OAT-Practice Directive

Practice Directive: Opioid Agonist Treatment (OAT)

Overview

This document outlines the Opioid Agonist Treatment (OAT) policy for pharmacy professionals, addressing the standards and guidelines for providing care to patients with Opioid Use Disorder (OUD). Approved on February 14, 2022, and identified by policy number GM-PP-OAT-01, this directive supersedes previous protocols, particularly the Methadone Practice Directive of 2012, reflecting contemporary practices and legislative changes.

Authority and Approval

• Authority Derivation: Council

• Original Approval: February 14, 2022

• Policy Number: GM-PP-OAT-01

This policy document can be accessed electronically at www.nbpharmacists.ca to ensure that practitioners are referencing the most current information.

Table of Contents

1. Preface

2. Acknowledgements

3. Introduction

4. Practice Directive

   • Deciding to Offer OAT Services

   • Preparing for Provision of OAT Services

   • Providing OAT

   • Transitions of Care

5. Glossary

6. References

7. Appendix A and B

Preface

The OAT Practice Directive establishes standards for pharmacy professionals to support the appropriate and safe use of opioid treatments for OUD. Key principles include the necessity of treating patients with respect and dignity, aligning practice with harm reduction strategies, and safeguarding against drug diversion. This directive aims to prevent outdated guidance and ensure that pharmacy professionals can meet patient needs effectively.

Acknowledgements

The directive was developed with contributions from various practitioners and organizations:

• Ellen Boyd, Pharmacist

• Bradley Adams, Pharmacist

• Amy Bain, Pharmacist

• Lyndsay Torunski, Pharmacist (Student)Organizations recognized include the Centre for Addiction and Mental Health (CAMH) and New Brunswick’s Coroner Services.

Introduction

Pharmacy professionals are expected to adhere to relevant provincial and federal laws while providing OAT services, which involves the prescribing of narcotics such as buprenorphine-naloxone and methadone. The directive elaborates on the risks associated with different opioid treatments, emphasizing the importance of patient safety and proactive risk management measures. New therapeutic options, such as injectable hydromorphone (iOAT), require specific attention due to their potential for diversion and patient risk.

Providing OAT Services

1. Deciding to Offer OAT Services

• Collaboration: Decisions to offer OAT should be made collaboratively within the pharmacy team. Each team member should understand their roles and responsibilities in care provision for OUD patients.

• Pharmacy Team Roles:

  • Pharmacy Technicians: Assist in processing prescriptions and monitoring compliance.

    • follow-up monitoring of patients for compliance with oral/buccal administration

    • provide technical support as such to Model Standards of Practice for Pharmacists and Pharmacy Technicians in Canada.

  • Pharmacists: Establish therapeutic relationships, prescribe medications, and conduct patient assessments.

  • Pharmacy Managers: Oversee service provision and ensure adherence to quality management protocols.

• Applying the Code of Ethics to the Provision of OAT

  • Pharmacy professionals have a responsibility to ensure public safety and well-being through the provision of Opioid Agonist Treatment (OAT). They must provide safe and effective care, guided by the four bioethical principles.

    1. beneficence- Pharmacy professionals must balance patients' desire to access care within their community with the ability to provide safe and effective Opioid Agonist Treatment (OAT). If resources do not allow for safe care, OAT services should be deferred, and patients must be referred to other providers

    2. non-maleficence- Pharmacists may assess that administering OAT poses risks to patients, leading to decisions to delay treatment or restrict take-home doses. the principle of non-maleficence (avoiding harm) must take priority.

    3. respect for persons- requires establishing a supportive and non-judgmental culture within the pharmacy. Pharmacy professionals must employ a harm reduction approach in caring for patients with OUD at all stages of their journey.

    4. justice- requires pharmacy professionals facilitate equitable access to services regardless of patient socioeconomic strata or geographic location.

2. Preparing for Provision of OAT Services

• Education and Training: Continuous professional development is required for pharmacy professionals involved in OAT services. Mandatory educational courses are outlined in Appendix B to ensure competency in managing patients with OUD. Pharmacy practitioners must be competent in dealing with opioid overdose and the use of naloxone

• Resources and Equipment: Pharmacy teams must ensure access to current guidelines and maintain equipment standards according to quality management requirements.

  • Measuring devices for methadone must have an error rate of no more than 0.1mL. Graduated cylinders are not acceptable; instead, calibrated oral syringes or manual/electronic pumps should be used

• Physical Environment: Patients requiring daily observed dosing must see a pharmacist daily. Pharmacy managers should balance patient access with pharmacy viability. In communities without seven-day pharmacy services, accommodations may be made for those not suitable for take-home doses, such as allowing limited access for daily assessments or coordinating with another pharmacy for observed dosing.

• Documentation: Pharmacy managers must create or adapt forms for documenting clinical activities and dispensing processes to establish expectations in the patient-pharmacy relationship.

  • Pharmacists and pharmacy technicians are required to record each step in dispensing Opioid Agonist Treatment (OAT), which involves stricter documentation due to potential dilution and the risk of drug diversion.

  • Follow-up documentation for patient observed dosing and patient assessments must also be recorded. Although no prior authorization from the College is necessary for OAT, pharmacy managers must notify the College of any OAT services provided, with this information made publicly accessible for patient assistance.

• Quality Management Program (QMP): Implementation of a robust QMP is critical for safety and adherence to standards in OAT.

3. Providing OAT

• Prescription Standards and Requirements: Adhere to federal and provincial regulations on controlled substances. Assure that prescriptions include necessary information regarding dosing and administration. Pharmacists delivering injectable hydromorphone (iOAT) services must have the pharmacy manager (or delegate) and one additional pharmacist complete a course from Appendix B to provide this service.

  • Methadone, SROM and iOAT: In addition, prescriptions must include start and stop dates and indicate observed dosing

  • Methadone: Prescriptions for methadone must include details regarding take-home dosing schedules.

  • CAMH: Pharmacist’s Guide contains prescription examples that conform to legislation and best practice
    

• Patient Assessment: Conduct comprehensive evaluations to ensure safe administration of OAT, including monitoring compliance with observed dosing.

Quality Management Program

3.4 - OAT Quality Management Program (QMP)

Effective quality management is vital in minimizing medication incidents and enhancing patient safety. The directive mandates documentation and reporting of any medication errors or incidents to ensure continuous quality improvement and adherence to established safety standards.

Glossary

Key definitions utilized throughout this practice directive include:

• OAT (Opioid Agonist Treatment): The use of opioid agents in a structured program to assist patients with OUD.

• Observed Dosing: A protocol where healthcare professionals monitor the administration of OAT medication to ensure proper ingestion.

References

The directive provides a comprehensive list of references that support its contents, including guidelines from CAMH and other relevant health authorities. Appendices A and B contain additional resources related to OAT practices and evaluations for pharmacy professionals.

Conclusion

This Practice Directive serves as a critical framework for pharmacy professionals involved in opioid treatment, emphasizing safe practices, ethical considerations, and the importance of quality management in patient care.