Report Pharmacy Access Issues Question Title * 1. In what city is the pharmacy located? Question Title * 2. What state is the pharmacy located in? Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Question Title * 3. Are you a member of ASAM? Yes No I don't know. Question Title * 4. What is the name of the pharmacy? Question Title * 5. What medication did you prescribe? Buprenorphine/naloxone film Buprenorphine/naloxone tablet Buprenorphine mono-product Naltrexone (oral) Disulfiram Acomprosate Varenicline Multiple, including buprenorphine mono-product Multiple, not including buprenorphine mono-product Other (please specify) Next