Transcript San Francisco County OBOT Pilot: Pharmacy Considerations

San Francisco County
OBOT Pilot:
Pharmacy Aspects
Sharon Kotabe, PharmD
Associate Administrator for
Pharmaceutical Services
Associate Clinical Professor of
Pharmacy, UCSF
In the beginning……
Pharmacy Subcommittee formed,
November 1999
Members represented
County Health Department
Local School of Pharmacy
State Board of Pharmacy
State Poison Control System
Local chain, independent & hospital pharmacies
Narcotic Treatment Programs (NTPs) and free
clinics
Pharmacy Subcommittee
Charge
“ To develop and recommend a ‘best
practices’ model to create medically
appropriate and geographicallyconvenient dispensing of methadone in
a PHARMACY-BASED SETTING in San
Francisco”
Pharmacy Subcommittee
Activities
Identified barriers to pharmacist
participation in project
Pharmacists not included in “traditional”
maintenance program models and in
California, restricted by law from dispensing
maintenance opiates to known addicts
Negative perceptions & beliefs re: addiction
Reimbursement for time necessary to
provide appropriate services
Pharmacy Subcommittee
Activities
Identified benefits of pharmacist
participation in program
Expertise counseling patients on
medication and drug therapy
Availability of patient’s entire drug profile
for drug-drug interaction and
contraindication monitoring
Increased access to treatment through
local “neighborhood” pharmacies
Pharmacy Subcommittee
Activities
Reviewed State and Federal regulations
for “traditional” narcotic treatment
programs
Reviewed materials training materials
used to educate pharmacy students
about addiction and addiction
pharmacology from various schools of
pharmacy
Pharmacy Subcommittee
Activities
Met with pharmacists engaged in officebased treatment models in other States
Matched zip-codes of clients already in
treatment with pharmacy locations to
target potential dispensing pharmacies
Conducted focus groups with
pharmacists from 10 zip-codes with
highest number of current clients
Focus Group Comments
Support for expanding access to
treatment
Participation perceived as a natural
expansion of professional role and
responsibilities and welcomed challenge
of learning new skills
Suggestions that program start slowly
with fewer initial clients, and for
scheduled “appointment times”
Pharmacy Subcommittee
Recommendations
(February 2001)
Training
Integrate with training for physicians,
counselors and others to foster
collaborative, team-approach to care
Focus on: (1) “mechanics” of maintenance
treatment and, (2) “raising consciousness”
on nature of addiction
Recommendations (continued)…
Create central database for ready
access to relevant client information
and recording dose administration
Allow pharmacies to establish dosing
“appointments” as dictated by workload
Require establishment of dosing areas
separate and private from main
pharmacy counseling windows
Recommendations (continued)…
Provide adequate security
Provide access to “on-call” system to
advise pharmacists dealing with
complex client issues
Pharmacists provide medication
counseling, counselors and physicians
provide drug abuse counseling
Provide adequate remuneration
….. and at last!
First patient enrolled, July 2003
Community pharmacy participation
Corporate vs. individual pharmacist views
Corporate view prevails
County operated pharmacies
Hospital-based outpatient pharmacy
(methadone dispensing)
Mental health clinic pharmacy
(buprenorphine dispensing)
Basic Program Components
All pharmacists involved in the program
undergo extensive training provided by the
California Society of Addiction Medicine
Central database with pertinent client
demographic and clinical information
Pharmacists record observed and take home
dosing in database
Communication and clinical data sharing
through “SOAP” notes format
Basic
Program Components
Program licensure allows exemption from
Board of Pharmacy prescription
requirements
“On-call” OBOT program staff to assist
with problems
Physical modifications were made to
enhance security and dosing area privacy
Program uses methadone tablets (vs.
liquid or diskette), or SuboxoneR
Observations, 1 year later
Establishing dosing “appointments” works!
Estimate of pharmacist time needed for
each observed dosing/take home
dispensing (5 minutes) too low
Regulatory agencies - e.g. DEA, state NTP
licensing agency - complimentary of
pharmacist record keeping, security, and
professional services provided to clients
more observations…...
Rapport between pharmacist and client
quickly and easily established
Pharmacists enjoy client interaction and
expanded responsibilities
Pharmacists initially reluctant to
“volunteer”, later filed labor grievance to
be allowed to participate
Clients prefer dosing and receiving take
home doses in a pharmacy setting
Lessons Learned
Listen to the “experts” - especially those
who actually do the work
Local buy-in may not be enough, engage
corporate decision makers if possible
Initial concerns about major legal and
regulatory obstacles did not materialize
Flexibility, open-mindedness, and patience
are required traits for anyone involved in a
pilot program
Questions?
Sharon Kotabe, PharmD
(415) 206-2325
[email protected]