Episode 1 Transcript
Substance use disorder treatment and the evolving role of pharmacists with Jeffrey Bratberg, Pharm.D.
Host - Intro
Welcome to Voices in Pharmacy Innovation, the podcast where we spotlight bold ideas and groundbreaking practices that are transforming pharmacy practice and healthcare care delivery. I'm Dave Dixon, professor and chair at the Virginia Commonwealth University School of Pharmacy and core faculty member of the Center for Pharmacy Practice Innovation. In each episode, we'll sit down with pharmacists, healthcare leaders, and change makers who are rethinking how pharmacy can improve patient care and push the boundaries of what's possible in our profession. Together, we'll share stories, explore new models of practice, and amplify the voices driving pharmacy innovation forward.
Host
Welcome to the inaugural episode of Voices in Pharmacy Innovation. Today, we're joined by Dr. Jeff Bratberg, clinical professor at the University of Rhode Island College of Pharmacy. Dr. Bratberg is a national leader in addressing substance use disorders. And today, we'll explore how he and his team are making a real difference in the lives of these individuals every day.
In case you didn't know, January is Substance Use Treatment Month and it's a reminder that recovery doesn't start with willpower. It starts with recognition. Today, one in six Americans is living with a substance use disorder, whether diagnosed or not. So it's very timely today that we have Dr. Bratberg on the podcast, who has truly been a national leader and advocate in this area for many years. So let's dive in. Dr. Bratberg, welcome to the podcast.
Guest
Thank you so much, Dr. Dixon. This is a pleasure and an honor. I know I've given one talk for your agency, and so it's wonderful to kick off the podcast on such an important and engaging topic.
Host
Awesome. Well, thanks so much for joining us. Before we jump into learning more about your work, can you tell our listeners a little bit about your background?
Guest
Yeah, thank you for asking. I did my training originally in North Dakota. I went to North Dakota State University. I did some residencies in Wisconsin and Michigan in infectious disease and critical care. And I became an infectious disease specialist in a hospital in Providence, Rhode Island, or a couple hospitals. And then as I was treating or helping the team treat people with infections, a lot of which were due to injection drug use, I became much more active in closing gaps in addiction care and particularly focused on addiction policy as I was also working with our state association to expand pharmacist's scope of practice there. So now they're sort of merged. I see pharmacist's scope of practice, reimbursement, payment reform, all linked to really going back to what I did before, this endemic of treating addiction and treating the sequelae of addiction like HIV and hepatitis C, which I've done research in, as well as now wound care and and making sure that folks have a recovery that includes medications, which are the gold standard of of therapy for many substance use disorders, particularly opioid use disorder.
Host
It's really fascinating your connection and how you went from infectious disease to kind of transitioning your career focus in substance use disorder and addiction. So I think that that's an excellent sort of way of trying to take your observations from practice and then looking to make change in a, in a different way, even if that wasn't maybe the initial career path that you set out on.
Guest
When I think a lot of, a lot, I was just in a meeting at our university yesterday and One one of my colleagues said something that that stuck with me, which is people choose careers not based on the college or a class, but who's teaching the class or who's your mentor, who's your preceptor. And so, you know, my mentors were physicians who were like, let's go to the state house and talk about changing these laws. And I've still engaged with some of my physician and research mentors. And so that's sort of what I do is I participate in collaborative care and collaborative documents to say, where should research in pharmacy addiction care go? Or what should the roles of pharmacists be? What's the role of community pharmacy as public health nodes that already exist in the community? How can they close the gaps in the whole cascade of addiction care, whether it's screening or referral or direct treatment or long-acting injectable treatment, all these things are happening. And I've probably become more interested in implementing things and implementation science. I started a website to talk about policy change and share toolkits. So I'm just becoming more and more, and the reason I accepted this podcast. This is a way to get people to say, oh, as I'm driving, this guy has some good ideas for how to change pharmacy practice. So ah hopefully that has the impact we're looking for here.
Host
Well, great. That is an excellent segue into our deep dive to learn a bit more about your work. And so I always like to think about innovation as trying to solve a problem. So describe for us what problem you and your team were trying to solve?
Guest
So our problem was not enough people who want medications to treat opioid use disorder like methadone, buprenorphine, naltrexone. We're not getting it. We had successfully innovated in Rhode Island and nationally for naloxone access, asking what prescribers did, lots of policy change, lots of national attention, state attention. I’m just starting my 10th year as one of the founders of our governor's overdose prevention and intervention task force, which is an extraordinarily multi-agency, multidisciplinary group, looking at, again, all phases of a harm reduction pillar, a prevention pillar, treatment, recovery, things like that.
And, yeah, it's just, you know, the gap that I saw with naloxone is this life-saving drug. We need to close gaps. How can pharmacists do it? We change policy. And now we have the highest saturation of naloxone in the country, I think, in Rhode Island with a bunch of things. But naloxone is only honestly a bandaid, right? It keeps you alive.
So what happens in those emergency departments? What happens on the street with EMS? What happens in pharmacists who are using naloxone to reverse overdoses in their stores or their parking lots? How do we get them to treatment? Well, pharmacies have the drugs, right? And we know that prescribers or prescribing clinicians are not filling the gap. You know, only one in five people, maybe one in four people, are actually getting the medications that reduce not only mortality from their addiction, but from all causes.
And so we said, how do we get pharmacists to actually prescribe the medicines that are already in their pharmacies? And so we, you know, now three years ago, we came out with a paper talking about our pilot study of 100 patients, showing that 90% of them liked the care and stayed in care for 30 days, at a month of therapy. And really at six months, almost two thirds of them were still in care. And that was the length of the study.
One of the limitations of the study is what we're trying to do now, which is that people need to get paid for providing these professional services. This is well known to your listeners, right? So now it's, I got a grant to study the policy change in all states and DC and Puerto Rico called pharmacybridge.org. So we'll put that in the show notes, right?
Pharmacybridge.org is now the hub that also was the gap, is what is happening in these states. States are where we change laws. Who is innovating? Is it Idaho? Is it California? Is it North Carolina? Places you can get DEAs and pharmacists can prescribe. Those places also have forms of payment, right? And, you know, Virginia, where you guys are, has forms of payment to pharmacists.
What are the barriers there? Is it credentialing? Is it this disease state? Is it 340B access to branded therapies like long-acting injectable buprenorphine? And so really sort of taking a whole system look at this. And now we're just collecting stories and anecdotes and doing podcasts and saying, hey, here are the laws. Here's what the priority of your law should be. Should it be a scope of practice? Should it be payment? Should it be telehealth? Should it be lab testing?
How do we help people advocate for the change in the laws, but also make sure that there's a structure and foundation for implementing the laws? Because laws don't work. If you're allowed to do something, then you don't do it. Policymakers say, we're not going to pass this extra stuff that you want. We're not going to authorize scope or payment when you don't seem to do the things that we did before.
So now we're trying to merge those things, provide toolkits, make toolkits, checklists, and things that say, here's what you do to do a CPA, if that's going to work in your community pharmacy, or here's the steps to become an independent practitioner.
And, you know, I know it's substance use disorder treatment month. I think it's really interesting that this is the thing where there's the largest gaps and we see the largest benefit when people actually get the meds that they want. And it isn't just mortality reduction. It's literally life-changing meds. You know, we're pharmacists in the community who are willing and ready to prescribe these meds.
Host
So I think a key word that you've said multiple times is implementation. Yeah. Right? Yeah. And so I hear you say that the tools are there. We've made incredible progress from a legislative standpoint, not saying there isn't much room for improvement, but we have made progress.
And so what do you think it is that that is one of the key barriers that might resonate with our listeners in terms of a small thing that they could think about in their own practice, or what have you learned from your work that's a key barrier for frontline clinicians in making sure that they're implementing what your team has shown to be effective?
Guest
So I wish I knew the answer to what makes it effective. I think I can speak generally to say anytime you start something new, the brain registers pain. And so every time I teach my students something new or new, you know, pharmacists have been asked to do more and more and more, I can't do that. That is, and payment can alleviate that.
But I always always slide on the quintuple aim, which really originally was the triple aim, which says help populations, help patients, make sure it's cost effective. Well, we know addiction care is all those things. But the other two things that were added to that are the workforce, the health of the workforce, and then also health equity.
So health equity, I think we cover with pharmacies. They're in rural areas. They're doing all these things. But we also know that health equity is suffering. Pharmacies are closing. We need them to be paid to just stay open to provide not only addiction care, but other things.
But realize all of the expansion I see nationally and in states for scope of practice are because of gaps that exist because of stigma. So reproductive health is stigmatized. Smoking cessation is stigmatized, right? HIV, PEP and PrEP. These are all things that many states are doing, some very successfully.
But now we need to make sure they're integrated into our didactic and experiential programs, residency programs. We did that with addiction care in family medicine residencies and primary care residencies and physicians. We now have to make this standard.
I always say that if a state can pass tobacco use disorder treatment accessible, that's just an interview to say, oh, you want treatment.
We need to make societies and families comfortable that people who have addiction, whether it's alcohol or cannabis or stimulants or opioids, can go into the pharmacy and, I want treatment, which was the first two patients I saw three years ago. They said, I want my use of fentanyl at 10 a.m. today to be the last I have, and it's 2 p.m.
The pharmacy was there. The pharmacists were trained. Our procedures were in place. And they left with therapy that will keep them alive at least that day. And again, of the patients who did stay in therapy, that they're alive today because we provided access to something. We provided a choice.
I always say, we're not taking away anything by expanding care to pharmacists as clinicians. We're just giving people more choice, some of whom never had a choice. And I think we treated a lot of folks that way in our study. And we aim for implementation to say, let's destigmatize this.
And I think everyone who treats addiction says, we don't want to tell people you're stigmatized, but we want to say, I want you to treat one person and see how they do. And I think that you'll be willing to treat everybody who comes through your door once you once you see the success of these medications for one person.
Host
Absolutely. So as you have hinted at, anytime that we are trying to innovate or make change, we have some successes, but we also have challenges. So what are one or two key lessons that you've learned from your successes and challenges along the way?
Guest
I think that, you know, our project is looking at collaborative practice agreements in community settings. And, you know, I think collaborative practice, I think working collaboratively sounds great. Expanding practice is great. But working out payments and documentation and sharing systems in the community is exponentially greater than in office settings where pharmacists—or inpatient settings where I've worked—where everyone has access to the EHR. Hopefully you can take notes and people do all those things. But we were still faxing notes to the docs who signed the CPAs.
We are still figuring out how we get the payment for the visit at the pharmacy in a CPA. So while there are many more states that allow CPAs for controlled substances like buprenorphine, it's so much easier. And again, easier means less time—less time spent on the clinical service means it's more likely to be implemented, more likely to be sustained. Pharmacists need to, at least for addiction care, need to be independent practitioners and a referral source for other health care providers who want to refer their patients to get just treated at the pharmacy—that works, right? Or as hubs that send folks to say, OK, we're going to refer you to this other care, but you'll always have your meds here at the pharmacy. There's lots of steps to take, but it really needs to be independent practitioners from a documentation and payment and referral source standpoint. I think that if you're going to do policy change, you really need independent practice for this.
Host
I couldn't agree more. And I anticipate as we go through future episodes on this podcast, that that will be a consistent message from many of our guests. And I can't help but also, as a side note here, you know, you mentioned fax machines. It is fascinating that in 2026 the fax machine is still thriving.
Guest
Yeah. Yes. Not even with paper. It's almost—it's fax software, which is what we probably should. Which is also helpful. I mean, you know, if you work in the VA system, it's the same software everywhere. Software that all of us taxpayers paid for. It could be a national healthcare care information system, but that's another podcast probably from an expert within that system.
But I think that, you know, some of the workarounds that some of my colleagues are doing is saying, okay, you fax it and it gets put into the independent pharmacy systems. We're working within independent systems and then chain systems. There are some chains that use very popular EHRs like Epic.
But they're not, again, that they don't have all the features. You know, while I could use my hospital system to make notes and check on patients before I even got to the hospital, just remote access. And this was 15 years ago. And a lot of people have remote access on their phones and things. That's just not what's happening here. You're still using fax to sort of document what you do. And we're not documenting that much stuff.
I think that, you know, my colleague, physician Sarah Wakeman, who runs the Addiction Treatment Bridge Clinic at Mass General and the addiction services there…We have to stop thinking about addiction being difficult to treat, which is perhaps a proxy for difficult patients. I sort of dislike the term about difficult patients. It's like you've had a difficult childhood, which led to likely adverse childhood experiences and trauma. And that's the other thing that may be a barrier—if all healthcare care professionals realized what degree trauma underlies so many chronic diseases, whether they're behavioral health or physical health, I think that we would be more compassionate to each other, more compassionate for our patients, our students. I think that's a universal that I would like to see applied, not just to addiction care, but to really sort of all care, to the benefit of everyone involved.
Host
Yeah, I love that message of empathy, right? You know, in my clinical world and in cardiovascular practice, I encounter quite a few patients that are also struggling with substance use disorder. And so while I am certainly not an expert in the area, over the years, I've really had to challenge myself to learn a bit more and also challenge my own ability to be empathetic to these individuals—and as we should be with all of our patients—while recognizing that everyone has a different background and different path in life. And, you know, we're here to serve, right? That's what this is, that's why we're in this profession.
Guest
Yeah. And to be very clear, we can be Pollyanna and say, let's treat everybody as a human, but we all come from a society that massively criminalizes drug use and has massive stigma against people. And I think that the simplest—and this is complex—but to say, we treat humans, if we believe someone's human, we treat them as a human. They're a family member, they're a patient, they're a colleague, a student. The moment that you have policies that impose a dehumanizing quality, or literally dehumanize people, it literally makes it easier and acceptable to treat “criminals” as less—not just others, but just less or nothing. And it is an image in our head. If you think of someone who injects drugs, it's disgust. And that the parts of our brain that light up with disgust make it very difficult to be empathetic for them. It takes a lot of energy. And that goes to that quintuple aim that we need to… stigma training isn't a one-time thing. Identifying discrimination isn't there. And I treat stigma and discrimination against all folks, for whatever reason, whatever identity, as a constant ebb and flow on where we're at. You know, it's just like med errors. We don't blame people for med errors. We say, what's with the system?
And in addiction, wow, it is a big societal system that says this person's bad and doesn't deserve things. And I wrote a paper to say it's about dignity, right? We all want dignity.
But it's hard to recognize someone's dignity when you think about their crimes, when you think about drug use, when you think about why they have this wound, and not more about, why did you take two months to come in? You know, again, in cardiovascular care, how many people's diabetes and hypertension are uncontrolled because they were just afraid to tell their healthcare provider that they had it?
Host
Sure.
Guest
That's hypertension. Now, imagine you're saying, “Yeah, I inject illegal opioids.” Imagine how difficult that is to tell a provider, and how we need to be ready to accept that. And again, to come back to what I do, is to say, and have the solutions. Pharmacists I talk to in all kinds of fields, especially public health, are, “Wow, if you allow me the ability to actually solve a problem and keep someone alive, I'm going to do that. I'm going to do chronic medication management, I'm going to do long-acting injectable antipsychotics, I'm gonna do any of these things.” If you give me the ability, I'm now more interested in doing this and closing those gaps in care by giving people more options to both say those things and then to be able to get treated and have remarkable outcomes.
Host
Right, right. Well said. All right, so let's move on to some broader implications and identify a couple of take-home points for our listeners. So if others wanted to replicate or implement this type of effort in their community or in their practice setting, what's one small thing that they could do? You know, we go back to the issue of implementation that we've talked about several times. So what's the low-hanging fruit here?
Guest
Well, it is so great that pharmacybridge.org exists. And so you can go there and find your state and find out what the laws are. Maybe you don't know that you can independently—or use a CPA—to administer buprenorphine. There you go. Now you at least have a piece of knowledge to do that. Maybe you don't know that in New Mexico, if you get a—just as an example—you can get an advanced practice designation and you can prescribe and get paid equitably for prescribing for managing patients on buprenorphine. That's great. We want to get the word out on what can be done right now, because policy change is also easy to say and hard to do.
But we're writing a paper on this right now, you know. To convince someone to change policy is to say that there's no way you could say no. Somebody told me that. And so it's the idea of, like, there's a gap, we're trained, we're present. It's not a workforce development issue. It's not a 10-year grant. This flips the switch and allows pharmacists to get DEAs. I think that's the other thing. If you live in a state that allows you to be registered in the DEA, go get it. Yeah. And then once you have that, think of all the other diseases that you can likely treat by being able to prescribe controlled substances. A scary thing, but I would say prescribing is the last 10% of the 90% of what pharmacists already do. We already check interactions, make sure the drug is right, make sure its guideline is developed, make sure the regimen.
This is why pharmacists are medication experts, and honestly, I think should get specialist payment for being an expert, right? And so I think those are things that get the knowledge and then start mapping out, okay, how do I incorporate this into my practice?
Go through, get credentialed if you can be paid by commercial or state public payers. You know, if your state hasn't expanded Medicaid, I'm not saying, “Hey, individual, go try to change that in your state.” That's very difficult. But there are definitely things that you can do to say, what is the small part? I think the other small part is just stocking buprenorphine. Studies have shown 20% of pharmacies aren't even stocking it. Some for good reasons, some for not. If you don't have the volume, if your expensive drug is expiring on the shelf, of course you're not going to carry it.
So even finding out, “Hey, how do I partner with addiction providers?” Or maybe an addiction provider reaches out to you, or to, you know, where you're working, and says, “We'd like to partner with you to prescribe this drug,” have a discussion about how important—and how life-saving—this drug is, and how you will have that patient potentially for life, right? Buprenorphine is not temporary for some folks, which may be another barrier. So I think just educating yourself on how good these drugs are, making these partnerships happen, and understanding that there's not just gaps in prescribing, but there's gaps in availability of the drug, and how much better the life of that person could be if they don't have to drive an hour or half an hour to the pharmacy that stocks it, but to the one that is the one they get all their meds from.
Host
Absolutely. That was incredibly helpful, and I think there's some great advice there for our listeners. So thank you for sharing that. Ah, so let's move on to our quick-fire round. We have a few questions here as we look to close out this first episode. So what resources have you found most influential in your own thinking about innovation in pharmacy practice from your experience?
Guest
I think that the most recent thing that came out is the National Academies of Science Innovations in Pharmacy publication. I think it's a long document. It's very rich. You probably are aware of it. I was just happy to have a quote in it. So that's my thing. My name's not in it, but my quote is in it. And that's my achievement. I think that's important. I think you started off with a great thing to say: innovation is about finding problems. And I think everything I do—in service, policy, advocacy, or teaching—is identifying the problem.
And I think that's being able to read a lot of different things and say, “Well, what is the problem?” Or I gave a talk on policy in Minnesota recently. And it's the—it's the why I say to students, “You may know nothing about intensive care today, your first day in May, your first rotation. But if you ask people why you have become an essential part of that patient's care, the team's care, you're presenting that. That's important.”
And so, I think that there's, you know, from an addiction standpoint, there's SAMHSA documents—TIP 63 is phenomenal. SAMHSA also has an implementation guide. The VA has been a massive leader in how pharmacists are prescribers and getting addiction care, especially for opioid use disorder, out. So they have publicly available guides. Yeah, that's the thing off the top of my head, I guess. Oh, ASAM, of course, has a wonderful guide. And those, again, are all publicly available. And pharmacybridge.org has a large section on resources that you can have links to all those documents.
Host
So that's plug number two.
Guest
Plug number two.
Host
I'm not sure that we can do more. So what advice would you give students, trainees, or even early career pharmacists who want to do work in this field?
Guest
That's the why not, right? Why am I not, addiction is a public health, you know, opioid use disorder and overdose is a public health emergency. It has been since 2017. It's not treated as that. And so ask, “Why not? Why?” Demand pharmacy education. Like everything is in some ways a business, and we serve what students want. And so you will get the addiction training if you ask for it.
And just as you've alluded to, or as you stated, that many of your patients being treated for chronic diseases—cardiovascular diseases—have addiction, we need to know this as a comorbidity. And you're not going to deliver the primary care you want and achieve those quality indicators that often pay for pharmacists when some of these addictions are not treated.
And so I think that's to know that there's a behavior—we always talk about adherence, right? And behavioral indicators of taking medications. Well, boy, you know what a big behavior to taking medications is? If you have an untreated addiction. And so we need to make sure that we have the tools to identify, to screen, refer, and in some ways make it part of primary care and treatment.
Host
Great, great point. So I also like to personally just always think about something I'm looking forward to, and this can be personal or professional. So Jef, what's something that you're looking forward to in the next six to twelve months?
Guest
What I'm looking forward to. I think, boy, what am I looking forward to? Expanding my website, pharmacybridge.org. Truly, you know, getting some papers out on our policy change, barriers, and facilitators to policy change in this area. I have some presentations coming up on the role of the pharmacist in addiction care and sort of the community pharmacy as the hub-and-spoke of the system and making it an essential—it already is, but a more essential part of the system.
I would love to see increasing numbers. I'm excited to talk to pharmacists and put them on my website and say, “Hey, this person did it in your state. Do more in that state,” or “How did you change the law in Colorado allowing statewide protocol for this?” Let's see where these innovations go. Let's track the implementation.
So I think it's more of an ongoing thing I'm looking forward to. You know, finishing my grant, getting folks approved CPAs, and having it be evaluated and saying, “Hey, this is the toolkit. Let's use it. Let's grow.” I'm working with some states on changing their policy based on some of the research. So excited to sort of provide technical assistance to states to say, “Where were your barriers, and what have you already done? Is it an implementation barrier or is it a policy barrier? And let's, you know, open the floodgates and say, how do we change this? And what is going to be the beneficial effect downstream?”
Host
Well, that's wonderful, Jef. And I want to thank you again for joining us on this inaugural episode, sharing your story, your insights, and your passion for individuals suffering from substance use disorders. And I know that you'll mention pharmacybridge.org, but are there other ways that our listeners can connect with you to learn more about your work?
Guest
I mean, I always say that my phone number and email are public on the web, and I keep getting emails saying that that's a danger, but, you know, I'm easily contactable. Again, I do have at this point a voluntary goal to work with anyone to highlight your story, get the information out. I mean, I write papers, but as you know, as an academic, sometimes the paper that's read by nine of your friends just stays within your friends. I want to try to make that wider, more widely available.
I think AMERSA.org is a great resource. It's an organization I've been involved with for 10 years as well—the Association for Multidisciplinary Education in Substance Use and Addiction. That's a long title; we call it AMERSA, but we have a pharmacist special interest group. And so you can think about joining that group and really every year there's wonderful new things I learn about. And we have a community that we're exchanging information in that organization as well.
They have lots of public policy statements. We have an advocacy team. We've done state-level work. We do federal-level work. So that's a great group to just get a sense of: “Do I just need to sign my name to this thing?” or “What policy efforts are being changed?” I think that's a leader that pharmacists are a growing part of.
Host
Fantastic. Well, thank you again. And I also want to thank our listeners for tuning in to this inaugural episode of Voices in Pharmacy Innovation. If you enjoyed today's episode, please subscribe, share it with a colleague, and join us next time as we continue to spotlight the innovations that are shaping the future of pharmacy practice and healthcare.
Host – Outro
Thank you for listening to today's episode. Voices in Pharmacy Innovation is published monthly. You can listen on Apple Podcasts, Spotify, or by visiting our website linked in the show notes. If you have any questions or comments, you can contact us through our email: cppi@vcu.edu. We appreciate your engagement and look forward to having you join us next month.