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 geographically- convenient 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 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

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 Suboxone R

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)