NDARC Technical Report No. 297 (2008)
The State-Wide Advisory Team (SWAT): Drug Health Streamed Shared Care was established in 2005 by Drug Health Services, Sydney South West Area Health Service and NSW Department of Health for the purpose of mapping, consulting and supporting opioid pharmacotherapy services, including treatment provision at community pharmacies across New South Wales (NSW). Specifically, SWAT had the objective of building capacity within existing specialist and community resources for the management of those with drug and alcohol problems, initially for those with opioid dependence.
This report presents the findings of the NSW Community Pharmacy Practice Survey conducted by SWAT during 2006. This survey was the first of its kind conducted in NSW in that it explored not only practical issues of treatment delivery, but also identified barriers to treatment expansion and problems experienced with both prescribers and clients.
Consultations with Area Health Services (AHS) and the NSW Pharmacy Guild revealed wide variation in the availability of community pharmacy dosing places across metropolitan, regional and rural NSW. Public clinics also varied widely in their practice regarding the transfer of clients from public clinic to community pharmacy dosing. Initial work by the SWAT project (Pharmacy Capacity Survey, SWAT, 2006) identified a large number of unfilled community pharmacy dosing places across NSW. Their under-utilisation in many cases was in part explained by a lack of referred clients.
After discussion with NSW Health and the NSW Pharmacy Guild, it was decided to undertake a study to explore factors that would encourage pharmacies to take on more clients, as well as explore their current work practices (with an emphasis on supervised dosing and medication diversion), including the range and frequency of problems experienced with both clients and prescribers.
A questionnaire was sent to all community pharmacies participating in the NSW Opioid Treatment Program. Responses were received from 407 pharmacies after three mailouts (response rate=69%). Where appropriate, results have been used to develop recommendations for clinical practice. A full list of the recommendations is provided in the report attached above.
Pharmacy client capacity and activity
Participating community pharmacies had been providing opioid treatment for a mean of 8.87 years, with 31% participating in the program for five years or less. The mean number of clients receiving treatment at each pharmacy was 13.61. Eighty-nine percent of clients at the community pharmacies were on methadone treatment. The mean number of methadone clients was 12.37; the mean number of buprenorphine clients was 2.6. Almost every pharmacy provided methadone (98%). Ninety-one percent provided Methadone Syrup®, 35% provided Biodone Forte®, and 29% provided both formulations. Fifty-nine percent of pharmacies provided buprenorphine and 5% provided buprenorphine-naloxone. Overall, 53% of pharmacies reported providing injecting equipment, with 39% reporting participation in the Pharmacy Guild Needle and Syringe Program (NSP), and 42% reporting selling injecting equipment to injecting drug users (IDU). Eighty percent of pharmacies reported providing access to a Home Medicines Review (HMR) service.
More than half of the pharmacies (59%) reported that they had current vacancies for dosing additional clients. The mean number of current vacancies reported at pharmacies with current vacancies was 7.95 (range: 1-48). There were a total of 1,907 vacancies reported by the 407 participating pharmacies. Extrapolating this data to all community pharmacies providing dosing in NSW suggested that there are approximately 2,800 unfilled dosing places across NSW. Of note, 5% of pharmacies providing methadone and 19% of pharmacies providing buprenorphine reported having no clients currently on that medication type.
The factors that pharmacies reported would provide them with the strongest encouragement to dose additional clients on opioid treatment were: ‘increased confidence that referred clients are stable’; ‘ability to return unstable clients to a public clinic immediately’; and ‘increased financial return per client’.
Almost all pharmacies provided takeaway doses of methadone. Thirty-seven percent of pharmacies dispensed methadone takeaways within current NSW guidelines: maximum of two consecutive takeaways and no more than four takeaways per week (NSW Department of Health, 2006). The remaining 63% of pharmacies dispensed methadone takeaways to at least some clients outside of these guidelines. Thirty-six percent provided a maximum three consecutive takeaways, and 27% provided four or more consecutive takeaways. Subsequent analysis suggested that remoteness and difficulty of access to the pharmacy were not major contributing factors associated with these pharmacies dispensing takeaway methadone doses outside of NSW guidelines.
Dispensing fees, credit and provision of buprenorphine-naloxone
For methadone, the majority of pharmacies (92%) charged a flat weekly dispensing fee (mean=$31.90) regardless of the number of takeaway doses provided. For buprenorphine, 75% of pharmacies charged a flat weekly dispensing fee regardless of the dosing schedule (mean=$31.00). The 25% of pharmacies not charging a flat fee for buprenorphine charged a mean weekly fee of $34.81 to clients on daily dosing, $20.50 to clients on alternate day dosing, and $15.68 to clients on thrice weekly dosing. Intended dispensing fees for buprenorphine-naloxone suggested that most pharmacies would not be offering a reduction in dispensing fees when a script indicates that no supervised doses are to be provided. A reduction in dispensing fees for buprenorphine-naloxone was only seen for clients in receipt of fortnightly takeaways and no supervised doses (mean=$38.37 per fortnight).
Seventy-one percent of pharmacies reported that they provided credit to clients, with approximately one-quarter of pharmacies stating they currently had clients in debt. The proposed termination of the Pharmacy Incentive Scheme by NSW Health (which provides $100 every six months per client for up to a maximum of 20 clients) may lead to some community pharmacies increasing their dispensing fees to compensate for any shortfall in remuneration. The impact upon existing community pharmacy clients and the ability to transfer stable public clinic clients to community pharmacy dosing may be significant should there be any increase in dispensing fees charged.
Refusal to dose and termination of treatment
Overall, 74% of pharmacies had refused to dose a client for any reason in the preceding 12 months, and 32% had refused to dose a client for any reason in the preceding month. The most common reasons for termination were: expired prescription; missing three or more doses; accumulated debt; intoxication; and aggression. The vast majority of pharmacies indicated that they always notified the prescriber/public clinic if a dose had been refused. Almost half the pharmacies (47%) had terminated a client’s treatment in the preceding 12 months, and 11% had terminated a client’s treatment in the preceding month. Based on available information, it is estimated that between 240 and 820 clients had their treatment terminated at the community pharmacies surveyed in the preceding 12-month period. The most common reasons for termination were client behaviour and non-payment of dispensing fees.
Administration and supervision of buprenorphine
The most commonly reported preparation of buprenorphine administered was tablets broken into two to six pieces, reported by 50% of pharmacies. Whole tablets were most commonly administered at 32% of pharmacies, and crushed tablets at 14% of pharmacies. There was wide variation between pharmacies in the level of supervision provided during buprenorphine dosing, which appears to reflect a variation in the perceived need for supervision of different clients.
Diversion of methadone and buprenorphine
Among pharmacies providing methadone, 37% had seen a client divert or attempt to divert a supervised methadone dose in the preceding 12 months, and 9% in the preceding month. Twenty-nine percent of pharmacies providing buprenorphine had seen a client divert or attempt to divert a supervised buprenorphine dose in the preceding 12 months, and 7% in the preceding month. There was a demonstrable lack of consistency between different pharmacists over what behaviours were considered to represent buprenorphine diversion.
Problems with prescribers
The most commonly reported problems experienced by community pharmacists in both the preceding 12 months and preceding month were difficulty contacting prescribing doctors, followed by pharmacy concerns over the prescribing of takeaway doses for clients considered unstable by the pharmacist.