San Francisco County OBOT Pilot: Pharmacy Aspects

1. San Francisco CountyOBOT Pilot:Pharmacy Aspects Sharon Kotabe, PharmD Associate Administrator for Pharmaceutical Services Associate Clinical Professor of Pharmacy, UCSF

2. 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

3. Pharmacy Subcommittee Charge “ To develop and recommend a ‘best practices’ model to create medically appropriate and geographically-convenient dispensing of methadone in a PHARMACY-BASED SETTING in San Francisco”

4. 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

5. 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

6. 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

7. Pharmacy Subcommittee Activities • Met with pharmacists engaged in office-based 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

8. 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”

9. 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

10. 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

11. 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

12. ….. 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)

13. 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

14. 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

15. 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

16. 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

17. 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

18. Questions? Sharon Kotabe, PharmD (415) 206-2325 sharon_kotabe@sfdph.org