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Summary of recommendations 

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

Please see Table 2 for an explanation of the levels of evidence used to classify recommendations.

Interprofessional collaboration and communication

These recommendations address the second and third questions posed by the panel at the beginning of the development process:

  • What is required in the pharmacy practice environment to ensure optimal MMT services?
  • What can MMT clients expect from the care they receive from pharmacists and pharmacy practice sites?

The panel recommends that:

1. MMT programs and methadone prescribers recognize the role of pharmacists in collaborative care and this role’s impact on their mutual clients’ treatment. Specifically, the College of Physicians and Surgeons of Ontario should emphasize in its Methadone Maintenance Guidelines the importance of collaboration and regular communication with the pharmacist and their impact on patient care and safety. [IV]

2. Prescribing physicians and MMT programs establish and then maintain communication with community pharmacists regarding client treatment plans and progress. [IV] In particular, the panel recommends that:

a. At the outset of MMT, the prescribing physician initiate contact and communication with the pharmacist who will be providing care for their mutual clients. [IV]

b. The physician and the pharmacist who will provide MMT client care agree upon suitable ways to share information with each other regarding their clients’ progress in treatment and any adjustments needed to treatment plans. [IV]

3. Pharmacists in different treatment settings communicate and collaborate effectively about their mutual MMT clients during transitions in care, to increase client safety. [IV]

Pharmacy environment and client perspectives

These recommendations address the first three questions posed by the panel at the beginning of the development process:

  • What knowledge and skills and attitudes do pharmacists need to provide optimal MMT services safely to opioid-dependent clients?
  • What is required in the pharmacy practice environment to ensure optimal MMT services?
  • What can MMT clients expect from the care they receive from pharmacists and pharmacy practice sites?

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]

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]

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

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]

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

Accessibility of MMT pharmacy services

These recommendations address the fourth question posed by the panel at the beginning of the development process:

  • What is needed to ensure that MMT pharmacy services are available across Ontario?

The panel recommends that:

9. The Ontario College of Pharmacists, in conjunction with a professional pharmacy organization or CAMH, develop a mechanism for tracking pharmacies providing MMT services throughout the province, with the objective of identifying areas where there is little or no access to service. [IV]

10. Researchers survey pharmacists, particularly those in under-serviced regions, for their views and concerns about participating or not participating in MMT provision, with the goal of finding ways to encourage pharmacies throughout Ontario to provide MMT services and to support those currently providing MMT services. [III]

11. Researchers study the efficacy of offering incentives to pharmacists in remote or under-serviced areas to begin a methadone practice. [III]

12. Researchers work with the Ontario Pharmacy Council or a professional pharmacy organization to investigate fair and equitable payment models for MMT pharmacy services. [III]

13. The Local Health Integration Networks and addiction and mental health networks in under-serviced regions encourage and support initiatives to increase MMT availability. Pharmacists in these areas can be invited to participate with other local health professionals, public health service providers and local hospitals to explore ways in which their communities could provide MMT dispensing and pharmacy services to people with opioid dependence. [IV]

14. Hospitals and other institutions (e.g., jails and prisons, long-term care facilities) ensure that they are able to meet the medication needs of persons maintained on methadone who are admitted to their facilities, and specifically that:

a. Pharmacists in these environments have the appropriate knowledge and skills to ensure safe provision of methadone services. [IV]

b. Pharmacists communicate and collaborate intraprofessionally during their mutual clients’ transitions into or out of institutions to ensure they have safe and uninterrupted access to methadone treatment. [IV]

c. These institutions provide access, monitoring and pharmacy care services for their clients on methadone as they would for any other client. [IV]

Pharmacist education in MMT

These recommendations address the first and fourth questions posed by the panel at the beginning of the development process:

  • What knowledge and skills and attitudes do pharmacists need to provide optimal MMT services safely to opioid-dependent clients?
  • What is needed to ensure that MMT pharmacy services are available across Ontario?

The panel recommends that:

15. Pharmacy managers/owners, hospital pharmacy directors and the Ontario College of Pharmacists support and encourage pharmacists providing methadone services to have education in and/or demonstrate knowledge and skills in core competency areas. These areas include:

a. Substance use disorders, including opioid dependence. [IV]

b. The varied models of substance abuse treatment, including harm reduction and its implications for pharmacy. [IV]

c. The impact of attitudes and stigma on client care. [III]

d. Methadone maintenance treatment clinical guidelines and their rationale, particularly with respect to practices to protect client safety, including:

  • assessing initial and increased doses for appropriateness
  • assessing methadone-dosing histories (for missed doses and irregularities in pattern of pickup) before dispensing a dose of methadone to a client
  • ensuring the safe provision of “carries” (take-home doses) to clients
  • dealing with intoxicated clients, including understanding the risks of polysubstance abuse. [IV]

16. All pharmacy students receive education on substance abuse, including opioid dependence, its treatment and practical intervention strategies, in their undergraduate curriculum. [IV]

17. Professional organizations, addiction and mental health agencies and pharmacists’ employers promote the development of, and provide encouragement for all practising pharmacists to participate in, educational events on substance abuse and opioid dependence, including the growing problem of prescription opioid abuse. [III]

18. The Ontario College of Pharmacists revise the current requirements for pharmacies providing MMT services to mandate earlier training to promote safety. The designated manager and one pharmacist must complete the training within six months of starting to dispense methadone. [IV]

19. CAMH or another approved provider of methadone training develop a brief electronic document (e.g., one page) outlining the key safety features of providing MMT services that can be made available for immediate use by pharmacies initiating MMT services. [IV]

20. CAMH produce an electronic version of its most recent pharmacist’s guide to methadone maintenance treatment that can be purchased online and downloaded immediately so that pharmacies initiating MMT services can access it without delay. [IV]

21. CAMH make the online component of its Opioid Dependence Treatment Course available immediately upon enrolment to pharmacists new to providing MMT services, with the stipulation that these pharmacists attend the workshop component within six months of beginning the course. [IV]

22. CAMH or another approved provider of methadone training monitor and respond to waiting lists for training programs by, for example, offering the training more frequently or by exploring other delivery methods, such as webinars or video conferencing, to help meet the needs of pharmacists in remote areas. [IV]

23. The Ontario College of Pharmacists and providers of methadone training collaborate on ongoing training requirements based on needs identified during the College’s pharmacy inspection process. [IV]

24. CAMH or another approved provider of methadone education deliver methadone training in a manner consistent with interprofessional education principles. [IV]

25. The Ontario College of Pharmacists and community colleges providing pharmacy technician training develop core competency requirements for regulated pharmacy technicians providing MMT services. [IV]

26. CAMH or another approved provider of methadone education undertake a needs assessment of pharmacists who have participated in the initial MMT training, and then use this information to develop an updated or advanced MMT course for pharmacists. [IV]

27. Professional pharmacy organizations, the Ontario College of Pharmacists, pharmacy managers/owners and hospital pharmacy directors encourage pharmacists to take courses on motivational interviewing, inter-vention strategies to use with difficult patients, and concurrent disorders, to enhance pharmacists’ skills in dealing with opioid-dependent clients. [IV]

28. Drug information service providers ensure that staff is trained on and familiar with common issues in MMT treatment and have a mechanism to refer to experts when necessary. [IV]

29. Professional pharmacy organizations develop a mechanism in conjunction with the Ontario College of Pharmacists to ensure that pharmacists dispensing methadone are informed in a timely fashion of new educational resources available. [IV]

30. Professional pharmacy organizations, CAMH and funding agencies develop a mentorship program to link new methadone service providers with experienced providers. [IV]

31. Professional pharmacy organizations and CAMH promote the CAMH Addiction Clinical Consultation Service to pharmacists providing MMT services. [IV]

Research in MMT pharmacy practice

These recommendations address all four questions posed by the panel at the beginning of the development process:

  • What knowledge and skills and attitudes do pharmacists need to provide optimal MMT services safely to opioid-dependent clients?
  • What is required in the pharmacy practice environment to ensure optimal MMT services?
  • What can MMT clients expect from the care they receive from pharmacists and pharmacy practice sites?
  • What is needed to ensure that MMT pharmacy services are available across Ontario?

In addition to recommendations #10, 11 and 12, the panel recommends that:

32. Scientists in Ontario develop a research program to investigate all aspects of pharmacy practice in MMT, including:

a. the effectiveness of different models of care (including those with pharmacists in community pharmacies and in clinic settings)

b. the impact of pharmacist interventions on client outcomes

c. pharmacoeconomic implications

d. factors that could affect community pharmacy capacity to accommodate MMT clients

e. possible ways to increase access to methadone pharmacy services in remote areas. [IV]

33. Investigators study the impact of educational initiatives on patient outcomes. [IV]

In Methadone Maintenance Treatment: Recommendations for Enhancing Pharmacy Services

Acknowledgments

Part I: Background

Part II: Recommendations and discussion

References

Resources

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