My time as a kiwi apothecary (part 3): Methadone dispensing

Greetings Drug Topics readers,

My biggest surprise upon starting work as a pharmacist in New Zealand was the fact that some pharmacies are contracted to supply methadone for opioid-dependent individuals. Naturally the location where I work is 1 of those pharmacies, or else I would not be writing this post. As a U.S.-trained pharmacist, I have to admit a certain amount of caution when dispensing methadone. Having worked in a retail setting, I always kept a close eye on any incoming prescriptions, making sure that it was clearly indicated for pain relief only.

The best U.S. pharmacy corollary for opioid replacement therapy is the dispensing of Suboxone. Many times I have seen Suboxone dispensed on a weekly or fortnightly basis while practicing in the United States, likely in an attempt to prevent diversion. In New Zealand, methadone is utilized in a similar fashion to Suboxone. Specialized prescribers are able to write prescriptions for daily doses of methadone for the patient to either consume at the pharmacy or to take away additional days’ doses, depending on the patients history and behavior.

How the program works

To enroll in a methadone program, the patient must contact the local Alcohol and Drug Services group. This group has case workers, nurses, and doctors who monitor the patient, provide counseling and support for the patient, and ultimately determine appropriate dosing and parameters for dispensing opioid replacement therapy. Typically, the Alcohol and Drug Services group will arrange a meeting with potential new patients and the pharmacy, allowing the pharmacy staff to explain any expectations of conduct from individuals in the program. In addition, the pharmacy may request a photograph of the patient for identification purposes, especially if the pharmacy often utilizes locum pharmacists.

A patient visiting the pharmacy must consume that day’s dose of methadone under the direct supervision of the pharmacist to ensure that the dose is not diverted. Pharmacies that dispense methadone in this fashion must have a specially designed private area, much like most modern pharmacies with MTM accommodations.

The dosage form is a solution of 10mg/ml in a sugar-free base, and apparently tastes quite bad, based on the grimaces and grunts of distaste from patients when they take their doses. Most of the patients have a few take-away doses each week. In those situations, they will take that day’s dose in front of the pharmacist and collect any additional take-away doses. The pharmacist will add water to the take-away doses to dilute the concentration in an effort to dissuade possible diversion.

A positive environment

I always try to make small talk with patients when I dispense their daily dose. It may be something as simple as a comment on the weather or an item in the local newspaper. Doing so makes the act of observing another adult take his or her medication a little less awkward, and helps to make the patient a little more comfortable. It may be idealistic, but sometimes I really feel like these brief interactions have a beneficial effect for the patient, providing them with a positive interaction, rather than further stigma.

At our location we have a dry erase board on which we write a motivational slogan for the patients. I found the idea a bit corny at first, but after seeing that many of the patients responded positively to it, I warmed to the concept. It is beneficial to the patients in the program for both their case workers and the pharmacy to provide a positive, non-judgmental environment.

There are many days when I feel like a bartender, mixing up methadone cocktails for the patients. Some of them take their daily dose with no additional water, some with a little, and some with quite a lot. After a few weeks of dispensing, I know exactly how all of them prefer their doses. Sometimes when the mood strikes, I like to put a little English on the medication cup as I give it to the patient. Often I find myself humming the lyrics to "Carmelita" as I do this.

When I first began this job in September 2011, our location had recently contracted to dispense methadone the previous month. We began with 4 patients, but as we are open 7 days a week, soon acquired more. As of this entry, we now have 12 patients. While it is commendable that we are providing a necessary social service to these individuals, there is also a financial incentive for the pharmacy. Because methadone is dispensed on a daily basis, each dose we dispense adds up to an additional dispensing fee for funding.

Questions raised

So does supplying methadone in a community pharmacy setting help improve patient outcomes? In many cases, we are merely substituting 1 addiction for another. Not to sound jaded, but just like in the United States, where we have people that are on Suboxone for years at a time, some of the clients here have been on their methadone regimen for 5 or more years. Rather than stepping down and coming off completely, they are maintained on a dose, or even have their doses increased from time to time. While I do not proclaim to be an addiction specialist, and I realize that everybody's needs are different, when more than 80% of your clients stay on the same dose, increase their dose, or have a relapse, are we really providing much of a service?

It’s a difficult prospect to deal with, but as healthcare providers, if we are able to “cure” (or overcome an addiction, as it is) even 1 out of 5 patients, we are still doing some good. In addition, even if the patients have substituted 1 addiction for another, at least it is a safer alternative that ideally leads to less criminal activity, and, hopefully, a healthier lifestyle for those in the program.

A measure of successful therapy

Much of the time as healthcare providers, we see things in terms of black and white. We need there to be a set terminus for every action. We need a conclusion to a program, or at the very least a tangible, measurable goal of therapy. In the case of opioid replacement therapy, it seems the only 2 end points we have are: the patient either "succeeds" and completely comes off of all treatment, or the client “fails” and slips through the cracks (not a thing we ever wish for obviously, but still a conclusion).

Unfortunately with these programs, the gray area is huge, and success can often only be measured by the individual who is being treated and not by his or her healthcare professionals. In some ways, the ambiguity of what constitutes successful therapy is what is most difficult about these programs.

Joel Claycomb, PharmD, is a community pharmacist in Manawatu, New Zealand. He can be reached at jcclaycomb@gmail.com.