free-text questions. Regarding their roles as a CPP in B-MOUD prescribing, many indicated that they are “integrated,” serve as a “medication expert,” and provide “comprehensive medication management.” CPPs indicated that for the most part they are the point of contact for patients with OUD interested in MOUD. Many CPPs indicated they were prescribing B-MOUD, were working toward prescribing, or were willing to prescribe.

Table 2.

Representative Free Text Responses.

QUESTION: CPPs may have DEA registration when authorized by their state of licensure and be granted controlled substance prescriptive authority through their VA scope of practice. Once a diagnosis is made, these DEA registered CPPs may prescribe buprenorphine for OUD (MOUD). CPPs without controlled substance prescriptive authority must collaborate with another DEA registered practitioner to prescribe MOUD. Using the above definition, do you think you are providing care as a CPP?
YES responses (n = 21, 95.5%): • A majority of the medication decisions are being made in a team-based environment, with the CPP acting as the medication expert. • CPP provides all care with exception of signing controlled substance order. • CPP reviews referrals, conducts histories via chart review and patient interview, and initiates and manages MOUD. • I am often the first contact or where Veterans are sent when they are interested in buprenorphine. • I am well integrated in the chronic pain and SCOUTT Team. I independently identify veterans who may be appropriate for MOUD and coordinate care with NP if/when evaluation and diagnosis is necessary. I develop plans for opioid transition, provide all initial counseling and follow-up, and provide active management and care coordination for comorbid disease states affecting chronic pain and opioid dependence. • I assess the patients as their primary Substance Use Disorder/Mental Health prescriber and prescribe buprenorphine/naloxone treatment when indicated. I collaborate with my team (including Psychiatrists, Social Worker, licensed practicing mental health clinician, nursing staff) in team meetings and determine further treatment options for their care. • I have been following with primary care providers who are less familiar with using buprenorphine for opioid use disorder. They rely on me for the closer follow up, assessment of the patient, recommendations for adjusting therapy, referrals for other levels of care, and general education about buprenorphine. Despite being a mental health pharmacist, in order to have clear and separate roles from the patient’s mental health [practitioner] and primary care practitioner, I only collaborate for management of their buprenorphine for OUD. Even in that capacity I do feel that I am providing care as a CPP. • I provide comprehensive medication management through my scope of practice. I ensure medications are assessed for appropriateness, effectiveness, and safety given the patient’s clinical status, comorbidities, other medications, and patient’s ability to adhere to medication regimen. I provide care coordination. I collaborate with DEA registered practitioners to prescribe MOUD. • Within my daily role, I aid in providing comprehensive medication management across the spectrum of mental health conditions and play an active role in assessing, counseling, and intervening in the treatment of co-occurring substance use problems and/or disorders. This includes time invested in coordinating care within the healthcare system (eg, PACT, specialty clinics, rescheduling, vaccine updates, sexual health care, etc.) for each patient that comes into the care of my clinic.
NO responses (n = 1, 4.5%): • I am facility PMOP coordinator and do not have a direct role as a CPP in an outpatient clinic (more focus in inpatient care).
QUESTION: Using the above definition, do you think you are the “primary conduit” for the patient?
YES responses (n = 17, 77.3%): • Because they see me the most often. • CPP is first point of contact for veteran. • CPP receives consults, does initial outreach/counseling, may be the initial point of contact for first visit and referral to additional care or higher level of care. • CPP serves as primary contact and manager of MOUD. • For most patients on MOUD, PharmD provides med management. • For MOUD within the pain team, I am the primary point of contact for the Veteran. • I am often the primary conduit for the patient because I am generally the most accessible, often more accessible than the patient’s assigned Mental Health Treatment Clinic; there are times when another member of the team may be more appropriate to serve as primary conduit for the patient. • I am often either the first contact or where Veterans are sent when they are interested in buprenorphine. • In most cases, I am seeing the patients the most and the hub of the cogwheel for their care. • More accessible to patient than other providers. • My access is such that I am the provider most often seeing the patient. • PACT do not initiate buprenorphine. They refer to CPP, STOP or MH. Most of the time the Veteran is referred to CPP. • Patients have my direct phone extension and always use me as their point of contact for buprenorphine related calls. • We can identify potential patients for targeted interventions through our population health dashboards. The Pain CPPs also serve as a step between Primary Care and Pain Clinic, so a lot of the times concerns cases are sent to us for an initial review and then we coordinate care afterward. • Within mental health services, the frequency of care a Veteran receives is typically far greater than that of their most likely conduit of care provider—their Primary Care team. Thus, by engaging more frequently with the Veteran, and by taking on a “conduit” role, we are able to better screen for due clinical reminders (eg, Hepatitis C testing, sexual health screening, Alcohol Use Disorder Identification Test – consumption questions (AUDIT-C, etc.), assist in rescheduling into care that is needed, or helping triage questions by the Veteran in the interim between their patient aligned care team/specialty appointments.
NO responses (n = 5, 23%): • (none)
QUESTION: If your state allows pharmacists to prescribe DEA-scheduled medications, are you, or do you intend to prescribe buprenorphine for opioid use disorder?
YES responses (n = 17, 77.3%): • Actively engaged in effort for local/state legislative updates to the language of those who may provide buprenorphine. • As above, following the elimination of the x-waiver, I immediately reciprocated my license to a state that allows pharmacist to prescribe DEA scheduled medications and applied for my DEA license specifically for this purpose. There is a gap in knowledge and care for OUD and pharmacist can help with both. • Have applied for my DEA. • I am already prescribing for about 30 patients. • I am licensed in a state that allows for pharmacists to obtain DEAs however my local facility policy is that our CPPs do no[t] prescribed controlled substances. I have asked pharmacy leadership to re-open this conversation and are currently advocating to change this local policy to allow for our CPPs to prescribe controlled substances. • I wish there was a maybe button. It really depends on the practice setting. Would I want to take on Suboxone/Subutex initiation for veterans with unclear indications in isolation—no. Would I prescribed for veterans in a team setting or veterans that are transitioning from an interdisciplinary substance use disorder/pain clinic—yes. • Increased access to care, I have adequate training, decreased barriers needing to find a provider to sign and staff the patient. • It is evidence based and a first line treatment for OUD, I am in progress to obtain a DEA license. • My state currently does not allow; however, if that changes, I would pursue DEA licensure. • Transferred license to state that does allow CPP to prescribe controlled substances.
NO responses (n = 5, 22.7%): • Not applicable to my state licensure. • As a CPP in PACT, I feel that OUD is difficult to maintain adequate follow up with our other clinical responsibilities and clinic burden.

Discussion

In a survey of VHA CPPs participating in SCOUTT, we found CPPs engaging in roles and activities that facilitate access to B-MOUD in non-specialty SUD settings. We found that responding CPPs participate in various aspects of patient care including serving as medication experts and medication management providers and were comfortable making or suggesting B-MOUD medication changes for their Veteran patients. Not all the 25 tasks we inquired about were performed by all CPPs, however, enhancing access to B-MOUD and care management of patients on B-MOUD are frequent tasks performed by SCOUTT CPPs. Opioid risk and risk mitigation activities (eg, prescription drug monitoring program checks, naloxone education and distribution) were near universal tasks performed by SCOUTT CPPs. We found that many SCOUTT CPPs were performing “initial reviews” of patients being considered for B-MOUD. This bodes well for potential expanded access in B-MOUD, especially if CPPs have prescriptive authority to prescribe B-MOUD.

Seventy-three percent (n = 16) of CPPs reported that they prescribe non-controlled medications for medical and mental health conditions while less than a quarter reported prescribing controlled substances. Controlled substance laws play a significant influence in CPP prescriptive authority in providing MOUD.^26,45 However, even in areas where state law does not authorize pharmacist DEA registration, CPPs still provide a valuable perspective on how to manage opioid withdrawal, assisting patients with initiating MOUD and timely follow-up, and prescribing non-controlled substances that could aid in relieving discomfort or co-morbid conditions and improving outcomes. CPPs in our survey indicated involvement in most tasks associated with B-MOUD care management.

Our results provide more evidence of the expanding role of CPPs in addressing and treating OUD and preventing overdoses. Most respondents (n = 17, 77.3%) saw themselves as the primary conduit for connecting the patient to health care services, including MOUD. Our results may demonstrate that CPPs are prepared and willing to engage in the different phases of patient care for OUD, including the direct prescribing of B-MOUD. In our survey, 21 out of 22 CPPs self-reported having a DEA registration to prescribe B-MOUD or collaborate with another DEA registered practitioner to prescribe B-MOUD after the OUD diagnosis is made. They indicated that they served as the medication management provider and were comfortable making or suggesting medication changes for their patients.

When asked if they are prescribing buprenorphine for OUD (or would if their state allowed pharmacists to prescribe DEA-scheduled medications), a vast majority (86.4%) stated they would. CPP prescribing may be ideally suited to prescribe B-MOUD or assist busy primary care, mental health, or pain clinicians in prescribing B-MOUD in non-SUD-specialty care settings. As pharmacists are among the most trusted health care providers,⁴⁶ B-MOUD prescribing or assistance in prescribing B-MOUD, may reduce stigma of OUD and ultimately improve access to barrier-free B-MOUD treatment. While much attention has been given to pharmacies not stocking formulations of B-MOUD—perhaps due to stigma against patients with the disease, the disease itself, and/or the B-MOUD treatment—CPPs, as treatment providers, may serve as another member of the health care team to engender trust and rapport with patients with OUD.^47-50 In addition, CPPs are a willing and capable resource available to provide B-MOUD in busy non-specialty clinics, thus enhancing reducing the care burden of other providers.

In July 2024, the American Society of Addiction Medicine called on “states to develop programs to promote best practices in, and incentivize appropriately qualified, licensed physicians and pharmacists to engage in, patient-specific collaborative practice agreements for addiction medications, including reimbursement for pharmacists’ services.”⁵¹ While there has been recognition of the clear potential for CPPs and pharmacists to expand access to B-MOUD in the US, several challenges to implementation remain.^11,52 It may be easier for CPPs to engage in B-MOUD care and/or prescribing in large health care settings like the VHA, it may be more difficult to establish collaborative practice agreements within community pharmacies, particularly in remote, rural areas. To expand pharmacists’ roles in B-MOUD care, developing competencies in this care through training and certification (eg, through the pharmacy boards), may require time, effort, and resources. Reimbursement models for this type of care likely need to be further developed.

Limitations

Our results are limited due to the convenience sample of CPPs at select VA facilities within primary care, mental health, or pain clinic environments that affiliated with SCOUTT; CPPs in other settings may not have responded similarly. In addition, we did not seek to or report on the different roles that CPPs may have had in different clinics (primary care, mental health, or pain clinics). We are unable to determine if we were able to capture the responses of all CPPs who are involved in SCOUTT. The survey was designed and pilot tested by the authors prior to execution; no further validation of the survey occurred. In addition, CPPs in the survey were not provided contexts regarding B-MOUD care or roles and responsibilities of other team members and respondents may not have responded to the survey based on similar clinical environments or staff. However, the VHA has standard clinical structures in primary care, mental health, and pain clinics where the roles and responsibilities of team members are relatively well defined, and our work further defines what roles and responsibilities CPPs may play for OUD and MOUD care in VHA environments.^8,12 In addition, the VHA is unique; the VHA provides clinical care within a team-based, collaborative care environment to address OUD and MOUD. The SCOUTT primary care, mental health, or pain clinic environments to provide MOUD care are not common outside the VHA; CPPs in primary care, mental health, or pain clinic environments outside the VHA may have responded quite differently to our survey. Finally, CPPs or community pharmacists outside the VHA may be ill-equipped or not credentialed to provide OUD and/or MOUD care. While we found that CPPs within SCOUTT are willing and able to provide OUD and MOUD care, it is not certain that this model can be implemented outside of SCOUTT or in non-VHA environments.

Conclusions

Despite these limitations, we found that CPPs who responded to a survey within SCOUTT provide a variety of services in VA clinics to enhance access to MOUD and specifically B-MOUD. Further research is needed to examine how this model of care can be expanded within and outside the VHA, including need for training, state practice acts that authorize pharmacist DEA, reimbursement models for this care, and addressing implementation challenges. Further inclusion of CPPs in B-MOUD activities, including prescribing, may improve the access of B-MOUD for patients and improve outcomes for patients with OUD.

Supplemental Material

sj-docx-1-sat-10.1177_29768357251381070 – Supplemental material for The Roles, Activities, and Opportunities of Clinical Pharmacists in a National Initiative to Improve Office-Based Buprenorphine Care

Supplemental material, sj-docx-1-sat-10.1177_29768357251381070 for The Roles, Activities, and Opportunities of Clinical Pharmacists in a National Initiative to Improve Office-Based Buprenorphine Care by Spencer G. Calder, Marie E. Kenny, Veldana Alliu, Terri L. Jorgenson, Tera Moore, Hildi J. Hagedorn, Eric J. Hawkins and Adam J. Gordon in Substance Use: Research and Treatment

Footnotes

Acknowledgements

The authors wish to acknowledge the contribution of Karen Drexler and Joseph Liberto for their leadership in the SCOUTT Initiative. Furthermore, the authors wish to acknowledge Veteran Health Administration clinicians who contributed to the vision and success of the implementation of the SCOUTT, particularly the clinical practice pharmacists who are participating in SCOUTT and were willing to complete our questionnaire.

Acronyms

AUDIT-C: Alcohol Use Disorders Identification Test

B-MOUD: Buprenorphine Medication treatment for Opioid Use Disorder

CPP: Clinical Pharmacist Practitioner

DEA: Drug Enforcement Agency

MH: Mental Health

MOUD: Medication treatment for Opioid Use Disorder

NP: Nurse Practitioner

OUD: Opioid Use Disorder

PACT: Patient Aligned Care Team

PDMP: Prescription Drug Monitoring Program

PharmD: Doctor of Pharmacy

PMOP: Pain Management Opioid Safety and Prescription Drug Monitoring

PROMS: Patient Related Outcome Measures

REDCap: Research Electronic Data Capture

SCOUTT: Stepped Care for Opioid Use Disorder Train the Trainer Initiative

STROBE: Strengthening the Reporting of Observational Studies in Epidemiology

SUD: Substance Use Disorder

VA: Department of Veterans Affairs

VHA: Veterans Health Administration

Author Note

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the US Department of Veterans Affairs or any academic institution.

ORCID iD

Adam J. Gordon

Ethical Considerations

The VA Salt Lake City Health Care System and University of Utah Institutional Review Board confirmed that this quality improvement evaluation did not require approval as human subjects research.

Consent to Participate

Respondents to the anonymous survey provided implicit consent to participate in this evaluation and could have terminated their participation at any time.

Author Contributions

All authors contributed consistent with CReDiT criteria. AJG, MK, and SC conceptualized this study. AJG acquired funding. MK and SC obtained, curated, and analyzed the data. SC and AJG initially drafted the manuscript. All authors contributed to the writing, review, and final approval of the manuscript prior to submission.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the U.S. Department of Veterans Affairs (VA), Office of Mental Health, Veterans Health Administration (VHA); the Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP) Initiative at the VA Salt Lake City Health Care System; the VA Center of Excellence in Substance Addiction Treatment and Education (CESATE); the VA Health Systems Research (HSR) Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Center (PEC) grants #19-001 (principal investigator: author AJG) and #18-203 (principal investigator: author EJH). Infrastructure support for author AJG was provided, in part, by the Greater Intermountain Node (GIN; NIH/NIDA 1UG1DA049444) of the National Institute on Drug Abuse Clinical Trials Network and the Department of Veterans Affairs Health Systems Research Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS; CIN 13-414) Center of Innovation. Supporting organizations had no further role in the design and conduct of the evaluation; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: 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 3 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.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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The Roles,Activities,and Opportunities of Clinical Pharmacists in a National Initiative to Improve Office-Based Buprenorphine Care

Abstract

Background:

Objectives:

Design:

Methods:

Results:

Conclusion:

Keywords

Highlights

Background

Methods

Results

Discussion

Limitations

Conclusions

Supplemental Material

sj-docx-1-sat-10.1177_29768357251381070 – Supplemental material for The Roles, Activities, and Opportunities of Clinical Pharmacists in a National Initiative to Improve Office-Based Buprenorphine Care

Footnotes

Acknowledgements

Acronyms

Author Note

ORCID iD

Ethical Considerations

Consent to Participate

Author Contributions

Funding

Declaration of Conflicting Interests

Supplemental Material

References

Supplementary Material