Well over two million Americans have died from an alcohol-related cause or drug-related overdose since 2000, exposing at least forty times as many Americans to devastating personal loss.1–9 Medication, specifically indicated and prescribed for addiction, is fundamental to effective treatment.10 While utilization rates remain low,11,12 addiction medications are cost effective, reduce harmful substance use and related morbidity and mortality, improve health outcomes, and enhance quality of life.13–21

Pharmacists help to ensure the safe and effective use of addiction medications, such as buprenorphine, the most commonly used medication for the treatment opioid use disorder (OUD) that can be prescribed or dispensed in clinicians’ offices.22 Despite buprenorphine’s distinct mechanism of action,23 safety, effectiveness, and lower risk classification than full opioid agonists under the Controlled Substances Act (CSA), some pharmacies still associate significant risk with ordering and dispensing buprenorphine, possibly conflating harms associated with diversion of medications like oxycodone and alprazolam with buprenorphine’s diversion risks.22,24 Notably, the use of diverted buprenorphine is largely associated with unmet treatment needs.25 Nationally, buprenorphine comprised an estimated 1% of drugs identified in all reports submitted to federal, state, and local forensic laboratories from law enforcement operations in 2022.25–27

Challenges to accessing buprenorphine at pharmacies are not always well-understood or clearly identified, nor have they been addressed sufficiently. Relatedly, settlement terms of large lawsuits involving pharmaceutical manufacturers, wholesale distributors, and retail chain pharmacies likely intensified pharmacies’ risk concerns.28,29 These terms have not been revisited or amended by state attorneys general to ensure adequate pharmacy access to medications for OUD (MOUD) or overdose reversal, specifically...