1. San Francisco County OBOT 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