Providing Care for OAT and iOAT Patients Over The Winter Holidays

PROVIDING CARE FOR OAT and iOAT PATIENTS OVER THE WINTER HOLIDAYS

With the winter holidays approaching and many pharmacies adopting holiday hours, as well as adjusting to the challenges posed by the ongoing COVID-19 pandemic, it is important for pharmacists to ensure that they are able to accommodate the dosing schedules of patients receiving Opioid Agonist Treatment (OAT).

The opioid overdose crisis continues to have a major impact on the province, with 1,386 illicit drug deaths recorded as of November 25 this year. Since the COVID-19 pandemic was declared a public health emergency in March 2020, the BC Coroners Service has detected a sustained increase of illicit drug toxicity deaths, recording eight consecutive months with over 100 overdose deaths, five of which saw more than 160 deaths.

Following the Provincial Guidelines for the Clinical Management of Opioid Use Disorder, Opioid Agonist Treatment - including buprenorphine/naloxone, methadone, and slow-release oral morphine - is provided to many patients at pharmacies across BC.

Many of these patients require supervised or witnessed dosing, meaning that their prescription requires them to visit their pharmacy in order to both obtain and ingest their daily dose of OAT therapy under the supervision of a pharmacist.

BCCSU – Interim Clinical Guidance

Risk Mitigation in the Context of Dual Public Health Emergencies

BC is in a unique situation, with the COVID-19 crisis compounding the existing opioid overdose crisis. At the intersection of these dual public health emergencies are a number of risks, including the risk for overdose and other harms related to a toxic drug supply, the risk of infection among those with underlying health conditions and those who face social marginalization, and risks due to withdrawal for those who must self-isolate or quarantine to prevent the spread of COVID-19.

This protocol, developed by the BCCSU, is intended to provide clinical guidance to healthcare providers to support patients to mitigate these competing priorities and compounded risks and enable social distancing and self-isolation measures, where possible, to reduce and prevent the spread of COVID-19.

Interim Clinical Guidance – Risk Mitigation in the Context of Dual Public Health Emergencies (PDF)

BCCSU 24/7 Addiction Medicine Support Line for Pharmacists

A 24/7 support line for clinicians and pharmacists is available through the BCCSU, offering live, in-the-moment addiction medicine support while they are meeting with patients across British Columbia.

See bccsu.ca/24-7 for additional information including contact information.

Providing Care to oat patients

During the winter holidays, contacting prescribers and other health practitioners can be challenging. In situations where a patient’s practitioner cannot be reached to clarify concerns or provide direction, the College expects registrants to use their professional judgment to act in the best interests of their patients and to ensure patients receive safe and accessible treatment.

Registrants should document their intervention, including steps they took to contact the patient’s prescriber, their therapeutic rationale, and plan for follow-up.

Registrants should also communicate their treatment interventions to the patient’s practitioners as soon as possible and retain proof of this communication.

FAQ: Is it acceptable for prescribers to issue blanket authorizations for carries “on holidays” or “when the pharmacy is closed” for OAT prescriptions?

Prescription authorizations must always be patient-specific, taking into consideration the needs of the individual patient. As such, blanket authorizations applied to more than one patient are not acceptable. The indicated directions on any prescription must always be expressed in a manner that makes the intent of the prescriber clear. Instructions that authorize carries “on holidays” or “when the pharmacy is closed” are ambiguous as they lack the specificity required to determine the number of days the patient is allowed to carry. For instance, if a pharmacy is closed for three days per week, the patient would receive three carries. Conversely, if a pharmacy is closed for one day per week, the patient would only receive one carry. A prescriber must ensure that they are providing directions that clearly indicate how many days the patient is authorized to carry.

OAT and Holiday Operating Hours

Under Professional Practice Policy-66: Opioid Agonist Treatment and the Policy Guides for Methadone, Buprenorphine/Naloxone, and Slow Release Oral Morphine Maintenance Treatment, a pharmacy’s hours of service must be consistent with the dosing requirements of the patient.

This means Pharmacists MUST check the start and end dates of a prescription, together with any dosing directions in consultation with the patient to ensure that the patient’s specific needs can be accommodated at their pharmacy BEFORE accepting the prescription.

For example, a pharmacist would need to ensure that the authorization for dispensing does not end on a day when the patient will not be able to see a prescriber for a new prescription (such as weekends and holidays). They would also need to review the dosing schedule included in the prescription directions (daily witnessed ingestion, take-home doses), including the specific dates and days of the week for each witnessed dose or take-home doses, to confirm that the pharmacy operating hours match the dosing schedule.

While a pharmacist may request a prescriber to write a prescription for carries to accommodate the holiday schedule, they must consider the patient’s needs first. For vulnerable patients, any changes to their normal schedule can be disruptive to their care and may leave them without needed support and monitoring.

If a pharmacy cannot accommodate a patient’s dosing schedule under their holiday operating hours, the pharmacist may refer the patient to another pharmacy or they may consider collaborating with their patients to arrange alternate opening hours on a holiday to ensure that patients receive their prescribed dose.

Note: Methadone, Buprenorphine/naloxone, and Slow release oral morphine prescriptions can only be accepted when written using an original Controlled Prescription Program form. When accepting a prescription, the pharmacist must ensure that the Controlled Prescription Program Form is completed by the prescriber as outlined in the Controlled Prescription Program.

Temporary Authorizations for the Delivery of Opioid Agonist Treatment by Non-Pharmacists

During the ongoing response to COVID-19, the College recognizes the importance of maintaining British Columbians’ access to controlled substances for medical treatments, including OAT.

Within the context of dual health emergencies, there has been an increased demand for OAT delivery services, especially for patients who must self-isolate due to COVID-19. BC’s pharmacy professionals must ensure that they are maintaining adequate continuity of care by providing these services safely and in a way that prevents the spread of COVID-19.

FAQ: We are receiving requests for delivery of OAT from patients self-isolating. What are my responsibilities? How do we prevent transmission?

As such, temporary amendments to Professional Practice Policy-71: Delivery of Opioid Agonist Treatment (PPP-71) allow pharmacists to authorize regulated health professionals with the appropriate scope and competence, as well as pharmacy employees, to deliver OAT, have been in effect since April 7, 2020.

The temporary amendments allowing pharmacists to authorize pharmacy employees to deliver OAT on a pharmacist’s behalf should be reserved for exceptional circumstances where it is not possible for a pharmacist or other regulated health professional to deliver the OAT drug.

Learn More: NEWS - Temporary Authorizations for the Delivery of Opioid Agonist Treatment by Non-Pharmacists

Temporary Authorization for Controlled Drugs and Substances

On March 19, 2020, Health Canada issued a temporary exemption for prescriptions of controlled substances under the Controlled Drugs and Substances Act and its Regulations, in order to support access to controlled substances when needed for medical treatments.

Controlled Drugs and Substances Act - Subsection 56(1) Class Exemption for Patients, Practitioners and Pharmacists Prescribing and Providing Controlled Substances in Canada During the Coronavirus Pandemic.

Frequently Asked Questions (Health Canada)

This temporary exemption:

Permits pharmacists to extend and renew prescriptions
Permits pharmacists to transfer prescriptions to other pharmacists;
Permits practitioners to verbally prescribe prescriptions with controlled substances; and
Allows an individual to deliver controlled substances to patients (at their homes or an alternate location).

The College Board has amended both the Pharmacy Operations and Drug Scheduling Act (PODSA) Bylaws, as well as the Community Pharmacy Standards of Practice made under the Health Professions Act to align with this exemption.

Providing Care for OAT and iOAT Patients Over The Winter Holidays Nov. 27, 2020