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Faced with a worsening drug crisis, policymakers in recent years have made it much easier for doctors to prescribe the highly effective opioid addiction treatment buprenorphine. However, many patients may still struggle to find pharmacies carrying the treatment, finds new research led by the USC Schaeffer Center for Health Policy & Economics.

Buprenorphine was available at just 39% of U.S. retail pharmacies in 2023, a modest increase from 33% in 2017, according to the study published Sept. 2 in Health Affairs. But disparities in who can access the treatment have persisted. Pharmacies in predominantly Black neighborhoods (18%) and Latino neighborhoods (17%) remain significantly less likely to carry buprenorphine as those in white neighborhoods (46%).

Buprenorphine is one of several medications that can ease opioid cravings and withdrawal, and it is the only one that can be prescribed in primary care settings and dispensed at retail pharmacies. Because these treatments are milder opioids and considered controlled substances, they historically have been subject to tight prescribing and dispensing rules.

Recent efforts to ease prescribing rules include the 2023 elimination of the so-called “X-waiver” that required doctors to receive specialized training and registration to prescribe the treatment. However, dispensing rates have changed little, suggesting that pharmacy regulations aimed at preventing opioid (and buprenorphine) diversion, abuse and misuse continue to discourage pharmacies from carrying the treatment, particularly in minority neighborhoods and some areas hit hardest by the opioid epidemic.

Relaxing buprenorphine prescribing rules was an important step in making this critical treatment more accessible, but too many patients lack a nearby pharmacy that carries it. Federal and state policymakers must reduce barriers that make it difficult for pharmacies to stock buprenorphine, especially in some of the more vulnerable communities.”

Dima Mazen Qato, senior scholar at the Schaeffer Center and the Hygeia Centennial Chair at the USC Mann School of Pharmacy and Pharmaceutical Sciences

Limited access in some hard-hit areas

Researchers analyzed buprenorphine claims from 2017 to 2023 from an IQVIA pharmacy database from covering 93% of U.S. retail prescription claims. Among their key findings:

• Although buprenorphine availability increased in most states, there were significant declines in five states (Florida, Ohio, Tennessee, Washington, Virginia) and Washington, DC.
• In nearly every state, buprenorphine availability was lowest in Black or Latino neighborhoods. In some states (California, Illinois and Pennsylvania), availability in these neighborhoods was about four to five times lower than in white neighborhoods.
• Independent pharmacies in Black and Latino neighborhoods were significantly less likely to stock buprenorphine and were also more likely to stop carrying it over time. But when these pharmacies did stock the treatment, they persistently filled about twice as many prescriptions per month compared with other types of pharmacies.
• Pharmacies in rural counties and those with high rates of opioid-related overdose deaths were persistently more likely to carry buprenorphine. Yet in 73 hard-hit rural counties, less than 25% of pharmacies carried the medication, and another 25 counties lacked a pharmacy.

Areas with fewer dispensing barriers had better access

Researchers said states should consider easing tight controls on buprenorphine dispensing, which can restrict access to the treatment in several ways.

When buprenorphine demand rises, suppliers may delay or pause shipments to pharmacies to avoid scrutiny from the Drug Enforcement Agency (DEA), and pharmacies often refuse to stock buprenorphine out of concern the orders will be flagged to the DEA. Some pharmacies carry the medication but refuse to dispense it for fear of running afoul of the federal Controlled Substances Act and similar state pharmacy regulations and laws, which require pharmacists to ensure that prescriptions for controlled substances are valid.

The researchers found buprenorphine availability was greatest in states with the least restrictive prescription drug monitoring programs, including those that limited how law enforcement could access the electronic databases to investigate suspicious prescribing.

The researchers said state and local governments should consider requiring pharmacies to maintain buprenorphine stock, noting that some have issued similar orders for the overdose reversal treatment naloxone and emergency contraception in an effort to improve access.

“If policymakers fail to introduce policies that increase equitable access to buprenorphine at local pharmacies, existing racial and ethnic disparities in opioid use disorder treatment and recovery will likely worsen,” said first author Jenny S. Guadamuz, an assistant professor at the University of California, Berkeley School of Public Health.

ISLAMABAD – “There was a lot of white vaginal discharge. There was also heavy bleeding — chunks of blood. This would go on for 15 to 20 days at a time and then stop. Come back again after 10 days. I was unable to go out for farm work or carry out household work. My hands and legs would feel weak and tremble. I went to Dr A in the local town. … It cost me more than 5,000 [INR]. There was no change in my condition. Then the same doctor referred me to the medical college hospital. I went there. … Nothing worked. … I went with my son to the cancer hospital in Chennai. … When I returned for the test results, they told me that it was the beginning stage of cervical cancer.”

This story of a cervical cancer survivor and mother of four from India, narrated in a World Health Organisation (WHO) report, is not unique. Cervical cancer is the fourth leading cause of cancer deaths among women around the world, especially in low- and middle-income countries such as India and Pakistan.

But here’s what many people don’t know — the disease is one of the few cancers that can be almost entirely prevented with early screening and vaccination. There are two approved vaccines that can reduce the risk of cancer by protecting against the infections that cause them — the hepatitis B vaccine and the cervical cancer or human papillomavirus (HPV) vaccine.

Pakistan is launching its first-ever cervical cancer prevention vaccine drive this month, and doctors and government officials are pushing to make it a success.

Virtually all cervical cancers are caused by persistent infection with HPV. Two high-risk types, HPV 16 and HPV 18, are responsible for 70 per cent of cases.

In 2006, the United States Food and Drug Administration approved a vaccine to be administered to females nine through 26 years of age. Gardasil, as the vaccine was called, aimed to protect from diseases caused by certain types of HPV, including cervical, vulvar, vaginal, and anal cancers as well as genital warts.

Nearly four years after its licensure, researchers who surveyed vaccinated women aged 14 to 59 found that among vaccinated girls aged 14 to 19 years, vaccine-type HPV prevalence dropped from 11.5pc to 5.1pc — a staggering decline of 56pc. Among other age groups, however, the prevalence didn’t seem to differ significantly.

In 2020, the WHO launched a global strategy aiming to accelerate the elimination of cervical cancer as a public health problem. By 2023, around 140 countries introduced the HPV vaccine into their national immunisation programmes, including those with large populations and cervical cancer burden, such as Bangladesh, Indonesia, and Nigeria.

In August, the WHO announced that it is partnering with the Government of Pakistan to train over 49,000 health workers for the country’s first HPV vaccine drive, planned from September 15 to 27. The campaign is being described as a “historic milestone,” and is set to target 13 million girls aged nine to 14 years across Punjab, Sindh, Islamabad Capital Territory, and Azad Jammu and Kashmir.

The Federal Health Ministry announced that it is launching the campaign in Sindh in collaboration with the provincial health department and urged close coordination with the education department to ensure as many girls as possible are covered in the campaign. Sindh Health Secretary Rehan Iqbal Baloch said the campaign aims to vaccinate about four million girls in the province.

Gavi, a global health alliance that helps lower-income countries access vaccines, is also providing support, he explained. The necessary doses will be available free of charge through the government-led Expanded Programme on Immunisation (EPI).

Why is the drive important?

According to infectious diseases epidemiologist at the Aga Khan University Hospital in Karachi, Dr Muslima Ejaz, the initiative is important because it targets adolescent girls, a group often left out of health interventions. “By reaching them early, before they’re exposed to HPV, we’re literally safeguarding their future health,” she told Images.

She explained that the drive sets a precedent. If Sindh succeeds, it can become a model for scaling up across other provinces. “This campaign is not only about vaccination, it’s about building systems, community trust, and a roadmap for integrating HPV into routine immunisation,” she said. Essentially, it’s a public health breakthrough for women in Pakistan.

New research to be presented at this year’s Annual Meeting of the European Association for the Study of Diabetes (EASD) in Vienna, Austria (15-19 September) and published in the journal Diagnostics shows that people with hepatitis B immunity induced by vaccination have a lower risk of developing diabetes of any kind. The study is by Dr Nhu-Quynh Phan, College of Medicine, Taipei Medical University, Taipei, Taiwan, and colleagues, under the supervision of Professor Chiehfeng Chen.

The liver plays an important role in glucose metabolism, specfically maintaining the balance of glucose levels (glucose homeostasis) and it is thought HBV infection may affect liver functions and disrupt these metabolic pathways, increase the risk of abnormal blood sugar profiles and eventually increase the risk of developing diabetes, Thus, HBV vaccination, which provides immunity against HIV infection, may reduce this risk. However the role of HBV immunity in diabetes prevention among individuals without HBV infection is underexplored. In this new study, the authors evaluated whether HBV immunity reduces diabetes risk in individuals without HBV infection.

This retrospective cohort study used deidentified electronic medical records from TriNetX (a global platform that provides access to data on diagnoses, procedures, medications, laboratory results, and genomic information for biomedical and clinical research. At the time of analysis, data were extracted from 131 healthcare organizations within the Global Network, which comprises multiple Local Networks: US, Europe, Middle East, and Africa [EMEA], APAC (Asia Pacific), and LATAM (Latin America).

This study included adults (≥18 years) with HbsAb blood serology results, a marker of hepatitis B immunity, excluding those with prior HBV infection. Participants were classified as HBV-immunized (HBsAb ≥10 mIU/mL) or HBV-unimmunized (HBsAb <10 mIU/mL). Because individuals with prior infection were excluded, HBsAb positivity was attributed to vaccination, whereas negativity indicated either non-vaccination or lack of immune response after vaccination. The study inlcuded 573,785 individuals in the HBV-immunized group (HBsAb ≥ 10 mIU/mL) and 318,684 individuals in the HBV-unimmunized group (HBsAb < 10 mIU/mL). 

Diabetes was defined on the basis of a diabetes diagnosis, diabetes medication use, or glycated haemoglobin (HbA1c – a measure of blood sugar control) of 6.5% or higher. The data was adjusted for demographics and comorbidities.

The authors found that the HBV-immunized group had a 15% lower diabetes risk than the HBV-unimmunized group. A dose-response effect was observed, with higher diabetes protection at higher hepatitis B antibody (HBsAb) levels. HBsAb levels of 100 mIU/mL and above and 1000 mIU/mL and above were associated with 19% and 43% reductions in diabetes risk, respectively, compared with HBsAb lower than 10 mIU/mL.

The diabetes protective effect was also associated with age. Overall, immunised individuals aged 18 to 44 years, 45 to 64 years, and 65 years and older had 20%, 11%, and 12% lower diabetes risks, respectively, compared with unimmunised individuals.

The authors discuss other important findings from the study, namely the geographical variation in the association, saying “stratified analysis revealed significant geographical differences in the protective effects of HBV immunity against diabetes. Notably, the United States-despite its wealth and advanced healthcare system, showed the least benefit in diabetes prevention associated with HBV immunity.” The authors say that other studies are needed to clarify possible reasons for this.

Regarding the effect of aging, the authors comment: “The association between HBV immunity and reduced diabetes risk was stronger in younger individuals compared to middle-aged and older individuals. This finding may be attributed to the natural aging of the immune system, also known as immunosenescence, which leads to diminished vaccine-induced immune responses in older adults.”

On health behavior, they observe: “From a behavioral perspective, individuals who complete vaccination schedules may be more health-conscious and more likely to engage in healthier behaviors, such as maintaining a better diet or exercising regularly. This raises the possibility that health behavior may act as a confounder in the observed association.” 

The authors conclude: “The potential for the HBV vaccine to prevent both hepatitis B and diabetes suggests that the HBV vaccine is a unique dual-benefit intervention. Traditional diabetes prevention requires lifestyle changes, dietary adjustments, exercise, or medication, which require long-term commitment and can be costly. By contrast, the HBV vaccine is accessible and cost-effective, especially in regions with a high prevalence of both HBV and diabetes, such as the Asia-Pacific region and Africa. Further studies are needed to confirm these effects and investigate the underlying mechanisms. If validated, the HBV vaccine could become a key tool for the prevention of both infectious and chronic diseases.”

A father’s exposure to passive smoking as a child may impair the lifelong lung function of his children, putting them at risk of COPD-a risk that is heightened further if they are childhood passive smokers themselves-finds research published online in the respiratory journal Thorax.

The findings highlight the intergenerational harms of smoking, say the researchers, who urge fathers to intercept this harmful legacy by avoiding smoking around their children.

Chronic obstructive pulmonary disease, more usually known by its acronym of COPD, includes chronic bronchitis and emphysema. Now the third leading cause of death around the world, COPD kills around 3 million people every year, say the researchers.

Several factors throughout the lifespan may increase the risk of poor lung function and subsequent COPD, and attention is now beginning to focus on the potential role of intergenerational factors, they explain.

While previously published research showed that passive smoking during a father’s childhood may be linked to a heightened risk of asthma in his children by the time they are 7, it’s not clear if compromised lung function may extend into middle age and beyond, they add. 

To explore this further, the researchers drew on 8022 child participants in the Tasmanian Longitudinal Health Study (TAHS), all of whom had tests to assess their lung function (spirometry).

Their parents completed an initial comprehensive survey on their and their children’s respiratory health. Further check-ups ensued when those children were 13, 18, 43, 50 and 53. These included spirometry to assess 2 measures of lung function (FEV1 and FVC) as well as questionnaires on demographics and respiratory symptoms/disease. 

Of the 7243 parents who were alive and could be traced in 2010, 5111 were re-surveyed about whether either of their own parents had smoked when they were under the age of 5 and/or up to when they were 15.

Among the 5097 respondents with complete data, 2096 were fathers. The final analysis included 890 father-child pairs with data on the father’s passive smoke exposure before puberty and lung function data for their children up to the age of 53.

More than two thirds of the fathers (nearly 69%) and more than half of their children (56.5%) had been exposed to passive smoking during their childhoods.

Around half of the children (49%) had a history of active smoking by middle age, and just over 5% of them had developed COPD by this time point, as assessed by spirometry.

After adjusting for potentially influential factors, including the father’s lifetime history of asthma/wheeze and his age, his passive smoke exposure as a child was associated with 56% higher odds of below average FEV1, but not FVC, across the lifespan of his children. 

Similarly, fathers’ childhood passive smoke exposure was also associated with a doubling in the odds of an early low-rapid decline in FEV1/FVC in their children. This was statistically significant even after adjusting for potentially influential factors.

And paternal exposure to passive smoking as a child was also associated with a doubling in the risk of COPD by the age of 53 in his children, although this was no longer statistically significant after adjusting for potentially influential factors. 

But children whose fathers had been exposed to passive smoking as a child were twice as likely to have below average FEV1 if they, too, had been exposed to passive smoking during their childhood.

The observed associations were only partly mediated through smoking and respiratory illnesses in fathers and their children (each contributing less than 15%).

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. And the researchers acknowledge that TAHS lacks data on paternal lung function and genetics, preventing assessment of familial aggregation as a potential mechanism. 

And their children’s childhood passive smoke exposure was defined as at least one parent smoking 6 days a week, which might have misclassified moderate/light smokers as non-smokers, they add.

But the period before puberty is especially critical for boys, when exposure to harmful substances may change gene expression and modify repair mechanisms, which may then become heritable, say the researchers by way of an explanation for their findings. 

“Our findings are novel as this is the first study to investigate and provide evidence for an adverse association of paternal prepubertal passive smoke exposure, rather than just active smoking, on impaired lung function of offspring by middle age,” they write. 

“This is of importance from a public health perspective, as passive smoke exposure affects about 63% of adolescents, which is significantly higher than the approximately 7% affected by active smoking.” 

They conclude: “These findings suggest that smoking may adversely affect lung function not only in smokers but also in their children and grandchildren…Fathers exposed to tobacco smoke during prepuberty may still reduce risk for future generations by avoiding smoking around their children.”