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Pharmacy environment and client perspectives 

From: Part 2: "Recommendations and discussion," Methadone Maintenance Treatment: Recommendations for Enhancing Pharmacy Services (© 2009 CAMH)

A non-judgemental and non-stigmatising attitude towards this area of health care is an essential starting point for quality care.

— Sheridan and Strang (2003, p. 1)

The pharmacy environment includes everything from the location of the pharmacy and the physical layout of the premises to the attitudes and services provided. All of these factors may influence a client’s decision to attend a particular pharmacy and may have an impact on his or her satisfaction with treatment. The panel recognizes that in some communities, especially non-urban or remote areas of Ontario, there may be few options or even only one. Studies have found that MMT clients choose a pharmacy for the same reasons as other consumers, for example, because the pharmacy’s location is convenient, close to work, school or home (Anstice et al., 2009; Luger et al., 2000; Matheson, 2003). These studies also identified longer operating hours, which allow clients to carry on with activities of daily living such as parenting or working, to be an important factor. However, in other respects MMT clients’ needs are unique. Because they take their medication daily in the pharmacy under observation, they have special requirements beyond the normal courtesy any pharmacy customer might expect, and they desire treatment that is discreet, quick and non-judgmental (Matheson, 2003).

Privacy

From the client consultation interviews

Clients talk about privacy

“We need more privacy when drinking meds or talking about an issue.”

“There should be a lot more privacy, to fully separate areas for discussion and pickup. I don’t want everybody to hear.”

“They have a side room but they don’t use it. It doesn’t bother me but for some people, it might bother them.”

The panel recommends that:

4. Pharmacy managers/owners offering MMT services ensure that the pharmacy has a suitable private area for respectful dosing and confidential discussion with clients. [III]

Pharmacies should be a safe place for methadone clients, other patients of the pharmacy and pharmacy staff. In this context “safety” means an environment in which people can feel secure not only physically but also free from social or emotional threats such as loss of privacy or stigma-tization. For MMT clients, a private space in which to take their dose of methadone or to consult the pharmacist is an important issue. Indeed, privacy and confidentiality are important for every patient, and many pharmacies are responding by creating a private area where clients may consult with the pharmacist about treatment or services in confidence.

Some MMT clients feel strongly about the need for privacy in the pharmacy, while others may be comfortable as long as they are treated with respect and discretion by the pharmacist. In a qualitative study, Anstice et al. (2009) interviewed MMT clients from four methadone programs in Ontario. Their findings confirmed that clients valued discreet service and privacy in the pharmacy for their observed doses.

In Luger et al.’s survey of methadone clients in London, England (2000), 60 per cent of the respondents said they did not feel comfortable drinking methadone in the pharmacy because they felt embarrassed and concerned that their conversations with the pharmacist could be overhead by other customers and staff. In response, some pharmacists asked clients to come at a time when the pharmacy was likely to be less busy. Some offered dispensing at a quiet corner of the store. The ability of many pharmacies to respond to this concern was limited because their premises did not offer a private area.

Lea et al. (2008) surveyed 508 clients in New South Wales, Australia, regarding their satisfaction with opioid treatment services provided by their pharmacy. Clients reported a high level of service in many areas, giving their pharmacies a mean rating above eight out of 10 on a number of aspects, with 10 indicating best service. These aspects included:

  • safety
  • staff quality
  • confidentiality
  • fair and consistent service
  • opening and closing hours.

However, clients reported less satisfaction with the privacy available to them during supervised dosing. In spite of the clients’ overall positive scoring of their pharmacies’ services, 25 per cent felt that they were not treated the same as other customers and 35 per cent reported having to wait longer than other customers and sometimes being made to wait while others were served first.

Pharmacists could discuss clients’ preferences with them so as to increase the clients’ comfort and to avoid embarrassment or misunderstandings. If no private area exists, pharmacists can discuss with the client his or her feelings about taking the dose in view of others. If clients are not comfortable taking the dose in view of others, pharmacists and clients may discuss the client arranging to come during a time of day when the pharmacy is quiet, rather than at peak hours; others may arrange that the client wait until other customers are out of view before taking the dose. For some clients there may be additional reasons to choose a pharmacy where they have less likelihood of seeing other MMT clients with whom they may have used drugs in the past. In the study by Anstice et al. (2009) of MMT clients in Ontario, some clients preferred to avoid dispensing sites where they could meet other MMT clients and the triggers to use drugs that resulted from being with others who were still using or dealing in drugs.

Attitudes and behaviours

Most clients want to be treated like any other patient of the pharmacy. Neale (1998) interviewed 124 clients in Scotland about their thoughts on pharmacy providers. The way that pharmacy staff behaved toward the client was considered an important part of the service delivered; in this study, female clients more frequently identified the importance of this behaviour. A good pharmacy service was described as one in which the clients felt they were treated like any other customer, where the service was friendly, discreet and confidential. In general, clients disliked intrusive questions. Clients valued ordinary interaction such as chatting about day-to-day issues and developing a personal rapport with the pharmacist and pharmacy staff. Clients in this survey preferred community pharmacies over centralized clinics. Although these clients considered their prescribers more important than the pharmacists in their treatment, they rated the physicians as less helpful.

From the client consultation interviews

Clients talk about pharmacy experiences

“Be more understanding about people on methadone. [At the pharmacy] they put other customers first. Sometimes I’ve waited all day to have my methadone prescription filled. By 3:00 p.m. I’m feeling rough . . . when I dropped it off at 9:00 a.m.”

“Some staff aren’t very nice. You get the feeling that they say ‘Here comes another junkie.’ You can feel when someone has an attitude.”

“I’ve overheard staff talking about other clients and laughing at them. It was very inappropriate.”

“I would be at the front of the line at the pharmacy and then often people would come after me and get served first. I told them I didn’t like it and we worked it out. It’s been better for the last month.”

“The pharmacy staff was very helpful when I started out. They were very encouraging. I didn’t feel well at first but they helped me hang in there.”
“They are really friendly; they phone the doctor for me about my other medication.”

 “Being in line for pharmacy isn’t good. People fight physically, deal drugs, talk about drugs. You see bad things when you are trying to get sober. It’s easy for me to get drugs here. The scene here can be very intense. It’s not a safe place, especially for children. Mothers bring children here.”

Pharmacies have other patients (not on MMT) who also have treatment needs that should not be affected by their pharmacy dispensing methadone. Lawrie et al. (2004) interviewed 80 customers (of 10 stores providing MMT services) in Glasgow to explore their attitudes about using a pharmacy that offers MMT services. One of the findings was that most were sympathetic toward drug misusers and had a fairly positive attitude toward methadone maintenance treatment. Although much of the customers’ knowledge about MMT was acquired from media reports and many of the customers did not have a clear understanding of why people were on MMT, most recognized that MMT clients should have some privacy in the pharmacy for taking their doses. This survey did not find that customers were deterred by a pharmacy’s dispensing methadone to MMT clients; in fact, some of the customers were not even aware that their pharmacy offered MMT services.

The panel recommends that:

5. Pharmacy managers/owners ensure that all staff (professional and non-professional) employ the same respectful, professional approaches and attitudes toward MMT clients as they would use toward any other client of the pharmacy. [III]

Pharmacy staff should treat all clients of the pharmacy in a positive, respectful, non-judgmental and professional manner. The manner in which a pharmacist interacts with an MMT client often affects the way the client deals with the pharmacist and staff (Matheson, Bond & Hickey, 1999).

Give respect to get respect

When interactions are positive and professional and clients receive the same respectful treatment as other customers, pharmacists can develop a rapport with their MMT clients.

When interactions are positive and professional, pharmacists can develop a rapport with their MMT clients (Matheson, 2003). The effect of the pharmacist and staff of the pharmacy on the MMT client can be considerable. Many clients already feel stigmatized by society and in some encounters with other health care providers involved in their treatment. Because the first visit to the pharmacy in MMT involves a lengthy period of time for establishing identification, completing the pharmacist-client agreement, discussing routines and so on, many clients may be frustrated with the time it takes to get their methadone dose. When pharmacists acknowledge this issue and proceed in a non-judgmental, friendly manner, they convey respect for the client (Matheson, 2003).

In surveys about pharmacists’ attitudes and practices, there was an association between positive attitude scores and professional practice activities such as preparing methadone doses in advance and treating MMT clients the same as other customers. Pharmacists who had taken training in opioid- dependence treatment had higher attitude scores than those who had not (Matheson, Bond & Mollison, 1999; Matheson et al., 2002; Sheridan & Barber, 1997; Sheridan et al., 2007).

From the client consultation interviews

Clients report on pharmacy care experiences

  • 80% reported that the lack of privacy (taking their medication or talking to the pharmacist in a public rather than private space) was the most challenging issue for them at pharmacies.
  • 17% had access to a private area in the pharmacy for discussion with the pharmacist.
  • 22% had access to a private area for taking their methadone dose.
  • 58% had a written agreement with their pharmacist.
  • 90% reported that a caring attitude and courteous, non-judgmental staff were the most positive aspects of dealing with the pharmacies where they drank their methadone.
  • Nearly 30% reported rude or judgmental staff during pharmacy service.
  • 26% had an educational session with the pharmacist before treatment began.

The panel recommends that:

6. The pharmacy have a treatment agreement with every client who is beginning methadone maintenance treatment at the pharmacy. [IV]

To ensure safety of clients and pharmacy staff, outlining each party’s expectations of behaviour in the pharmacy is an important component of the treatment agreement. When done early in treatment, it encourages mutual respect between clients and staff and provides agreed boundaries. Pharmacists should spend time verbally reviewing the written agreement and clarifying any issues with the client. When the pharmacist receives advance notice from the prescriber/MMT team about a new client starting treatment at the pharmacy, he or she can set aside appropriate time for this review with the client.

The agreement can outline what the client can expect from the pharmacy and what the pharmacy can expect from the client. It can outline appropriate behaviour in the pharmacy so that the pharmacy is a safe place for the client, other clients and staff. To avoid the development of problematic behaviours, the treatment agreement can provide information such as, but not limited to, what the client can expect if doses are missed or if the client arrives at the pharmacy intoxicated. The treatment agreement could also address issues of loitering or drug dealing in the vicinity of the pharmacy.

The panel recommends that:

7. Pharmacy managers/owners inform relief pharmacists or new pharmacists that the practice site offers MMT services so that the pharmacists can ensure they are adequately prepared to offer this service. [IV]

Pharmacy managers should as much as possible hire new or relief staff that have taken the appropriate training (Sutcliffe, 2009). The appropriate MMT reference materials and written pharmacy store policies should be readily available to new or relief pharmacists starting at the pharmacy.

The panel recommends that:

8. Pharmacy managers ensure that there is a good system for communication among pharmacists within their practice environment regarding clients’ treatment. [IV]

It should be clear to a pharmacist starting a shift at the pharmacy if there are any outstanding issues or clinical concerns regarding a client’s methadone treatment. For example, some pharmacies use a communication book to highlight unresolved concerns and to prepare pharmacists coming on to a shift.

In Methadone Maintenance Treatment: Recommendations for Enhancing Pharmacy Services

Acknowledgments

Part I: Background

Part II: Recommendations and discussion

References

Resources

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