Understanding Buprenorphine First-Prescription Abandonment

Key Takeaways

• Among insured adults with opioid use disorder receiving a first buprenorphine prescription, 25.8% of prescriptions were abandoned. Annual abandonment of first buprenorphine prescriptions rose from 19% in 2020 to 37% in 2024, and the increase was statistically significant.
• Abandoned prescriptions were linked with younger age, Hispanic ethnicity, higher pharmacy deductibles, and a greater share of commercial insurance enrollment.
• Dispensed prescriptions were more common among adults with prior opioid use disorder or overdose, another substance use disorder, or a mental health diagnosis.

Starting treatment for opioid use disorder (OUD) can break down after a first buprenorphine prescription is written but before medication is dispensed. Insurer processing, pharmacy availability, out-of-pocket costs, and patient-level barriers can all interrupt that handoff even after treatment has been offered. Investigators examined this treatment-initiation gap in an insured adult cohort.

In a JAMA Network Open research letter on first buprenorphine prescription abandonment, investigators used de-identified electronic health record data linked with administrative claims from the Optum Labs Data Warehouse. They identified adults with a first buprenorphine prescription for OUD from January 2020 through September 2024 if they had at least 180 days of prior medical and pharmacy benefits, at least 30 days afterward, and no more than a 45-day gap in coverage. The cohort included 1,428 adults with commercial insurance or Medicare Advantage plans.

Abandonment was defined as prescriptions not filled by patients or rejected by insurers or pharmacies. Overall, 25.8% of first buprenorphine prescriptions were abandoned. The annual proportion increased from 19% in 2020 to 37% in 2024 (p=0.02).

Compared with dispensed prescriptions, abandoned prescriptions were associated with higher pharmacy deductibles at $483.80 versus $296.40 and a larger share of commercial insurance at 51.8% versus 29.4%. Abandoned prescriptions were also more often associated with younger age and Hispanic ethnicity, while dispensed prescriptions were more common among adults with prior OUD or overdose, another substance use disorder, or a mental health diagnosis.

Interpretation is limited to commercial insurance and Medicare Advantage populations, and investigators could not distinguish patient nonfill from insurer or pharmacy rejection. The authors also discussed coverage restrictions, pharmacy stocking, stigma, out-of-pocket costs, language barriers, and retail pharmacy access as possible contributors rather than established causes.

Clinician Questions

How was buprenorphine prescription abandonment defined in this cohort?

Abandonment meant a first buprenorphine prescription for opioid use disorder was not filled by the patient or was rejected by an insurer or pharmacy. The available data could not separate those pathways, so the analysis could not identify which step most often drove non-dispensing.

Which patients do these findings apply to?

The cohort included adults in the Optum Labs Data Warehouse with commercial insurance or Medicare Advantage who received a first buprenorphine prescription for opioid use disorder during the study period and met continuous coverage requirements before and after prescribing. The findings are not generalizable to uninsured patients, Medicaid populations, or other coverage groups.

What unresolved access question did the authors highlight?

The authors said the findings warrant further analysis of insurance benefits design, including prior authorization, quantity limits, and cost-sharing. Because the data could not distinguish patient nonfill from insurer or pharmacy rejection, the main unanswered question is which part of the access pathway is most responsible for non-dispensing.