The changes include the recent temporary easing of the numerical limits on takeaway doses outlined in the OTP Clinical Guidelines, based on individual risk assessment. The Interim Guidance for the delivery of medication assisted treatment of opioid dependence in response to COVID-19: a national response is a useful reference.

The following procedures are to manage continuation of service for patients in self-isolation from COVID -19 and should be read together with the Community Pharmacy OTP dosing point - Contingency planning for the potential impacts of COVID-19.

It is critical that pharmacists and prescribers work together to ensure continuing treatment and establish the ongoing safety for patients to receive doses in the absence of regular observed dosing at the clinic or pharmacy. Arrangements should be documented and reviewed as required.

Services that may be considered in collaboration with prescribers to continue OTP for patients in isolation:

• delivery of takeaway doses to a patient at their home
• supervised dosing at the patient’s home
• preparing takeaway doses on behalf of the public OTP clinic
• collection of doses on behalf of the patient by a nominated person or agent.
  

Prior to agreeing to provide services outside of standard care in OTP

Confirm with the prescriber that self-isolation is clinically required for the patient.

Discuss and document the individual plan for the patient, e.g. How long will the special arrangements be required? On what date will the plan be reviewed? Confirm and document last dose details if the patient is not an existing client at the pharmacy. Discuss secure storage of takeaway doses with the patient, especially if there are children or others at home.

All patients should be given advice on how to respond to an overdose and provided take home naloxone, currently available free for patients in NSW as part of an Australian Government Pilot.

Note that each takeaway dose must be individually packed and labelled in accordance with the NSW Opioid Treatment Program Community Pharmacy Dosing Point Protocol (TG201-5).

Ensure patients know how to contact the community pharmacist for advice and information if required – provide any written information together with takeaway doses prepared.

Payment for doses and delivery may be arranged via EFTPOS, Centrepay or direct debit in preference to cash on delivery.

Delivery of take away doses to a patient at home where supervised dosing is not required

Only a responsible adult (18 years and above), nominated by the pharmacist may deliver takeaway doses of OTP medicines. The delivery person does not have to be a pharmacist, however should have the skills, experience and knowledge to support the pharmacist in their duty of care. Contact the Pharmacy Guild if you require support for delivery services.

Ensure processes and protocols are in place to ensure safety and security of delivery staff, given the risks of theft.

Delivery staff should be familiar with the COVID-19 infection control and contactless delivery protocol. The contact number for the patient and the pharmacy should be provided to delivery staff to help manage delivery.

• Wait at a minimum of 1.5 metres distance and ask the patient to confirm their identity by stating their name and date of birth. Report any difficulties in speech and other physical signs of intoxication or withdrawal to the pharmacist on duty (by phone) and follow any specific instructions before proceeding to deliver the dose(s).
• Place the delivery down and stand back to wait for the patient collect it. Schedule 8 and Schedule 4 Appendix D medicines must not be left unattended (e.g. on a doorstep), and must be returned to the pharmacy.
• Advise the patient to confirm receipt of the doses with the pharmacist as soon as practical – an email or phone confirmation (recorded by a call log) may be accepted in lieu of signing for the doses, provided the pharmacist can confirm the identity of the patient. Explain to the patient that without confirmation, deliveries may not continue.

Supervised dosing at a patient’s home – make individual arrangements with the clinic

Supervised dosing at the patient’s home may be considered where patients must be isolated and have been clinically assessed as requiring supervised dosing to continue treatment safely. If indicated, supervised dosing at home should be a time-limited arrangement made in collaboration with the public OTP clinic, for example:

• A registered nurse employed by the LHD accompanied by another responsible person would be able to deliver and supervise doses.
• A registered pharmacist may deliver and supervise doses if the clinic is not able to arrange supervised dosing. Consider whether this is a service your community pharmacy can provide. Fees charged for pharmacist-supervised dosing at home should be reasonable, accounting for additional requirements, including pharmacist’s time.

Correct use of a surgical face mask is recommended if a distance of 1.5 metres cannot be maintained. Longer times of exposure and the potential requirement to provide clinical care should be taken into account when considering safety protocols.

Preparing takeaway doses on behalf of a NSW public drug and alcohol services

Some NSW public health facilities may require additional capacity to prepare takeaway doses during the COVID-19 outbreak and may reach out to community pharmacies to assist with this service.

Consider if your community pharmacy is able to support public clinics on a temporary basis by either:

1. preparing takeaway doses on behalf of a public clinic and delivering to the clinic, or
2. preparing and delivering takeaway doses to patient’s homes.

Dispensing and delivery fees should be discussed and agreed to with clinics. The Pharmacy Guild of Australia’s guide to home delivery of medicines may be a useful resource.

Ensure regulatory requirements are met, including a separate valid prescription specifying the takeaways doses for each patient, accurate dispensing records, safe storage of doses and maintenance of Schedule 8 drug registers. If delivery is required, refer to procedures outlined above.

Nominated person (‘agent’) collecting doses on behalf of the patient at the pharmacy

There is increased risk of diversion with this option – consider for a strictly limited time if other options are unavailable, with careful monitoring.

The agent must be an adult, agreed to by both the prescriber and the patient. When deciding on suitability, consider risks of diversion, concerns for patient (or family) safety, and secure storage and transport etc. The clinic must discuss the strict procedures to be followed, documenting the discussion and the agent’s agreement to adhere to this.

Pharmacists should request this documentation from the clinic together with a validated copy of the agent’s photo ID (forwarded by the prescriber), details and timeframe for the arrangement to include in the patient’s file before commencing. The pharmacist on duty must verify the agent’s identity against photo ID in the patient records before any doses are given.

• The agent must sign for receipt of the dose(s).
• The pharmacist should remind the agent that dose(s) must be delivered directly to the patient and must not be left unattended at any time.
• The patient must confirm receipt of the doses by email or phone call, provided the pharmacist can confirm the identity of the patient. If confirmation is not received, no further doses can be provided to the agent. Any loss or suspected theft of doses should be investigated and reported as per usual procedure.

Regular phone / telehealth contact with the patient must be maintained by the clinic or pharmacist to document any adverse outcomes and assess the safety of continuing the arrangement.