BUPRENORPHINE GUIDELINES - WORKING TOGETHER: PHARMACISTS AND TECHNICIANS TEAMING UP IN ONTARIO COMMUNITIES - Pharmacy Connection
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WINTER 2012 • VOLUME 19 NUMBER 1
THE OFFICIAL PUBLICATION OF
THE ONTARIO COLLEGE OF PHARMACISTS
BUPRENORPHINE
WORKING TOGETHER: GUIDELINES
PHARMACISTS AND
TECHNICIANS TEAMING
THANK YOU TO
UP IN ONTARIO
PRECEPTORS AND
COMMUNITIES
EVALUATORS
Council Members
Council Members for Districts are listed below
according to District number. PM indicates a public
member appointed by the Lieutenant-Governor-
in-Council. U of T indicates the Dean of the Leslie
Dan Faculty of Pharmacy, University of Toronto.
U of W indicates the Hallman Director, School of
Pharmacy, University of Waterloo.
H Doris Nessim PM Margaret Irwin
H Christine Donaldson PM Javaid Khan
K Mark Scanlon PM Lewis Lederman
K Esmail Merani PM Aladdin Mohaghegh
L Tracy Wiersema PM Gitu Parikh
L Farid Wassef PM Lynn Peterson
MISSION STATEMENT
L Saheed Rashid PM Shahid Rashdi
The mission of the Ontario
M Sherif Guorgui PM Joy Sommerfreund
(President) U of T Henry Mann
M Tracey Phillips U of W David Edwards
College of Pharmacists is M Don Organ
N Bonnie Hauser Statutory Committees
N Peter Gdyczynski • Executive
to regulate the practice N Christopher Leung
(Vice President)
• Accreditation
• Discipline
of pharmacy, through the
P Rachelle Rocha • Fitness to Practice
P Jon MacDonald • Inquiries Complaints &
T Amber Walker Reports
participation of the public and TH Tracy Wills • Patient Relations
• Quality Assurance
PM Thomas Baulke • Registration
the profession, in accordance PM
PM
William Cornet
Corazon dela Cruz Standing Committees
with standards of practice
PM Babek Ebrahimzadeh • Communications
PM Jim Fyfe • Finance
PM David Hoff • Professional Practice
which ensure that our
College Staff
members provide the public Office of the Registrar
x 2243, urajdev@ocpinfo.com
with quality pharmaceutical Office of the Deputy Registrar,
Director of Professional Development ,
service and care. Pharmacy Connection Editor
x 2241, ltodd@ocpinfo.com
Office of the Director of Professional Practice
x 2241, ltodd@ocpinfo.com
Office of the Director of Finance and Administration
x 2241, ltodd@ocpinfo.com
Registration Programs
x 2250, jsantiago@ocpinfo.com
Structured Practical Training Programs
x 2297, vclayton-jones@ocpinfo.com
Investigations and Resolutions
x 2274, membry@ocpinfo.com
Continuing Education Programs and
Continuing Competency Programs
x 2273, lsheppard@ocpinfo.com
Pharmacy Openings/Closings, Pharmacy Sales/
Ontario College of Pharmacists Relocation, ocpclientservices@ocpinfo.com
483 Huron Street Registration and Membership Information
Toronto, Ontario M5R 2R4 ocpclientservices@ocpinfo.com
Pharmacy Technician Programs
T 416-962-4861 ocpclientservices@ocpinfo.com
F 416-847-8200 Publications x 2229, dcross@ocpinfo.com
www.ocpinfo.com
PAGE 2 ~ WINTER 2012 ~ PHARMACY CONNECTION
The objectives of Pharmacy Connection are
to communicate information about College
activities and policies as well as provincial and
federal initiatives affecting the profession; to
encourage dialogue and discuss issues of interest to
pharmacists, pharmacy technicians and applicants;
to promote interprofessional collaboration of
members with other allied health care professionals;
and to communicate our role to members and
stakeholders as regulator of the profession in the
public interest.
We publish four times a year, in the Fall, Winter, On the Cover:
Spring and Summer. Phillip Chiu and Stacy O’Neill from Keswick, ON
are just one of the many teams of pharmacists
We also invite you to share your comments, and technicians teaming up to deliver patient
suggestions or criticisms by letter to the Editor. care in Ontario communities.
Letters considered for reprinting must include the Story on page 8.
author’s name, address and telephone number.
The opinions expressed in this publication do not
necessarily represent the views or official position of
the Ontario College of Pharmacists.
WINTER 2012 • VOLUME 19 NUMBER 1
Sherif Guorgui, B.Sc.Phm., R.Ph.
President CONTENTS
Marshall Moleschi, R.Ph., B.Sc. (Pharm), MHA
Registrar
Editor’s Message 4
Della Croteau, R.Ph., B.S.P., M.C.Ed.
Editor, Deputy Registrar, Registrar’s Message 5
Director of Professional Development
dcroteau@ocpinfo.com Council Report 6
Anjali Baichwal
Pharmacists and Technicians Working Together 8
Associate Editor
abaichwal@ocpinfo.com
Integrating Technicians into the Workplace 16
Agostino Porcellini
Production & Design / Webmaster Coroner's Geriatric & Long-Term Care Review 18
aporcellini@ocpinfo.com
Buprenorphine for Treatment of Opioid Dependence 21
Privacy Enhances Patient Consultation 30
Accessible Customer Service Regulation 33
Member Survey results 34
Discipline Decisions 36
ISSN 1198-354X Focus on Error Prevention: Computer Alerts 39
© 2012 Ontario College of Pharmacists
Canada Post Agreement #40069798 Thank You Preceptors! 40
Undelivered copies should be returned to the
Ontario College of Pharmacists. Not to be Evidence-based Information for Practitioners 50
reproduced in whole or in part without the
permission of the Editor. Annual CE Coordinators Meeting 53
CE Resources 54
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 3
EDITOR'S MESSAGE
If you are integrating
technicians into your
team, I’d like to hear what
you have learned that
could be shared with
others.
Della Croteau, R.Ph., B.S.P., M.C.Ed.
Deputy Registrar/Director of
Professional Development
Last fall, OCP conducted a survey you are looking for information on our website and allows us to provide
over a period of three weeks to practice-related issues. Columns more timely information than what
help us improve our communica- like “Focus on Error Prevention” we publish in Pharmacy Connection.
tions with members, We were and Q&As on practice are well-read
particularly interested in hearing and valued. But you want even Our regular e-blasts to members
your feedback on Pharmacy more articles on practice and we will received favourable comments.
Connection, both print and online. work on delivering that to you. This Members told us that these blasts
I want to take this time to thank all issue’s cover story on technicians provide valuable information on a
of the members who participated being integrated into the workplace timely basis.
in the survey. We had an excellent is a good start. It contains real life
response, with some 30% of examples of best practices for Going back to the print vs
members providing their input. This working together, profiling three electronic format of Pharmacy
is considered to be great success in practice settings, and addressing Connection, we heard from many
terms of surveys so we thank you. some of the major questions that members on their preference.
are occurring with this new model. There is still a large number of
So what did we learn from all of you who prefer print, but there
this? We provide you a summary If you are integrating technicians are certainly significant numbers
on page 34 of some of our key into your team, I’d like to hear what who would now, or at some time
findings. Among them is the fact you have learned that could be in the near future, be satisfied
that you are in communication with shared with others. with an online-only version of the
us. The response rate itself tells us publication. As more and more of
you want to provide input, and assist As well, our colleagues with exper- you incorporate mobile devices
us in providing communications tise in buprenorphine have provided into your lives, you’ve expressed an
that you find valuable. So we will an extensive update on its use and interest in receiving information in
continue to ask for your input on a place in practice, in relation to the that format. We will work to deliver
regular basis to make sure that our recently released clinical guidelines.. on these needs as we plan future
communications are reaching you in communications.
an effective manner. You also conveyed a need for more
resources focusing on continuing
You also told us that Pharmacy education. I want to remind you to go
Connection is an important vehicle to our website where we continually
for information and that many provide up to date information on
of you are enjoying the online CE opportunities for all members. It
version. Responses revealed that is one of the most popular areas of
PAGE 4 ~ WINTER 2012 ~ PHARMACY CONNECTION
REGISTRAR'S MESSAGE
The College continues to
meet with public health
and other stakeholders
to discuss how to best
collaborate and enhance
the current system.
Marshall Moleschi,
R.Ph., B.Sc. (Pharm), MHA
Registrar
As you’ll read in our Council Report, fall. As you know, I spent much of support and enable members to
last December, Council approved a my first few months as Registrar, on use their professional skills, knowl-
change to the previously submit- the road, travelling to communities edge and judgment in an integrated,
ted Bill 179 regulation, and as across the province, delivering evidence-based, patient-centered,
a result, the updated regulation important messages about moving outcome-focused health care
was re-circulated, along with an our profession forward. The system. Doing so will do wonders
expanded list of substances to discussions we’ve had in large and to improve the health of our
be administered by injection and small group settings, the comments population. Taking a more patient-
inhalation for routine purposes, I’ve received – they are all very focused approach, and building
including immunizations. Council helpful to me and the team here at our confidence as practitioners is a
made this change because it OCP as we set forward to continue mission all of us must undertake.
considered that it was in the public our work regulating the profession
interest to permit pharmacists to in the public interest. An important If I didn’t get a chance to meet
exercise a broader scope in the part of that is our new strategic you last fall, I hope to do so at the
administration of drugs by injection planning process which will begin in earliest opportunity. As always, if
and inhalation. March and set the course for the you have any thoughts or ideas you
College over the next three years. would like to share, I encourage you
By the time you read this, the to contact me so we can continue
consultation period will be If you weren’t able to come out to our dialogue on the important
complete. I hope that you had a one of the district meetings, I hope issues facing us this year.
chance to add your thoughts to you were able to take a look at our
this important development. The website where we’ve made the
College continues to meet with presentation available to review at
public health and other stakehold- you leisure.
ers to discuss how pharmacists
and pharmacy technicians can “Navigating the Grey” continues to
best collaborate and enhance the be a theme I’m incorporating into
current system. Thanks to all of you all my work here as Registrar. To
who participated in this process. every meeting, whether it be with
Providing your input is an important council, our provincial and national
responsibility. counterparts, associations and
government, I have been trying to
I want to thank those of you too drive home the same message: that
who came out to meet with me last the time is now for the college to
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 5
COUNCIL report
DECEMBER 2011
Council Meeting
Proposed Amendments to the Strategic Plan Update Council approves revocation
General Operating By-law #2 of sections 41 and 42 of
Ratified Progress continues towards Ontario Regulation 58/11 to
meeting the goals and objectives the DPRA
As reported previously, amend- set out in the Strategic Plan and
ments to the by-laws respecting a Council received the progress Council approved a motion to
revised fee structure for pharmacy report of action taken by all revoke sections 41 and 42 of the
related transactions were circulated College areas since the September Ontario Regulation 58/11 to the
to the membership for comment. 2011 Council Meeting. Activities Drug and Pharmacies Regulation
These amendments were ratified set in March 2009 are expected Act (DPRA), at the time that the
by Council in December and will to reach completion in 2012 Bill 179 Regulations under the
enable the College to better align when Council will embark upon a Pharmacy Act are proclaimed.
the fees with the activities associ- new Strategic Plan. To this end, the
ated with the processing of a new College has engaged the services Refill authority is currently only
certificate of Accreditation. For the of Dr. Wayne Taylor who will first permitted in community pharma-
updated by-laws, please refer to the conduct a governance review with cies under the authority of the
College’s website www.ocpinfo.com Council, and Ms. Anne Grant who DPRA and the new provisions,
will facilitate the strategic planning upon proclamation, will broaden
exercise. this scope to all members. This
Proposed amendment to Bill
motion is a simple housekeeping
179 Regulation – Approved
Council also heard a presenta- measure which Ministry officials
for Circulation
tion from eHealth Ontario requested the College approve.
regarding their progress with the It was acknowledged that upon
Council approved a change to the development of the Medication proclamation of these regulations,
previously submitted Bill 179 regu- Management System, which they comprehensive communication will
lation, and as a result, the updated anticipate will be in place by 2013. be forwarded to the membership to
regulation is being re-circulated, Also noted for information was help clarify the expectations.
along with an expanded list of the recent release of a report
substances to be administered by by Don Drummond on Canada’s
Model Standards of Practice
injection and inhalation for routine healthcare system. These, together
for Canadian Pharmacy
purposes, including immunizations. with other backgrounders, will
Technicians Adopted
In discussing this matter, Council be used by Council during the
considered that it was in the public strategic planning session to
interest to permit pharmacists to develop a Vision Statement, define College Council approved the
exercise a broader scope in the values and develop broad strategic adoption of the Model Standards of
administration of drugs by injection priorities for this College for the Practice for Pharmacy Technicians
and inhalation. next three years. as developed through NAPRA (the
National Association of Pharmacy
Updated copies of the proposed Regulatory Authorities). The format
regulation, the list of routine adopted for these standards was
injections and immunizations and drawn from that of the model
drugs for inhalation are available on standards developed for Canadian
the OCP website. pharmacists but adjusted to reflect
PAGE 6 ~ WINTER 2012 ~ PHARMACY CONNECTION
COUNCIL report
the technician’s competencies. The Government Relations align well with the College’s current
standards are available on the OCP philosophy. Registrar Moleschi has
website. Effective November 1st, 2011, and already met with several individuals
following an evaluation of proposals within the government, both at the
from other GR advisors, the firm bureaucratic and political levels, and
Registration Regulation
of Leffler Consulting was selected it is anticipated that these efforts
Resolutions approved
to support the College in our will continue so as to enable the
government relations endeavors. College to influence the develop-
Under the Registration Regulation, Ms. Sandra Leffler has previously ment of any new programs at an
there are references to require- provided GR support to the College early stage.
ments which are to be approved by and her experience and background
Council. These requirements are
approved through resolutions and
allow the College to make changes
in these specific areas to keep the
regulation current, without having
to actually change the regulation.
The requirements in the regulation
will continue to be monitored by Member Annual Renewal
the Registration Committee and
further recommendations for IS due March 10, 2012
change will be brought to Council
for approval as necessary. For a
complete chart of the requirements The College’s online Member Annual Renewal is now available.
approved by Council and their NOTE: no form will be mailed to you, however email
reference in the regulations, please reminders will be sent.
refer to the College’s website at
www.ocpinfo.com Before you begin your online renewal you will need:
• Credit Card or Interac (Debit Card) if paying online
• User ID - This is your OCP number
New Council Members
• Password - If you have forgotten your password,
Welcomed
click 'Forgot your Password or User ID?' and a new
password will be emailed to you.
Council welcomed Ms. Christine
Donaldson, who won the Once you’re ready:
by-election in District H (hospital • Go to www.ocpinfo.com and click on 'Member Login'.
district) to the table. Also welcomed • Enter your User ID (your OCP number) and your password.
was returning public appointee, • Once you have successfully logged in, click on 'Member
Mr. Babek Ebrahimzadeh, who was Renewal' on the left hand side of the screen.
reappointed to serve on College
Council for a further three-year
term.
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 7
WORKING
TOGETHER
8 Santosh Manjunath, R.Ph., and
Andrea Ball, R.Ph.T of Zehrs
Pharmacy in Brantford, Ontario
Pharmacists and It has been more than a year since phar-
macy technicians have become recognized
Technicians are as regulated health professionals in Ontario.
teaming up in Ontario To date, the College has registered more
than 500 individuals as technicians, and
communities to deliver there are up to 5,000 individuals who are
patient care on the road to regulation. Technicians
play a vital role in the pharmacy setting,
supporting the pharmacist in providing
more comprehensive patient care services.
By taking responsibility for the technical
components of dispensing within the
pharmacy, technicians allow pharmacists to
expand their services and scope of practice
to improve patient care.
With changes to pharmacists’ scope of
practice on the horizon, the role of the
technician in the pharmacy setting is
becoming more vital. And while there still
may be some barriers to full and effective
integration of technicians in the pharmacy,
there are some great examples where this
new model of professional collaboration
is working well – where technicians can
practice within their scope allowing the
pharmacist to take on more duties related
to direct patient care.
In this article, we showcase three of these
practice settings. Each of these pharmacies
took part in a pilot program organized by
their parent company, Loblaw. The aim of
the pilot was to fully integrate the registered
technician in the pharmacy, measuring
success as when the following takes place:
• he registered technician spends most
T
of the day performing their duties, which
include accepting responsibility and
accountability for the technical aspects of
both new and refill prescriptions;
• The pharmacist spends most of the
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 9
working together
day evaluating the therapeutic Phillip Chiu, R.Ph., and is the biggest benefit,” he says.
relevance of each prescription Stacy O’Neill, R.Ph.T “The technician frees up our time
and talking to patients, providing Zehrs Pharmacy, Keswick ON so that we can spend it with our
professional services and other patients. Since we are not tied
medication management func- down to the counter as much,
tions (i.e. pharmaceutical opinions Phillip is standing in the store we can float around a lot more,
and MedsChecks); of the Keswick, ON Pharmacy going out to the floor, to approach
• The prescription-filling process where he has worked for more patients, to provide them counsel-
does not slow down. than a decade. But he’s not in his ling. There’s a lot more time to be
usual spot – behind the counter. proactive with the patients.”
Each of these pharmacies reflect Rather, he is walking around the
on the pilot and how they have store’s pharmacy area, approach- Phillip works with Stacy O’Neill, a
been able to work in a model that ing patients who look like they registered pharmacy technician.
maximizes each professional’s work. may need some assistance in They have worked together for
These individuals also shed light on making health-related choices. more than ten years in this store,
some of the challenges of integrat- “This is something that I’ve only where Phillip is the designated
ing technicians – and how best to been able to do because I have a manager. When Stacy became
meet them. technician on staff – and it really regulated last year, they integrated
Loblaw Initiative to
Integrate Technicians
The three stores profiled in this article were all presented. It sought to help staff understand
part of a pilot program through Loblaw, which the changes in the pharmacy industry that
recognizes and supports the expanded role of necessitated the integration of technicians
the pharmacist and thus the expanded role of and provided training on maximizing oppor-
the technician in pharmacy practice. Loblaw tunities for delivering professional services.
recognized that integrating technicians would Lynn Halliday, an in-house pharmacist for
require a shift in the way every pharmacy Loblaw (and non-Council committee member
employee would think and behave and set out for OCP), developed and presented training
to provide support to pharmacies shifting to strategies aimed at excelling in professional
this new model. The three pharmacies were services delivery.
chosen for the pilot based on the following:
• They are busy pharmacies with overlapping Another live training session in June focused
pharmacists on assessing learning to date and further
• They had pharmacist staff who were demon- strategizing on best ways to deliver professional
strating a good level of support for delivering services. Further meetings took place last fall to
professional services to their client base continue to prepare pharmacy teams on how
• They employed pharmacists who were willing to best adapt to new changes in scope with
to support the integration into the new roles the technician playing a prominent role in the
process.
Since February 2011, the pilot has involved
regular conference calls with the pharmacies Since the pilot program began, Loblaw reports
to discuss the integration of the technicians. that it more than tripled its prior year results
In April, a four hour live training session for with respect to the delivery of professional
pharmacy managers and technicians was services, including MedsChecks.
PAGE 10 ~ WINTER 2012 ~ PHARMACY CONNECTIONworking together
her into the workflow in such a way
that she, as the technician, takes
care of the technical portion of the
prescription and the pharmacist
checks the prescription for thera-
peutic accuracy at the end of the
process.
It’s a process that pharmacies in the
Loblaw pilot have implemented and
to date it is proving effective.
“Sometimes, the flow gets inter-
rupted when, for example, a patient
may approach me with their
prescription in hand,” says Phillip,
who explains that this requires him
to take care of the therapeutic
portion of the prescription at the
front-end. In reality, the therapeutic
check can take place at any point
in the process, but Phillip prefers
it take place at the end. “There
is some advantage to doing the
therapeutics at the beginning of the
process, but we were finding that
we couldn’t spend as much time
with patients as we need to at the
end because we were simultane-
ously entering information into the
computer.” So Phillip is at the end of
the counter, or floating in the store
to best optimize his role.
As for Stacy’s role, along with
checking prescriptions, she is also
responsible for checking compli-
ance packs and taking telephone day to day changes to our roles.” satisfaction. “The new model has
prescriptions from physicians She admits that adapting to the allowed me and the other pharma-
and other prescribers. “As the new model took some time. “There cists working in the store, to expand
technician, Stacy has become this was definitely a steep learning curve the amount of time we have to
incredibly great filter for me. It frees in getting the whole team on board engage and interact with patients,
up my time to counsel patients,” – to have all staff in the dispensary going more in-depth to their health
says Phillip. understand their roles,” she says. situation than ever before.”
Stacy estimates that it took a good
While Phillip and Stacy have worked two to three months for all staff Both Phillip and Stacy agree that
together for some time, they both in the pharmacy to get on board the biggest challenge has been
have learned a great deal interact- with the new model, to understand changing old habits and creating
ing within this new model. Stacy’s role and how it would affect new ones. Says Phillip: “I know
them. for myself, that when Stacy first
“We didn’t know what to expect became regulated, I couldn’t help
once I became regulated,” says For Phillip, the end result couldn’t but check for technical accuracy
Stacy. “We realized quickly though have been better. Having a while I was doing the therapeutics.
that everyone on the team, not just technician, in Phillip’s words has I was so used to checking that part
the two of us had to be ready for been a source of true professional of the prescription. But the more
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 11working together
we work within this new model, the Santosh Manjunath, R.Ph., and of the prescription allows him
more comfortable we are with the Andrea Ball, R.Ph.T and the other three pharmacists
technician’s ability.” Zehrs Pharmacy, Brantford ON on his team to take on more of
the medication management
For Stacy, there were challenges issues facing patients. “Having the
inherent in learning a new skill and In Brantford, confidence is the technician on the team gives us
applying it to real-life situations as name of the game as technician more free time which has resulted
well as the challenges in helping Andrea Ball works alongside in us spending more time with our
staff to understand the new role of pharmacist and manager Santosh patients,” he says.
the technician. “The other clerks Manjunath in a truly coordinated
had to understand what I was effort. Having Andrea, a technician That free time is spent, Santosh
doing – what my role was, and at on the team, according to Santosh says, performing MedsChecks, and
times there were some challenges has made a significant difference. counselling on a variety of issues
in making those clarifications. But such as smoking cessation, weight
overall the acceptance level with “I can say definitively that there is a control and cholesterol monitoring.
them has been very good. Other major benefit in having a registered
staff have certainly showed interest technician on the team,” says “Previously, patients always had to
in my role and in understanding Santosh. Like his counterparts in make appointments for this type
the duties that I took over from Keswick, Santosh points to the of counselling,” he says. “And while
the pharmacist. Overall, I think fact that having the technician appointments make it easier for us
everyone in our pharmacy would handling the technical portion to schedule seeing patients, they
agree that it’s been a very positive
situation.”
Do they have any advice for other
pharmacy practitioners that may
want to integrate technicians into
the workflow and don’t know where
to start?
Phillip says it’s all about having an
open mind. “Technicians can really
help you in your practice,” he says.
“And the results are really gratify-
ing – you can see them in terms
of the number of patients that you
can help counsel and to whom you
can provide extra care. It’s great to
have another professional on the
team that can help take away some
of the workload.”
Stacy adds that having support
from other stores involved in the
pilot has helped as has the support
from the management team. “It’s
certainly made the transition easier,”
she says. As for any advice for other
technicians who are integrating into
a new role, she says “Just go for it.
There’s no reason to be reluctant.
It’s a great profession and many
more opportunities to develop.
We’re just getting started.”
PAGE 12 ~ WINTER 2012 ~ PHARMACY CONNECTIONworking together
can now walk in and often find me Having the develop their own similar rapport
and my other pharmacist colleagues, with her and develop their own
available to do these important technician on the relationship.”
procedures and checks. It helps the
patients, and the public at large in team gives us more Andrea’s role in the pharmacy has
monitoring their health issues.” rubbed off on others: all five of their
Santosh says his role has changed
free time which assistants are pursuing regulation.
“I’m so happy for them,” says
dramatically with the technician
on board. “I feel like an advisor/
has resulted in us Andrea. “It’s a really good sign – it
shows that in this pharmacy, every-
coach who has directly helped my
patients towards achieving healthy
spending more time one is on board and supportive of
the technician role. I think that my
outcomes. It’s very satisfying.” colleagues can definitely learn from
with our patients me and watch with anticipation on
Andrea, a regulated technician who how they are going to work in their
also volunteers as a non-council new role.”
committee member with OCP has says. “But we have been fortunate
worked in pharmacy with Loblaw to have such a supportive team. For Santosh, this is all good news
for 16 years –the past 10 with From the beginning, the staff has as he continues to build deeper
Santosh. She says that having her all been very generous and patient relationships with patients as he
take on more responsibility in the with the shifts in responsibilities.” counsels them. “When we spend
pharmacy has contributed to a Santosh admits that it took him more time with patients they get
growing bond between patients and some time to get used to the to know us by name. For me, that
the pharmacists. “I see a definite idea of Andrea, as the technician, means that they walk in and look
increase in the confidence level our checking the technical aspects of for me specifically. On a professional
patients have with the pharmacist,” the prescription. “I couldn’t help it at level, I feel very satisfied by this.”
she says. “In our pharmacy it’s first – I was so used to checking the
great because everyone is ready prescription from a technical basis, Both Santosh and Andrea point to
to change and accept the different that it was just natural to continue the pilot program as an important
roles and responsibilities.” to do so. But after a couple of catalyst for establishing their
weeks in the new model, that workflow and determining the
Like their Keswick colleagues, in this overlap stopped.” new roles in the pharmacy. “Other
setting, the workflow is one that puts pharmacists in town have been
the pharmacist at the end of the “I’m very fortunate that Andrea is asking me how it works and I’ve
process. The technician or assistant is so capable in her work which gives been speaking with them to share
responsible for inputting information me the added confidence of her the knowledge we’ve had the good
into the system to start the produc- performing her role,” he says. fortune to gain from our head
tion required to fill a prescription. The office.”
technician performs the technical Still, Santosh says, there were
aspect – making sure the right some bumps along the road as
medication and dose is dispensed other pharmacy staff became Hemal Mamtora, R.Ph., Vipul
for the right patient. The pharmacist accustomed to Andrea’s new role in Patel, R.Ph., and Kim Lumsden,
comes in at the end of that process the pharmacy. “In the beginning, the R.Ph.T.
to provide the therapeutic check and assistants would avoid consulting Real Canadian Superstore,
to counsel. with Andrea as a technician. They Strathroy, ON
were accustomed to coming to
Andrea admits that the process me directly with questions,” says
wasn’t always smooth and it took Santosh. “I made it clear that Hemal Mamtora recalls a recent
some time for all members of the Andrea was and will continue to be, phone call he received from a
pharmacy team to be confident as a regulated technician, respon- patient. “This patient called me
in each other and the new roles sible for doing the technical check to say how grateful he was that I
brought about by regulation. “It and made them go to her directly. spent so much time with him to
was definitely a little hard in the It’s a matter of sticking by those help assess his diabetes risk,” says
beginning. Everyone’s a bit nervous rules in order to help everyone’s Hemal, the pharmacy manager
about taking on a new skill,” she comfort level. It allowed them to of the Real Canadian Superstore
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 13working together in Strathroy, ON. “He said he was technician working on his team – can now spend time with patients so surprised by the effort I made that vital health professional who and provide counsel to them. It’s to help him understand his risk can take responsibility for so many important to so many different profile, and how much he learned duties in the pharmacy – allowing kinds of patients – for the newly about his own health as a result.” Hemal to provide one-on-one diagnosed diabetic, for example, I The interaction with this patient, counselling to patients. “The can assist with their blood-glucose says Hemal, was only possible accessibility that patients now have monitoring, and be available for due to the fact that he had a to me is so valuable,” he says. “I follow up.” Hemal Mamtora, R.Ph., Vipul Patel, R.Ph., and Kim Lumsden, R.Ph.T. of Real Canadian Superstore in Strathroy, Ontario PAGE 14 ~ WINTER 2012 ~ PHARMACY CONNECTION
working together
Kim Lumsden is the registered As a pharmacist, if into the workflow and communicate
pharmacy technician in the phar- that with fellow staff members,”
macy. She has worked there for 13
years. In their pharmacy, Kim is also
you want to move he says. “At the same time, the
pharmacist/manager should also be
situated at the point in the process
where the technical check of the
forward and adapt able to determine what extended
services he or she is planning to
prescription is completed.
to changes in scope, provide to patients.”
Hemal says that within a couple Vipul Patel, Pharmacy Director of
of months of Kim performing her then this new model Operations for the store, agrees.
new role, he felt confident that he He says it is vital that pharmacists
didn’t have to double check her is fantastic. working with technicians are in a
work. “We have great confidence unique position to devote more
in her training and ability – she has time to patients, and that they must
really added value to the team.” Kim with a technician. “Like everything, plan on how they are going to best
admits that when she first became communication is critical. Not use this time. “As a pharmacist,
a regulated technician, there were all pharmacists may be used to if you want to move forward and
some challenges in defining her working with a regulated technician, adapt to changes in scope, then
role among her colleagues. “The so it is natural that there may be this new model is fantastic. It allows
main challenge was to have other some confusion as to why I’m doing you to practice your counselling
staff understand my new role. I what I’m doing. So it’s important to and hands-on patient care skills.
would say that it took about a let everyone know how the process It gives you the time to deliver
month for everyone to understand works and educating them on what more patient care. In that, it allows
and be comfortable with who the technician is responsible for.” you to grow and change with the
was doing what and who was profession.” But you have to have
responsible for what,” she says. Still, Hemal says that for pharmacies a plan of action, he says. “You need
Kim recalls times when there have who are thinking about integrating to plan what you are going to do
been misunderstandings about a technician into their practice, he with all this extra time in place. It’s
her role, particularly, for example, if says it’s important to plan. “You have a perfect time to expand your role,
there is a relief pharmacist on duty, to draw up a plan on how you are your services and get to know your
who may not be used to working going to integrate the technician patients and their needs.”
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 15working together
Integrating Technicians into the workplace
Tips and Reminders
Over the past several months, the College has visited
a number of pharmacies to understand how the role
of the pharmacy technician has been incorporated.
Each visit provided the pharmacy team members
with an opportunity to discuss their successes and
challenges and also seek clarification and feedback
from College staff about their understanding of the
technician role. For College staff, the visits have been
invaluable, allowing us to share collective learning,
correct some misconceptions and encourage others
to benefit from the integration of these new team
members. Although the process and model for
integration of the technician was unique to each
workplace, the discussion and issues were consistently
related to the new role of the pharmacy technician in
the dispensing of a prescription.
Responsibility:
Every professional is responsible for meeting the
standards of practice of their profession.
Technicians are responsible and accountable for the
technical aspects of all prescriptions that they check,
both new and refill. (e.g. the correct patient, product
and prescriber in accordance with the prescription).
Pharmacists remain responsible and accountable for
the therapeutic/clinical appropriateness of all prescrip-
tions, both new and refill.
Accepting Verbal Prescriptions:
Pharmacy technicians are able to accept verbal
prescriptions, with the exception of narcotics and
controlled drug substances.
Once legislative changes to the Food and Drug Act
regulations are in place, pharmacy technicians will also
be able to independently receive and provide prescrip-
tion transfers.
PAGE 16 ~ WINTER 2012 ~ PHARMACY CONNECTIONworking together
technician checks the technical aspects of the weekly
Independent Double Check:
compliance packaging and signs for this activity. The
pharmacist continues to review the profile on a regular
The requirement to have an “independent double basis as well as with each new prescription and when
check” may have been a barrier to the integration changes are made to any existing prescriptions.
of technicians in some practice settings. Standards
of practice for technicians are now in place and
The common objective of all pharmacies we visited is to
allow for more flexibility. Whenever possible, a
increase opportunities to deliver professional services
final check should be performed by a pharmacy
such as MedsChecks, Pharmaceutical Opinion Program
technician (or a pharmacist) who did not enter the
and Smoking Cessation and to improve the quality of
prescription into the pharmacy software system or
who did not select the drug from stock. However, such interactions. All of the pharmacy teams agreed
if another member of the team is not available, a that the pharmacist generally had more time to spend
final check can be completed by one professional with patients and this had a very positive effect on the
providing there are other systems in place to patient-pharmacist relationship.
ensure safe medication practices.
Creating Intra-professional
Work Flow and Processes Relationships
There is no one model that fits all. While the objective Every site the College visited reported that they began
is to optimize the role of the technician and pharmacist, to integrate the technician role slowly and cautiously.
workflow will be dependent on physical layout, Pharmacy technicians acknowledged that they wanted
resources/staffing, patient population/characteristics etc. time to gain confidence and adjust to the new level of
The pharmacist may best be positioned at the beginning accountability. They also realized that they needed to
of the workflow process and assess the appropriateness demonstrate their ability so that the pharmacist could
of the prescription even before the data is entered into feel confident in letting go of the technical functions.
the computer by the assistant or technician. Alternately
the pharmacist may perform this activity at any time Pharmacists told us they had to rethink how to perform
during the process or at the end. their job and learn how to separate the technical
and therapeutic functions. For some pharmacists it
Note that the technician cannot release the product was difficult to see the added value of making these
to the patient until the pharmacist has performed the adjustments, particularly if the pharmacy technician
therapeutic check. It is important that the pharmacist’s was not being utilized to their full capacity. Both team
signature is clearly visible on the prescription to allow members described the importance of being able to
the team to establish that this has occurred. Some openly discuss their roles and test out new approaches
pharmacies use a stamp to mark the place for the collaboratively.
pharmacist’s signature.
The introduction of a pharmacy technician role on the
The pharmacy manager must establish a method of team also resulted in new relationships with pharmacy
differentiating and preserving the identification of the assistants. The pharmacy technicians acknowledged the
pharmacist and technician responsible for each prescrip- challenge of accepting new responsibility for the work
tion. Although signatures are the traditional method of of others particularly when managing errors. They also
accepting or declaring responsibility, pharmacy teams may noted how fortunate they were to be in their new role,
wish to utilize other mechanisms within clearly defined recognizing that the opportunities for these roles have
and understood protocols. Future electronic workflow been limited. This realization added to the technician’s
processes should consider this requirement. sense of responsibility to represent their profes-
sion well and a desire that their success will lead to
An example of where a protocol could be utilized would increased opportunities for other regulated pharmacy
be when dispensing within a compliance program. The technicians.
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 17Geriatric and Long-Term Care 18
Report of the The purpose of the Geriatric and Long-Term Care
Review Committee (GLTCRC) is to assist the Office
Coroner’s Geriatric and of the Chief Coroner in the investigation, review
Long-Term Care Review and development of recommendations towards the
prevention of future similar deaths relating to the
Committee provides provision of services to elderly individuals and/or
individuals receiving geriatric and/or long-term care
recommendations for within the province.
use of drugs in the
Established in 1989, the committee consists of
elderly members who are respected practitioners in the
fields of geriatrics, gerontology, family medicine,
emergency medicine and services to seniors. Elaine
Akers, a former OCP council member, is currently
the pharmacist representative on the committee.
In 2010, the GLTCRC reviewed 11 cases and
generated 22 recommendations directed toward
the prevention of future deaths. Common issues
that the GLTCRC dealt with were:
• edical and nursing management;
M
• Use of drugs in the elderly;
• Communication between healthcare practitioners
regarding the elderly;
• The use of restraints in the elderly; and
• Medical/nursing documentation.
For the purpose of educating members, we have
reprinted one case and recommendations pertain-
ing to the use of drugs in the elderly. To read the full
report, go to www.mscs.jus.gov.on.ca
Case: 2010-01
OCC file: 2007-7779
Issue:
Concerns were identified relating to the care
provided in a retirement residence and an acute
care general hospital as well the use of narcotics
and other medications.
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 19GERIATRIC report
Summary: in impaired drug metabolism, further increasing the
potential for the development of adverse drug effects.
This was the case of an 83-year-old woman whose
past medical history included: chronic lymphocytic Records indicated that the decedent received four
leukemia, scoliosis, gastroesophageal reflux disease, doses of dimenhydrinate over the last two days of her
osteoarthritis with bilateral knee replacements, toe and life. It was noted by the Committee that dimenhydrinate
bunion surgery, hysterectomy, hernia repair, bilateral is a drug that is rarely of benefit in the elderly and the
cataract surgeries and an elevated uric acid. use of this drug may have further contributed to the
adverse outcome in this case.
In December 2006, the woman experienced a fall that
resulted in a left wrist fracture, fractured ribs and a The decedent also developed constipation during the
probable pelvic fracture. It was unclear if the fractured terminal phase of her illness. While constipation may
wrist was treated with a splint or a cast. It appeared that present as an overflow diarrhea in the elderly, it was
the fractured wrist remained a significant cause of pain noted that loperamide hydrochloride should not be
for which her family physician prescribed increasing prescribed for elderly patients taking opioids. It should
doses of oxycodone hydrochloride. She was also taking only be given when the diagnosis of constipation has
two different benzodiazepines. been properly excluded.
Medical records and documentation relating to the
Recommendations:
woman’s fall and initial management of her multiple
fractures were not available for review. From the avail-
able medical records, the decedent was already taking 1. Health care professionals should be reminded that
a high dose of oxycodone when she was admitted to loperamide hydrochloride should not be prescribed
the retirement home in May, 2007. It could not be for elderly patients taking opioids who have diarrhea
determined if alternate management strategies had until the presence of constipation has been excluded.
been tried prior to starting the oxycodone (e.g. immo- 2. Health care professionals should be reminded that
bilization of the wrist, local blocks for the fractured dimenhydrinate is a medication that is rarely indicated
ribs, and regular administration of acetaminophen may for use in the institutionalized or hospitalized elderly.
have been helpful in decreasing the need for an opioid The combination of dimenhydrinate with other
analgesic). psychoactive or anticholinergic medications can
result in the development of potentially serious drug
The attending physician attempted to decrease the interactions resulting in adverse outcomes.
amount and dosages of medications being given to 3. Health care professionals should be reminded of
the woman. In early June, she developed abdominal the importance of using caution when prescribing
distention, nausea and diarrhea. She was treated with opioids for elderly patients with chronic pain. The
loperamide, dimenhydrinate and a suppository. She use of non-pharmaceutical interventions and non-
was subsequently transferred to hospital where she narcotic medications such as acetaminophen should
was found to be in heart failure. She was admitted and be considered for use as a first intervention in an
treated with furosemide, dimenhydrinate, morphine, attempt to minimize the dosage of an opioid required
scopolamine and a Fleet enema. She died in hospital to control pain.
about 15 hours after arrival. 4. Health care professionals should be reminded that
the potential toxicity of opioid medications can be
An autopsy found cardiomegaly, valvular heart increased by the concomitant use of other psycho-
disease and evidence of congestive heart failure. active medications.
Toxicologic analysis found supratherapeutic levels of
oxycodone and diphenhydramine and therapeutic
levels of morphine, lorazepam, acetaminophen and
chlorpheniramine.
It was noted by the Committee that research has
shown that there have been identified risks of using
oxycodone with other psychoactive medications,
including benzodiazepines and dimenhydrinate. It was
also noted that the development of heart failure results
PAGE 20 ~ WINTER 2012 ~ PHARMACY CONNECTIONbuprenorphine
Buprenorphine for
the Treatment of
Opioid Dependence
UPDATE ON Buprenorphine has been available as a prescription opioid
in Canada since 2008. It is marketed as Suboxone® by RB
BUPRENORPHINE FOR Pharmaceuticals, Canada, in combination with naloxone
THE TREATMENT OF in a sublingual tablet. This medication has been available
for several years in many parts of the world, including the
OPIOID DEPENDENCE United States. In Canada it is indicated for substitution
treatment in opioid drug dependence in adults.
Laura Murphy, RPh, BScPhm, PharmD
Altum Health, University Health Network, Toronto Buprenorphine treatment provides an alternative to
methadone maintenance treatment in Canada. As with
Pearl Isaac, RPh, BScPhm methadone treatment, patients prescribed buprenorphine
Centre for Addiction and Mental Health, Toronto should be carefully monitored within a framework of
Leslie Dan Faculty of Pharmacy, University of
medical, social, and psychosocial support as part of a
Toronto
comprehensive opioid dependence treatment program.1
Eva Janecek, RPh, BScPhm
Centre for Addiction and Mental Health, Toronto Pharmacist involvement in buprenorphine treatment can
Leslie Dan Faculty of Pharmacy, University of include the supervision of drug administration, monitor-
Toronto
ing patients, communicating with the treatment team,
Anne Kalvik, RPh, BScPhm providing encouragement and support, and dispensing
Centre for Addiction and Mental Health, Toronto take-home doses (‘carries’).
Leslie Dan Faculty of Pharmacy, University of
Toronto Involvement in the treatment of opioid dependent patients
with buprenorphine has the potential for pharmacists to
Sarah Woodworth, RPh, BSc(Pharm)
Leslie Dan Faculty of Pharmacy, University of expand their scope of practice and provide a satisfying
Toronto professional opportunity to participate in the recovery
of individuals dependent on opioids. This area of practice
Beth Sproule, RPh, BScPhm, PharmD may be of particular interest to those pharmacists involved
Centre for Addiction and Mental Health, Toronto
in the provision of methadone maintenance treatment.
Opioid dependence is a complex disorder; therefore
pharmacists who take training specific to buprenorphine
therapy and other treatment options will be best able to
provide pharmacy services to these patients.
With buprenorphine maintenance treatment, as with
methadone maintenance treatment, patients benefit from
physicians and pharmacists working together effectively to
provide optimal treatment.
Recently, clinical practice guidelines were developed by
the Centre for Addiction and Mental Health (CAMH)
to provide clinical recommendations for the initiation,
PHARMACY CONNECTION ~ WINTER 2012 ~ PAGE 21buprenorphine
maintenance and discontinuation injecting, but does not eliminate Narcotics Safety and Awareness Act,
of buprenorphine/naloxone the risk. 2010, as part of Ontario’s Narcotic
maintenance treatment in the - c an be titrated to a stable Strategy for monitored drugs.14
ambulatory treatment of adults and dose within days, in contrast
adolescents with opioid depen- to methadone which typically The new Guidelines highly
dence in Ontario.2 Information may take weeks to achieve the recommend that pharmacists
in this article has been updated optimum dose. who provide buprenorphine
from its first appearance in OCP -p rescribed at maximal doses services undertake training. These
Connection (Jan-Feb 2008) to may not be sufficient for all pharmacists must be aware of the
reflect these new guidelines. The patients. When the maximum unique nature of buprenorphine
Guidelines are available from the daily dose does not stabilize a dispensing and specific issues that
CAMH, OCP or CPSO websites, patient, consideration should be exist in dispensing medications
and should be reviewed before given to using methadone. for the maintenance treatment of
dispensing buprenorphine. -m ay induce withdrawal in substance dependence. Training
patients dependent on opioids if resources are included at the end
administered too soon after last of the article.
Key Messages for use of full opioid agonist.
Buprenorphine -h as also been successfully
used for medical withdrawal How Buprenorphine
• uboxone® is an opioid prescrip-
S treatment (detoxification) from Works
tion medication containing opioids7,12 and for the treatment
buprenorphine 2 mg and 8 mg of pain13 (both are unapproved
(in sublingual tablets) in fixed indications in Canada). Buprenorphine is a synthetic opioid
combination with naloxone 0.5 with a unique profile: it is a partial
and 2 mg respectively (to deter mu-opioid receptor agonist.1
injection drug use). Regulatory Framework Buprenorphine has a lower intrinsic
• Sublingual dissolution of for Buprenorphine activity at the mu-opioid receptor
Suboxone® sublingual tablets than a full agonist (e.g., methadone
usually takes 2 to 10 minutes. Buprenorphine/naloxone does or oxycodone). This means that
• Buprenorphine: not require a special prescribing there is a “ceiling effect” to its opioid
- is efficacious as substitution exemption, unlike methadone, so agonist effects at higher doses15
therapy in the treatment of prescriptions may be written by any making it safer in overdose and
opioid dependence.3-5 practitioner licensed to prescribe reducing its potential for abuse.
- is an alternative to, but not narcotics. The College of Physicians In addition, there is little increase
a substitute for, methadone and Surgeons of Ontario (CPSO) in efficacy with doses above 16-32
maintenance treatment.6 expects all physicians who wish mg daily. Although it is a partial
- acts primarily as a partial agonist to use buprenorphine to treat agonist, buprenorphine has a very
at mu-opioid receptors.1 opioid-dependent patients to have high affinity for (i.e., binds tightly
- is considered safer in overdose training/education on this drug, to) the mu receptor. This tight
than methadone, although and addiction medicine generally, binding means that buprenorphine
if combined with other CNS prior to initiating buprenorphine can block the effects of other
depressant drugs (e.g., benzodi- treatment. opioid agonists (e.g., methadone
azepines) respiratory depression or oxycodone), and precipitate
can occur.7 If clinical symptoms Prescriptions for Suboxone® have withdrawal in those physically
of overdose occur, higher doses the same requirements as other dependent on opioids by displacing
of naloxone or other measures "straight narcotics", however, in agonists from opioid receptors.1
for treatment may be required.8 addition it would be good practice The tight binding is also associated
-m ay have a lower potential to also indicate: with a slow dissociation from the
for abuse and dependence • start and stop dates mu receptor resulting in a long
than pure agonists such as • days for supervised administration duration of action.1 This is why
morphine9-10, although abuse • days for take home doses buprenorphine is associated with
does occur.9-11 The addition of a milder withdrawal syndrome and
naloxone to the Suboxone® As with other opioids, dispensing has been used to assist in detoxifi-
product formulation is intended procedures for buprenorphine/ cation from other opioids.7,12
to further reduce the risk of naloxone must comply with the
PAGE 22 ~ WINTER 2012 ~ PHARMACY CONNECTIONYou can also read
