IN THIS ISSUE: Continuous Quality Improvement An Essential Component of Patient and Medication Safety 30 A Shared Responsibility for Ethical and ...
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WINTER 2017 • VOLUME 24 NUMBER 1
THE OFFICIAL PUBLICATION OF
THE ONTARIO COLLEGE OF PHARMACISTS
IN THIS ISSUE:
Continuous
Quality Improvement
An Essential Component of
Patient and Medication Safety 30
A Shared Responsibility
for Ethical and Effective
Pharmacy Services
Learnings for Directors,
Managers, Pharmacists
and Pharmacy Technicians 26
Ontario College of Pharmacists
483 Huron Street, Toronto, ON M5R 2R4
COUNCIL MEMBERS
T 416-962-4861 • F 416-847-8200 Elected Council Members are listed below according to District. PM indicates a
www.ocpinfo.com 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
QUICK CONTACTS indicates the Hallman Director, School of Pharmacy, University of Waterloo.
Office of the CEO & Registrar
registrar@ocpinfo.com
H Christine Donaldson PM Kathy Al-Zand Statutory Committees
ext. 2241
(Vice-President) PM Linda Bracken • Accreditation
Office of the President H Régis Vaillancourt PM Carol-Ann Cushnie • Discipline
ocp_president@ocpinfo.com (President) PM Naj Hassam • Executive
ext. 2243 K Esmail Merani PM Javaid Khan • Fitness to Practise
OCP Council K Tracey Phillips PM James MacLaggan • Inquiries Complaints & Reports
council@ocpinfo.com L Billy Cheung PM Elnora Magboo • Patient Relations
ext. 2243 L James Morrison PM Sylvia Moustacalis • Quality Assurance
L Sony Poulose PM Shahid Rashdi • Registration
Pharmacy Practice
pharmacypractice@ocpinfo.com M Fayez Kosa PM Joy Sommerfreund
ext. 2285 M Don Organ PM Ravil Veli Standing Committees
M Laura Weyland PM Wes Vickers • Drug Preparation Premises
Registration Programs N Gerry Cook U of T Heather Boon • Elections
regprograms@ocpinfo.com N Christopher Leung U of W David Edwards • Finance & Audit
ext. 2250 • Professional Practice
N Karen Riley
Member Applications & Renewals P Jon MacDonald
memberapplications@ocpinfo.com P Douglas Stewart
ext. 3400 T Vacant
Pharmacy Applications & Renewals TH Goran Petrovic
pharmacyapplications@ocpinfo.com
ext. 3600
Strategic Framework
2015 - 2018
Mission The Ontario College of Pharmacists regulates pharmacy to ensure that the
public receives quality services and care.
Vision Lead the advancement of pharmacy to optimize health and wellness through
patient-centred care.
Values Transparency Accountability Excellence
Strategic Core Programs Optimize Practice Inter & Intra
Priorities Fulfillment of Mandate within Scope Professional
Collaboration
Patients First
Strategic
Initiatives Effective Communications
Continuous Quality Improvement
PAGE 2 WINTER 2017 ~ 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,
Spring and Summer.
We also invite you to share your comments,
suggestions or criticisms by letter to the Editor.
Letters considered for reprinting must include the
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.
PUBLISHED BY THE COMMUNICATIONS
& POLICY DEPARTMENT
communications@ocpinfo.com WINTER 2017 • VOLUME 24 NUMBER 1
FOLLOW US ON SOCIAL MEDIA! CONTENTS
Registrar’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Council Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
www.facebook.com/ocpinfo
Membership Renewal . . . . . . . . . . . . . . . . . . . . . . . . . 7
In the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
www.twitter.com/ocpinfo Bringing the Code of Ethics to Life . . . . . . . . . . . . . . . 10
White Coat Ceremonies . . . . . . . . . . . . . . . . . . . . . . 13
Naloxone: Five Things Pharmacists Need to Know . . . . . . 14
www.youtube.com/ocpinfo
Ready, Set, PACE . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Pharmacists Now Authorized to Administer
Additional Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . 18
www.linkedin.com/company/
5 Things to Know About Administering Vaccines . . . . . . . 20
ontario-college-of-pharmacists
ISMP Safety Bullentin . . . . . . . . . . . . . . . . . . . . . . . . 21
ISSN 1198-354X Close-Up on Complaints: A Shared Responsibility
© 2017 Ontario College of Pharmacists for Ethical and Effective Pharmacy Services . . . . . . . . . . 26
Canada Post Agreement #40069798
Undelivered copies should be returned to the CQI: An Essential Constituent of
Ontario College of Pharmacists. Not to be Patient/Medication Safety . . . . . . . . . . . . . . . . . . . . . 30
reproduced in whole or in part without the
permission of the Publisher. Thank You, Preceptors and Evaluators . . . . . . . . . . . . . 34
Discipline Decisions . . . . . . . . . . . . . . . . . . . . . . . . . 42
5 Things to Know About Renewing Prescriptions . . . . . . 53
Focus on Error Prevention: Limited Duration of Therapy . 54
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 3
REGISTRAR’S MESSAGE
OCP WELCOMES
NEW REGISTRAR
NANCY LUM-WILSON
On November 24, 2016, Regis Vaillancourt, President of
OCP, announced the appointment of Nancy Lum-Wilson
as Registrar and CEO effective January 9, 2017.
Read the full announcement here.
Nancy Lum-Wilson,
R.Ph., B.Sc.Phm., MBA
Registrar and CEO
As I begin my tenure as Registrar better learnings for practitioners appropriately address current
and CEO of the College, I would and improved care for patients. practice and clearly establish
like to sincerely thank all of those standards of ethical conduct.
who have extended to me such a For many years, I have worked Upon annual renewal this year,
warm welcome. I am excited to get in a wide variety of leadership each member will be required
started and continue the work of and policy roles within Ontario’s to declare that they have read
the College in our role to ensure healthcare system. It is well known and understood the code. This is
patients are provided the highest that our healthcare system must a commitment that they will be
quality of care. transform if it is to be sustainable. held accountable to – whether a
An aging population, an increasing pharmacist, pharmacy technician,
It was my pleasure to attend the complexity of care and shrinking designated manager or director.
December meeting of College funding are resulting in major
Council. While listening to the structural change. Pharmacists and From the regulation of pharmacy
discussion taking place, I witnessed pharmacy technicians alike must technicians to expanded scope
the steadfast commitment from look at better ways of collectively to vaccines, the role of the
both professional and public bringing more value to the table as pharmacy professional has grown
Council members to ensuring members of the healthcare team. tremendously over the last few
that all patients are provided with The focus must be on how they years. As we embark on another
effective and ethical care. The can serve the public with their year, there is opportunity for
College took a big leap forward medication knowledge and clinical transformation, for growth, and for
at this last meeting, approving judgement. a re-commitment to the primary
responsibility as a healthcare
professional: to serve and protect
How we choose to govern ourselves patients. How we choose to
and practice our profession will chart govern ourselves and practise our
profession will chart the course for
the course for years to come. years to come. Ultimately, both the
College and each pharmacist and
pharmacy technician will need to
a motion to move forward with One of the ways in which the continue to develop and earn the
establishing third party medication College has sought to support the public trust.
incident reporting as the standard. expanded role of the pharmacy
While the details are still being professional is through the
developed, it is the College’s firm adoption of the Code of Ethics.
belief that this step will enable The Code was designed to more
PAGE 4 ~ WINTER 2017 ~ PHARMACY CONNECTION
COUNCIL REPORT
DECEMBER 2016
COUNCIL MEETING
As recorded following Council’s regularly scheduled meeting
held at the College offices on December 12th, 2016.
COUNCIL DEBATES Although the College continuously 2016. These standards were based
MEDICATION SAFETY reminds practitioners of their on those that are already in place
responsibility to appropriately in Quebec, which are in turn based
Following a recent tragic incident manage medication incidents on General Chapter of
linked to a compounded medication in their practice through broad the United States Pharmacopeia
error, the College reviewed how communications, and as part of – National Formulary (USP – NF).
medication incident reporting discussions during regular pharmacy Responses were received from
is addressed in practice and practice assessments in hospitals a number of stakeholder groups
what resources are available to and community pharmacies, it including pharmacists, pharmacy
improve and strengthen existing does not currently mandate the technicians and pharmacy
measures. This review also included reporting of medication errors to organizations, the submissions
the protocols and reporting an external body. generally being supportive
requirements of other provincial and providing suggestions to
regulatory authorities, specifically In discussing this issue, Council aid clarity. Feedback will be
Nova Scotia’s SafetyNET-RX and was unanimous in its support of submitted to NAPRA, who will
Saskatchewan’s COMPASS CQI requiring such reporting. The review submissions from across
programs that enable community expectation is that aggregate the country and determine what
pharmacies to anonymously report analyses of medication incidents changes to make, if any. When
medication incidents to a third will be received by the College for NAPRA has completed work on
party (such as the Institute for targeted practice improvement the standards, Council will consider
Safe Medications Practices [ISMP] initiatives. To this end, a Task Force their adoption as well as timing of
Canada). The objective of this will be established to fully examine implementation.
approach, which includes analysis of this subject and to develop a model
factors contributing to the error, is for consultation during January and It is the College’s intention that,
to ensure that all practitioners learn February 2017. The model will be wherever possible, national
from these incidents and review presented to Council for approval standards will be adopted. Most
and enhance their policies and at its meeting in March 2017. recently, Council approved the
procedures to reduce the likelihood implementation by January
of recurrence thereby improving NAPRA’S DRAFT MODEL 2019 of the Model Standards
patient safety. STANDARDS FOR PHARMACY for Pharmacy Compounding
COMPOUNDING OF NON of Non-hazardous Sterile
In a recent letter to the College, STERILE PREPARATIONS Preparations and Model Standards
Minister Hoskins stated “Medication for Pharmacy Compounding of
safety in Ontario is a priority for my NAPRA (National Association Hazardous Sterile Preparations.
ministry, and given recent tragic of Pharmacy Regulatory
events that have been reported in Authorities) developed the draft LEGISLATIVE INITIATIVES
the Ontario media, the proposed Model Standards for Pharmacy
work of the ISMP and OCP is timely. Compounding of Non-Sterile On December 7, the government
I am very supportive of initiatives Preparations which the College introduced the Medical Assistance in
like this to improve transparency posted for consultation between Dying Statute Law Amendment Act,
and safety in pharmacies”. October 20 and November 17, 2016. The Act consists of a series
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 5
COUNCIL REPORT
of amendments that would provide •E
xpand the list of acts of sexual • Improve colleges’ complaints,
more clarity on medical assistance abuse that will result in the investigations and discipline
in dying for patients, families and mandatory revocation of a processes.
health care providers. It would regulated health professional’s
ensure that appropriate coroner license; *In anticipation, the College
oversight of medical assistance in commenced work and has already
dying situations will continue. •R
emove the ability of a regulated implemented changes to the
health professional to continue to public register that support the
Legislation has also been practice on patients of a specific transparency initiative. More
introduced that would, if passed, gender after an allegation or information on these legislative
further protect patients in Ontario finding of sexual abuse; initiatives will be communicated as
and keep them healthy, including it becomes available.
strengthening and reinforcing • Increase access to patient therapy
Ontario’s zero tolerance policy on and counselling as soon as a NEXT COUNCIL MEETING
sexual abuse of patients by any complaint of sexual abuse by a
regulated health professional. Bill regulated health professional is Monday March 20, 2017
87, Protecting Patients Act, 2016 filed;
includes legislative amendments For more information respecting
that would: • * Ensure that all relevant Council meetings, please contact
information about regulated
• Clarify the time period after health professionals’ current and Ms. Ushma Rajdev, Council
the end of a patient-provider past conduct is available to the and Executive Liaison at
relationship; public in an easy-to-access and urajdev@ocpinfo.com
transparent way;
Designated managers are held responsible by the College for the security of drug inventory.
Are your narcotic reconciliations conducted to minimize errors? Here are some best practices:
https://www.youtube.com/watch?v=1OqHH0J6-ak&list=UUzUJKl3pb-vmaFmwLD5I5Qg
Follow @OCPinfo on Twitter and get a helpful practice tip each week.
#OCPPracticeTip
PAGE 6 ~ WINTER 2017 ~ PHARMACY CONNECTION
MEMBERSHIP RENEWAL REMINDER
DUE MARCH 10, 2017
NOTE: No form will be mailed to you, however email reminders will be sent.
If you fail to pay your fees by March 10, a penalty will apply.
Before you begin your renewal you will need:
• Credit Card
• User ID: This is your OCP number
• Password: If you have forgotten your password,
click “Forgot your Password of User ID?”
A new password will then be emailed to you.
Once you’re ready:
• Go to www.ocpinfo.com and click on "Login to my Account"
and then click on "My Account"
• Enter your User ID (your OCP number) and your password
• Once you have successfully logged in, click on "Annual Renewal"
NEWS
This feature in Pharmacy Connection is a place to find information
about news stories we’re following. Here, you’ll read summaries of
recent stories relating to pharmacy in Ontario and Canada.
For the latest updates, stay tuned to e-Connect and www.ocpinfo.com
PROTECTING PATIENTS ACT Term Care to play a greater role patient, to be able to administer the
On December 8, 2016, the in the governance of Ontario’s vaccine safely. The College provides
Ministry of Health and Long Term health regulatory colleges, such as a Guideline – Administering
Care introduced the Protecting making regulations around College Injections and an Administering
Patients Act (also known as Bill committees and panels. Injections practice tool. Also see
87), which makes legislative pages 18-20 for further resources.
amendments around the sexual The introduction of the Act comes
abuse of patients by regulated as a result of the findings and DRUG ABUSE STRATEGY
health professionals. Amendments recommendations of the Minister’s
include: Task Force on the Prevention of According to data from the
Sexual Abuse of Patients and the coroner’s office, at least 165
• Expanding the list of acts of Regulated Health Professions Act. people in Ontario died as a direct
sexual abuse that will result in a result of the use of fentanyl in
mandatory revocation of a license; SHINGLES VACCINE FREE 2015, more than double the
FOR ONTARIO SENIORS number of deaths in 2010.
• Increasing fines for health AGED 65-70
professionals and organizations Governments at all levels are
that fail to report an allegation of As of January 1, 2017, seniors taking action to reduce and
patient sexual abuse to a college; aged 65 to 70 are eligible to prevent an increasing number
receive the shingles, or herpes of overdose deaths related to
• Establishing a minimum time zoster, vaccine free of charge opioids like fentanyl. In the fall,
period after the end of a patient- in Ontario. The vaccine greatly the government of Ontario
provider relationship during which reduces the risk of developing undertook a number of actions,
sexual relations are prohibited; shingles. including delisting high strength
formulations of long acting opioids
• Removing the ability to continue The vaccine is available from from the Ontario Drug Benefit
to practise on patients of a a primary care provider or a Formulary, expanding access to
specific gender after an allegation pharmacy. Patients can receive naloxone overdose medication,
or finding of sexual abuse; the vaccine directly from their and establishing the Patch for
primary care provider at no charge. Patch program. See a recent
• Increasing access to patient Patients who wish to receive the ISMP Safety Bulletin on Opioid
therapy and counselling as soon vaccine at a pharmacy must get Prescribing on page 21.
as a complaint is filed; and a prescription from their primary
care provider and may have to In December, the federal
• Ensuring that all relevant pay the pharmacy a fee for the government introduced the
information about current and vaccine. Shingles vaccine should Canadian Drug and Substances
past conduct is available to the be considered a Schedule I drug at Strategy, which focuses on harm
public in an easy to access and this time, per NAPRA. reduction as the core pillar of
transparent way. Canada’s drug policy. The federal
Pharmacists are reminded they Minister of Health also introduced
The Protecting Patients Act will must have sufficient knowledge, skill Bill C-37. The Bill would alter
also increase the ability of the and judgement respecting both the a number of acts to help both
Minister of Health and Long vaccine and the condition of the health professionals and law
PAGE 8 ~ WINTER 2017 ~ PHARMACY CONNECTION
NEWS
enforcement in their efforts to risks of opioids, supporting better Pharmacists can dispense any
reduce the harms associated with prescribing practices, and reducing formulation of naloxone available
drug use. Amendments include: easy access to unnecessary opioids. for sale and distribution in Canada,
as long as it is in accordance with
• Streamlining the application Many municipal governments have all of the requirements outlined
process for supervised also undertaken strategies to deal in the College’s Guidance –
consumption sites; with opioid abuse in their individual Dispensing or Selling Naloxone. It
communities, including ensuring is the professional responsibility
• Prohibiting the unregistered that first responders are equipped of a pharmacist to ensure that he
import of pill presses; with naloxone. or she has sufficient knowledge,
skills and abilities to competently
• Making it a crime to possess or NALOXONE deliver any pharmacy service. More
transport anything intended to guidance on naloxone is available
be used to produce controlled Public health authorities and on page 14-15.
substances; and governments are strongly
encouraging individuals who are The College has included links to
• Supporting the faster and safer at risk of opioid abuse, or who external training resources for
disposal of seized chemicals and are aware of someone who is, to pharmacists to ensure they are
other dangerous substances. obtain naloxone kits from their prepared to safely and effectively
local pharmacy or public health provide naloxone to a patient or
Health Canada will also continue unit. Ontarians with a health card patient’s agent.
to take actions that align with their are eligible for a free take home
Opioid Action Plan, including better naloxone kit through the Ontario
informing Canadians about the Naloxone Pharmacy Program.
STERILE COMPOUNDING
STANDARDS: IMPLEMENTATION
As previously reported, Council has approved both the Model Standards of Practice for Pharmacy
Compounding of Non-hazardous Sterile Preparations and the Model Standards for Pharmacy
Compounding of Hazardous Sterile Preparations for implementation by January 1, 2019.
The standards will apply in all pharmacies where sterile compounding is done, including drug
preparation premises, community pharmacies and hospital pharmacies.
Community and hospital practice advisors have developed a joint plan to align expectations for
implementation, building on the baseline reviews of hospital pharmacies completed over the last
year and the identification of community pharmacies whose practice includes sterile preparations.
It is expected that pharmacies where sterile compounding is done will have started the process of
conducting a gap analysis comparing the Model Standards against the pharmacy’s own policies,
procedures and facilities. Based on this analysis, a plan will be developed leading to compliance
before the implementation date.
Over the next several months, additional supporting material will be posted to assist
pharmacies in moving forward in this area.
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 9
CODE OF ETHICS
BRINGING THE CODE
OF ETHICS TO LIFE
In 2016, the College launched a series of e-Learning modules to assist current and
future pharmacy professionals in understanding and applying the Code of Ethics in
everyday practice.
Council approved the new Code at their December YOU ARE ACCOUNTABLE
2015 meeting following an extensive development TO THE CODE
and consultative process. Although practice expecta-
tions in the new Code are unchanged, it was updated You are required to make an annual declaration of
to more appropriately address current practice and commitment to the Code of Ethics, starting with this
clearly establish the standards of ethical conduct for year’s renewal. By making this commitment, you are
pharmacy professionals. declaring that you have read and understand the Code
and your accountability to it.
The Code is a comprehensive document that outlines
the core ethical principles that dictate a healthcare All pharmacists and pharmacy technicians must apply
professional’s ethical duty to patients and society. The these ethical principles — not their own beliefs or
Code supports these principles with standards that values — to inform their behaviour and conduct. Your
indicate how a practitioner is expected to fulfill their actions and decision-making in practice should support
ethical responsibilities. these principles and demonstrate your commitment
to serving and protecting patients and society. As a
reminder, the four core ethical principles that the Code
CODE OF ETHICS
is founded on are:
Declaration 1. Beneficence (to benefit)
of Commitment 2. Non maleficence (to do no harm)
I commit to serve and protect my patients and society 3. Respect for Persons/Justice
In keeping this promise:
4. Accountability (Fidelity)
I will put my patients first.
I will “do good” and benefit my patients and society. Abiding by these principles is not optional. In fact,
I will “do no harm” and, whenever possible, prevent harm from understanding and committing to them is part of
occurring. your overriding role and responsibility as a healthcare
I will protect my patients’ vulnerability and respect their rights professional.
as autonomous persons.
I will act as a responsible and accountable fiduciary of the
public trust.
I will act with integrity and will honour the ideals, values and
commitments of my profession.
I will faithfully abide by my profession’s Code of Ethics.
I make this commitment as a healthcare professional
to my patients, society, my profession and to myself.
PAGE 10 ~ WINTER 2017 ~ PHARMACY CONNECTIONCODE OF ETHICS
RESOURCES AVAILABLE
TO SUPPORT YOUR
APPLICATION OF THE CODE
E-LEARNING MODULES
e-Learning modules feature a variety of learning techniques including true and false
questions, whiteboard video and case studies with reflective discussion.
AN INTRODUCTION TO THE CODE OF ETHICS PRINCIPLE OF BENEFICENCE (TO BENEFIT)
This module explores the role and purpose of the As a healthcare professional, you must actively and
Code of Ethics, outlines the professional role and positively serve and benefit your patients and society.
commitment of healthcare professionals and provides This module will emphasize how to apply this principle
an overview of the core ethical principles of healthcare in practice and help you understand that your respon-
that must guide your everyday practice. sibility extends beyond simply ensuring you have
accurately filled the prescription.
PRINCIPLE OF NON MALEFICENCE (DO NO HARM) PRINCIPLE OF RESPECT FOR PERSONS/JUSTICE
In all circumstances, you have an obligation to be You have a dual obligation as a healthcare professional
diligent in your efforts to do no harm and, whenever to respect and honour the intrinsic worth and dignity
possible, to prevent harm from occurring. This module of every patient as a human being, and to treat all
provides examples of the ways that you can help patients fairly and equitably. This module will outline
protect patients from harm, including real life examples components of this principle including recognizing the
where a patient was harmed from lack of action. vulnerability of patients, respecting their autonomy and
decisions, and protecting their privacy.
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 11CODE OF ETHICS
PRINCIPLE OF ACCOUNTABILITY/FIDELITY PROFESSIONAL BOUNDARIES
This principle requires you to be a responsible and Woven throughout the Code is the expectation that
faithful custodian of the public trust, accountable you will assume the responsibility, at all times, for
not just for your own actions and behaviours, but for maintaining appropriate professional boundaries with
those of your colleagues as well. This module explores patients. This module discusses these responsibilities
the professional promise that all health professionals and explores them in practice.
share – to always and invariably act in the best interest
of your patient, not your own.
VIDEO PRACTICE EXAMPLES
The video practice examples provide you with the opportunity to participate in an interactive learning tool that
focuses on a specific ethical dilemma that you may encounter in everyday practice.
APPLYING
CONFIDENTIALITY CONTINUITY OF CARE PROFESSIONAL JUDGMENT
A neighbour comes to you for It’s Friday night and a regular It’s a busy night at the pharmacy
information about her fourteen patient of your pharmacy has and a father is picking up an
year old daughter as she is recently been discharged from antibiotic for his four year old
concerned about her recent hospital. His prescriptions from the daughter. You question the dose
behaviour. What do you do? hospital do not include a regular and duration; the doctor’s office is
medication that he has been taking. closed. What do you do?
You can’t reach his physician; what
do you do?
PAGE 12 ~ WINTER 2017 ~ PHARMACY CONNECTIONWHITE COAT CEREMONIES
White Coat Ceremonies at
UNIVERSITY OF TORONTO
and UNIVERSITY OF WATERLOO
The University of Toronto and University of Waterloo recently hosted ceremonies to formally
mark the beginning of incoming pharmacy students’ professional journey. During the ceremonies,
students make their commitment to ethics and integrity and are welcomed into the professional
community. College Registrar and CEO Nancy Lum-Wilson attended both ceremonies.
OCP Registrar Nancy
Lum-Wilson and OCP President
Regis Vaillancourt speak at the
University of Toronto’s University of Waterloo’s White
Pharmacy Class of 2020 Coat Ceremony
University of
Waterloo’s
Pharmacy
Class of 2020
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 13NALOXONE
NALOXONE:
5 Things Pharmacists Need to Know
Maria Zhang, RPh, BScPhm, PharmD, MSc and Beth Sproule, RPh, BScPhm, PharmD
Centre for Addiction and Mental Health (CAMH)
Leslie Dan Faculty of Pharmacy, University of Toronto
1. NALOXONE IS NOW formulations, intranasal assist a person at risk of
A SCHEDULE II DRUG naloxone is also available opioid overdose.3
without a prescription.
On March 22, 2016, Health Essentially, any Ontarian with a
Canada delisted naloxone as a 2. ONTARIANS WITH health card should be provided
prescription drug.1 The National A HEALTH CARD ARE with a naloxone kit and training,
Association of Pharmacy ELIGIBLE FOR A FREE upon request. Pharmacists’ main
Regulatory Authorities (NAPRA) TAKE-HOME NALOXONE role in this program is to provide
then reclassified naloxone as a KIT THROUGH THE education to naloxone kit recipients
Schedule II medication when ONTARIO NALOXONE and minimize barriers to access.
used in an emergency opioid PHARMACY PROGRAM Those who do not have health
overdose situation outside of Pharmacies are provided up to cards can be directed to local public
hospital settings. $70.00 for each naloxone kit they health units. Intranasal naloxone
dispense and provide training on. is available for free for recently
While most take-home Eligibility criteria for the program released at-risk inmates4.
naloxone kits currently contain include anyone who is:
intramuscular formulations of 3. PATIENTS ON
naloxone, there is an Interim •C
urrently using opioids, CHRONIC OPIOID
Order, issued by the Minister of THERAPY SHOULD
Health that allows the importation •A
past opioid user who is at risk BE OFFERED A TAKE-
and sale of NARCAN® nasal spray of returning to opioid use, or HOME NALOXONE KIT
for the emergency treatment While there are known factors
of known or suspected opioid • A family member, friend, or that increase the risk of opioid
overdoses.2 Like the parenteral other person in a position to overdose, including concurrent
use of other sedating agents (e.g.,
alcohol, benzodiazepines) and
concomitant medical conditions
such as chronic obstructive
pulmonary disease (COPD), it is
clear that there is a link between
daily doses and overdose death.
The risk of opioid-related
mortality is increased even at
doses of 50 mg of morphine
equivalents per day.5 Therefore,
take-home naloxone kits should
be proactively offered to anyone
on chronic opioid therapy,
regardless of dose.
PAGE 14 ~ WINTER 2017 ~ PHARMACY CONNECTIONNALOXONE
Given the profound stigma around people living with 4. PRE-ASSEMBLED TAKE-HOME
substance use disorders, pharmacists may encounter NALOXONE KITS ARE AVAILABLE
patients on opioids who do not wish to receive a Pharmacies no longer have to self-assemble take-
naloxone kit. Pharmacists can highlight that having home naloxone kits as pre-assembled ones are
a naloxone kit around the house is a way to protect available for ordering. Pharmacies are encouraged
the person using opioids, and anyone who may to check with their usual pharmaceutical distribution
inadvertently consume them, and describe it as similar channels.
to having a first-aid kit.
5. RESOURCES EXIST TO SUPPORT PHARMACISTS
IN PROVIDING NALOXONE KIT TRAINING
Centre for Addiction and Mental Health:
• Pharmacists’ Checklist (vial or ampoule)
• “ 5 Steps to Save a Life” kit insert for naloxone kit recipients
•P
oster for dispensing area
•P
ortico clinical tools for opioid misuse and addiction,
including specific naloxone resources
University of Waterloo
•N
aloxone at pharmacies: what you need to know to combat the opioid crisis
•V
ideo: How to administer naloxone (ampoule)
*Note: do not need to open (or use) an alcohol wipe to open an ampoule
Ontario College of Pharmacists
•G
uidance for Pharmacists on Dispensing or Selling Naloxone
Ontario Pharmacists Association
•T
ake home naloxone in community pharmacies: online module
REFERENCES: Ontario Naloxone Pharmacy Program. Retrieved
from: http://health.gov.on.ca/en/public/programs/drugs/
1. Health Canada. 2016a. Notice: Prescription Drug naloxone.aspx
List (PDL): Naloxone. Retrieved from: http://www.hc-sc.
gc.ca/dhp-mps/prodpharma/pdl-ord/pdl-ldo-noa-ad- 4. Margison, A. 14 October 2016. Ontario inmates
naloxone-eng.php first to get naloxone opioid overdose spray. CBC
News. Retrieved from: http://www.cbc.ca/news/canada/
2. Health Canada. 2016b. Notice - Availability of kitchener-waterloo/ontario-inmates-first-to-get-
Naloxone Hydrochloride Nasal Spray (NARCAN®) naloxone-opioid-overdose-spray-1.3804151
in Canada. Retrieved from: http://www.hc-sc.gc.ca/
dhp-mps/prodpharma/activit/announce-annonce/ 5. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, &
notice-avis-nasal-eng.php Juurlink DN. (2011). Opioid dose and drug-related
mortality in patients with nonmalignant pain. Arch
3. Ministry of Health and Long-Term Care. 2016. Intern Med. 171(7):686-91.
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 15PACE
Ready, SET, PACE
COLLEGE LAUNCHES NEW APPROACH TO ASSESSING
APPLICANTS’ READINESS FOR PRACTICE
All registered pharmacy students who started the SPT process practice opportunities. Following
beginning the registration process before January 18, 2017. assessment, guidance will be
in Ontario must now go through offered to candidates with
the new Practice Assessment of In PACE, a candidates’ ability to identified practice performance
Competence at Entry (PACE), demonstrate entry-to-practice gaps to support appropriate
unless they are actively engaged competence in a practice setting individualized development prior to
in the University of Waterloo or is assessed by College-appointed re-assessment. The practice-based
University of Toronto PharmD pharmacists - PACE Assessors. registration requirement is met
programs. The existing Structured Candidates demonstrate their when a candidate demonstrates
Practical Training (SPT) program will knowledge, skills and abilities entry-to-practice competence to
continue for interns and students while engaged in on-site the validated standard.
THE PACE PROCESS
STEP ORIENTATION (ONE WEEK)
1 The candidate has an orientation to the practice site and gets familiar with the workflow and
processes before engaging in practice.
STEP ASSESSMENT (TWO OR THREE WEEKS)
2 The candidate engages in the scope of practice of the profession over 70 hours on either a
two-week full time or three-week part-time basis to demonstrate their competence. The PACE
Assessor observes their practice and assesses it against the PACE Assessment Criteria. The
candidate will also document examples and situations of their practice experience in an online portal.
STEP OUTCOME (UP TO TWO WEEKS)
3 The candidate is notified of the outcome of the assessment: Competence Demonstrated or
Development Required.
STEP FEEDBACK & PLAN DEVELOPMENT
4 (FOR CANDIDATES REQUIRING DEVELOPMENT)
The candidate creates a self-directed learning action plan to address gaps in their competence.
College staff provide support to the candidate in the development of their learning action plan.
The candidate works with a coaching pharmacist to implement their plan.
PAGE 16 ~ WINTER 2017 ~ PHARMACY CONNECTIONBE A PACE ASSESSOR:
SUPPORT THE FUTURE
OF THE PROFESSION
The Role of a PACE Assessor
PACE assessors supervise candidates to help
the College determine if that candidate has met
the practice-based registration requirement.
Assessors directly observe the candidate over
a specified period of time. Once this period is
over, they use the validated Ontario Pharmacy
Patient Care Assessment Tool (OPPCAT) to
rate the candidate’s ability to demonstrate the
entry-to-practice competencies outlined in the
PACE Assessment Criteria, and then submit
their completed assessment to the College.
The College applies a standardized scoring
rubric to the assessor’s ratings to determine if
the candidate has successfully demonstrated
their competence at entry-to-practice or if
additional development is required.
• Currently practicing a minimum of 24 hours per
The Benefits week in a community or hospital pharmacy in
PACE assessors: Ontario that supports a diverse patient population
and delivers a wide range of pharmacy services;
• Receive specialized training and have opportunities
for ongoing skills development; • Understanding of and commitment to the
Standards of Practice and the Code of Ethics;
• Develop skills and experience that will be
valuable for future roles with the College; • Strong advocate of outstanding patient care and
public protection;
• Ensure that future pharmacists are
competent to deliver patient care; • Willing to engage and maintain competence in
using the assessment tool;
•A
re publicly recognized as practice
leaders in Pharmacy Connection; and • Experience in fostering collaborative
relationships; and
•R
eceive an official Certificate of
Appointment from the College. • Excellent verbal, written and listening skills.
The Qualifications To learn more and explore whether you could be
a PACE Assessor, please visit the PACE Assessor
The College looks for the page under Key Initiatives on the College website or
following when selecting contact regprograms@ocpinfo.com
assessors:
PACE will allow for support from the profession in roles
• Experience providing beyond being an assessor. If you have enjoyed being a SPT
patient care as a preceptor for students and interns in the past, please contact
pharmacist in us to find out how you can continue to positively influence
Canada for at least and share your expertise with new practitioners within the
two years; PACE model.
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 17VACCINES
PHARMACISTS
NOW AUTHORIZED
TO ADMINISTER
ADDITIONAL
VACCINES
Amended regulations under the Pharmacy Act expand patient of their option to have the vaccine
pharmacist authority relating to the administration administered by their primary health care provider
of vaccines. Building on the success of pharmacists’ free of charge prior to administering the vaccine
participation in the administration of flu shots at a cost to the patient.
through the province’s Universal Influenza Immuniza-
tion Program (UIIP), these recent changes provide Authority includes vaccinations for:
patients with more convenient access to many routine
1. Bacille Calmette-Guérin (BCG)
vaccines, particularly related to travel. Additionally,
patient safety will be improved because temperature 2. Haemophilus influenzae type b (Hib)
sensitive vaccines can now be administered on-site
3. Hepatitis A
at the pharmacy, instead of having to be transported
to another location for administration by a different 4. Hepatitis B
healthcare provider.
5. Herpes Zoster (Shingles)
CHANGES TO THE REGULATIONS 6. Human Papillomavirus (HPV)
7. Japanese Encephalitis
Pharmacists, pharmacy students and interns who have
registered their injection training with the College are 8. Meningococcal disease
now permitted to administer vaccines to any patient
9. Pneumococcal disease
five years of age or older for 13 vaccine preventable
diseases in the following circumstances: 10. Rabies
11. Typhoid
• The patient is prescribed a Schedule I vaccine
specified in the regulations; and/or 12. Varicella
13. Yellow Fever
• The patient requires a Schedule II vaccine specified in
the regulations.
Additionally, the authority to administer the influenza
Where a patient meets eligibility criteria for publicly vaccine in accordance with the Universal Influenza
funded vaccines (e.g., routine childhood immunization, Immunization Program (UIIP) has been extended to
HPV for grade 7 or 8 students, pneumococcal for pharmacy students and interns.
seniors aged 65+, etc.), pharmacists must inform the
PAGE 18 ~ WINTER 2017 ~ PHARMACY CONNECTIONVACCINES
REQUIREMENTS FOR THE The College has developed an Administering a
ADMINISTRATION OF VACCINES Substance by Injection or Inhalation Guideline to
The requirements for the administration of these new provide further guidance to pharmacy professionals
vaccines align with the requirements already established when administering a vaccine.
for the administration of any substance by injection or
inhalation. INJECTION TRAINING AND
REGISTRATION WITH THE COLLEGE
These include: Injection training requirements and courses are the
• All injections are administered in an appropriate same for administration of any injection. Pharmacists
environment that is safe and clean; must successfully complete OCP approved pharmacist
injection training, maintain certification in CPR and First
• The appropriate infection control procedures are Aid, and register their training with the College.
in place;
Pharmacy students and interns are permitted to
• A practitioner may only administer a substance by administer vaccines subject to the terms, limits and
injection after receiving informed consent from the conditions imposed on their certificate of registration.
patient, or his or her authorized agent; Students and interns who attend the University of
Waterloo (2012 and onward) and graduates of the
• A practitioner has sufficient knowledge, skill and judge- University of Toronto (2013 onward) receive the
ment respecting both the vaccine and the condition of injection training as part of their curriculum. Prior to
the patient, to be able to administer the vaccine safely; administering an injection, the supervising pharmacist
• A vaccine is only administered when it is in the best must confirm that the student or intern has completed
interest of the patient, given the known risks and all necessary training.
benefits and the safeguards and resources available Pharmacy professionals are reminded that they are
to safely manage any outcomes after administration, accountable for practising within their scope of practice,
including any adverse events; the terms, conditions and limitations on their certificate
• Documentation requirements are met; and of registration, if any, and in accordance with their
knowledge, skill, and judgment. A pharmacy professional
• The patient’s primary care provider (if any) is notified is expected to assess his or her continuing education
within a reasonable time after administration. needs prior to administering a vaccine.
MESSAGE FROM NAPRA:
IMPORTANT INFORMATION FOR ONTARIO
PHARMACISTS ON VACCINE SCHEDULING
Pharmacists may have questions regarding • HPV vaccine is part of routine immunization
the schedule of certain vaccines. Of the programs in all provinces and territories and
13 additional vaccines now permitted, would therefore be considered Schedule II.
11 are specifically listed in the National
Drug Schedules (NDS). However, human • Shingles vaccine is currently part of the
papillomavirus (HPV) vaccine and herpes zoster routine program only in Ontario and would
(shingles) vaccine are not listed. therefore not meet the criteria for Schedule
II. Shingles vaccine should be considered a
The NDS states that vaccines are Schedule I Schedule I drug at this time.
unless they are “part of a routine immunization
program in most/all provinces and territories,” in Information on routine immunization
which case they are Schedule II. It is permissible schedules across Canada can be found at
to apply the criteria to other vaccines that are healthycanadians.gc.ca
not specifically listed in the NDS.
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 195 THINGS TO KNOW
5 Things to Know
About Administering Vaccines
Pharmacy professionals have As with any learned skill, practice • Details on the vaccine
an ethical and professional is important to be comfortable administered (e.g., name, strength,
responsibility to recognize and and confident when performing volume, site of administration, lot
practice within the limits of their injections. When not part of number, DIN, expiration date);
competence and with the patient’s routine practice, it may be • Circumstances relating to any
best interest in mind. challenging to gain hands-on adverse reaction experienced
experience. Consider taking a by the patient, and treatment
1. Identify Learning Opportunities refresher course or enlisting recommended or administered as
the support of a peer who has a result;
Pharmacists, interns, and students
mastered the technique to help you
must possess sufficient knowledge • Notification to the patient’s
brush up on your injection skills.
of the vaccines and associated primary care provider; and
conditions to administer them safely. 3. Store Vaccines Appropriately • Provision of proof of vaccination
This includes assessing the patient to the patient for their vaccine
to determine the clinical appro- Designated managers are respon- administration record.
priateness of a vaccine, whether sible for overseeing inventory
Refer to the College’s
prescribed, requested by the patient management in the pharmacy.
Documentation Guidelines for
or recommended by the pharmacist. Policies and procedures must be in
additional guidance.
place to handle and store vaccines
Pharmacists are expected to appropriately and address any 5. Know the Limits of
engage in routine self-assessment deviations. This includes managing Independent Authority
and to pursue continuing education the cold-chain from procurement
when gaps are identified. OCP to administration, regular monitor- Situations may arise where a
provides a number of tools to assist ing of the ambient pharmacy pharmacist is asked to administer
practitioners with ongoing learning temperature, and temperature an injection that falls outside of the
and professional development, control of the refrigerators and/ vaccines or circumstances included
including a listing of CE resources or freezers used. In addition to in Regulations. In these instances,
available on the OCP website. having adequate storage facilities, delegation of authority from
pharmacy staff must be familiar another healthcare professional
2. Use Proper Technique
with and adhere to OCP’s Policy with this authority would be
Pharmacists, interns, and students — Protecting the Cold Chain. required, such as a Medical
must possess sufficient skills Directive or a Direct Order.
4. Maintain Effective
to perform a vaccine injection
Documentation Prior to accepting delegation,
properly. This is essential to
members should be familiar with
minimize the potential for adverse Documentation on the patient OCP’s Policy of Medical Directives
reactions and ensure effective record should include relevant and Delegation of Controlled Act
levels of immunity are attained. details, such as: and understand their professional
Prior to giving an injection to a responsibilities in doing so.
• Information on the pharmacist
patient, the practitioner must Collaboration and communication
who performed the injection (and
use aseptic technique, properly with the prescriber in both
the supervisor, if applicable);
landmark the appropriate injection delegation scenarios is important
• The clinical assessment and to ensure the best possible patient
site, select the appropriate needle
information gathered from outcomes.
length and volume, and decide if a
the patient;
bunching or flattening technique
should be used1. Other learned skills •C onfirmation that an informed
consent was given by the patient
1
http://healthycanadians.gc.ca/publications/
include inserting the needle at the healthy-living-vie-saine/1-canadian-immu-
correct angle and depth, the rate of or his or her authorized agent; nization-guide-canadien-immunisation/
administration, and managing the •T he date and location the act was index-eng.php?page=8#p1c7a3b
patient’s pain perception. performed;
PAGE 20 ~ WINTER 2017 ~ PHARMACY CONNECTIONISMP CANADA
Institute for Safe Medication Practices Canada A KEY PARTNER IN
REPORT MEDICATION INCIDENTS
Online: www.ismp-canada.org/err_index.htm
Phone: 1-866-544-7672
Volume 16 • Issue 8 • November 29, 2016
Safer Decisions Save Lives: Key Opioid Prescribing Messages
for Community Practitioners
the community, as well as regulatory colleges,
• Do not prescribe potent opioids for minor pain. legislators, and the general public.
• Chronic opioid therapy should be reserved for
chronic pain that impairs daily function and has Selection of Patients for Opioid Therapy
not responded to non-opioid treatments.
• If opioid therapy is chosen, it should be treated as a Do not prescribe potent opioids for patients
therapeutic trial. Prepare patients for the possibility with minor pain.
that therapy will be discontinued if it is ineffective
or there is evidence of harm. Potent opioids (e.g., morphine, oxycodone,
hydromorphone) are not needed for treatment of
• Educate patients about opioid-associated harm
minor pain (e.g., pain resulting from musculoskeletal
and prevention of overdose.
injuries, minor surgery, or dental work), and their use
• Understand how to recognize opioid use disorder in this context can delay a patient’s return to work.
and how to initiate or refer a patient for treatment. These drugs are suitable for pain associated with
major trauma (e.g., fractures, major surgery), but
should not be prescribed for longer than the expected
recovery time (usually less than 1-2 weeks).
In fall 2015, ISMP Canada brought together a panel Emergency, urgent care, and walk-in clinic physicians
of opioid experts from across Canada to identify should prescribe quantities that will last only a few
prescribing and management practices likely to result days, until patients can be seen by their regular
in better opioid prescribing in the community, physician.
especially for treatment of chronic noncancer pain.
The panel identified a number of themes on opioid Reserve opioids for patients with severe, chronic
prescribing and management, which were further noncancer pain that impairs daily function.
refined into key opioid prescribing messages.*
Although the practices described in these messages Opioids should be considered only after adequate
will be particularly helpful to community prescribers, trials of all non-opioid treatments that are appropriate
their relevance extends to all healthcare providers in for the underlying condition. Do not prescribe opioids
*
This bulletin is not intended to be comprehensive and must be evaluated in the context of professional standards, regulations, and
expectations. Not all evidence, knowledge, or advice may have been available or taken into account when this document was prepared,
and not all possible practices informing opioid prescribing may have been considered or presented. The opinions, principles, guidelines,
practices, and advice outlined in this document are not necessarily those of the project participants, the partnering organizations, or
Health Canada, which funded the project.
ISMP Canada Safety Bulletin – www.ismp-canada.org/ISMPCSafetyBulletins.htm 1 of 7
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 21ISMP CANADA
for fibromyalgia, headache, or low back pain. There Start with weak opioids first.
is no compelling evidence of effectiveness in these
situations, the pain relief will be minimal, and any Weak opioids include codeine, tramadol products,
benefits are typically outweighed by side effects and and transdermal buprenorphine. Switch to a potent
risk of harm. opioid only if the weak opioid is ineffective. If a
potent opioid is needed, use low doses of a
Prescribe opioids with caution for patients at short-acting formulation for initial titration. Avoid
high risk of addiction. fentanyl. Do not prescribe benzodiazepines
concurrently with opioids.
There are 2 major risk factors for opioid addiction:
• current or past history of alcohol or substance use Recommend the lowest possible dose for the
disorder shortest possible time.
• current or past history of a psychiatric disorder
(including anxiety, depression, and post-traumatic Low doses and slow dose titration are appropriate for
stress disorder) all patients, but are especially important for those at
risk for opioid-induced falls, sedation, and other
Do not prescribe potent opioids for high-risk patients harms. Risk factors for opioid-induced falls, sedation,
unless they have a pain condition that interferes with and other harms include advanced age, concomitant
daily life and has not responded to a full trial of all benzodiazepine or other sedating medications,
major pain treatments (e.g., nonsteroidal alcohol use, sleep apnea, and impairment of renal,
anti-inflammatory agents, antidepressants, hepatic, or respiratory function. Do not prescribe
anticonvulsants, physiotherapy and other opioids for nighttime use by elderly patients who are
nonpharmacologic therapies). In cases where opioids at high risk for falls.
are to be prescribed for high-risk patients, avoid
hydromorphone, fentanyl, and oxycodone; dispense Advise patients about opioid-related harms and
small quantities at frequent intervals (rather than prevention of overdose.
larger amounts at extended intervals); order regular
urine drug screens to identify use of nonprescribed Use patient-specific handouts, such as Opioid Pain
opioids, benzodiazepines, or other drugs; and educate Medicines–Information for Patients and Families, to
patients and families about overdose and harm support discussion of the following issues of concern:
prevention. • impairment of ability to drive or operate machinery,
especially after initiation of an opioid or after an
Opioid Selection and Dosage increase in dose
• avoidance of the combination of opioids with
Treat all opioid prescribing as a therapeutic trial. alcohol, benzodiazepines, or illicit drugs
• the need to alert family members and friends to the
There have been no long-term (> 1 year) controlled initiation of opioid treatment, as well as the
trials of the effectiveness of opioids, and cohort symptoms and signs of opioid toxicity
studies have indicated that patients receiving long- • the requirement for secure storage of opioids,
term opioid therapy have worse pain and function especially if children or young adults live in the
outcomes than patients with similar pain conditions same house as the patient
who are not taking opioids. Therefore, the opioid • the requirement to not share opioids with others or
should be tapered and discontinued if it does not take opioids from others
significantly improve pain and function at a dose of • the method for obtaining naloxone from
50 mg MED† or if the patient experiences fatigue, community naloxone programs or pharmacies,
sedation, or other side effects. where available
†
MED = morphine equivalents/day, also known as morphine milligram equivalents (MME)/day. This is the total amount of opioid
consumed in a 24-hour period, converted to the morphine-equivalent daily dose in milligrams. Potency ratios: morphine = 1,
oxycodone = 1.5, hydromorphone = 5 (available from http://nationalpaincentre.mcmaster.ca/opioid/cgop_b_app_b08.html).1
ISMP Canada Safety Bulletin – Volume 16 • Issue 8 • November 29, 2016 2 of 7
PAGE 22 ~ WINTER 2017 ~ PHARMACY CONNECTIONISMP CANADA
Keep the dose below 50 mg MED. Opioid Use Disorder: Diagnosis and
Management
Most patients respond well to doses of 50 mg MED
or less. For patients receiving opioid doses above Know how to diagnose opioid use disorder.
90-120 mg MED, strongly consider requesting a
second opinion from another healthcare provider, and The clinical features of opioid use disorder include
advise these patients to get a naloxone kit from the requirement for higher doses than expected for an
pharmacy, where available. The risk of overdose and underlying pain condition, resistance to tapering
the inherent risk of addiction increase steeply at despite poor analgesic response, alarming behaviours
higher doses. (e.g., patient frequently runs out early; patient
accesses opioids from other sources; patient snorts,
Tapering Opioids crushes, or injects oral opioids), poor psychosocial
function and mood, and binge use with frequent
Taper the opioid dose when necessary. withdrawal symptoms.
Taper the dose in the following situations: If the diagnosis is unclear, prescribers should:
• patient has experienced no improvement in • closely monitor the patient with frequent visits and
function with opioid therapy urine drug screens (at least every 2 weeks)
• patient is experiencing opioid-induced sedation, • dispense opioids frequently (1-7 times weekly) in
depression, fatigue, sleep disturbance, or other small quantities
harm • closely monitor the patient’s pain and function
• there is a concern that the patient is experiencing • refer patients to and/or seek a consult (by phone or
opioid-induced hyperalgesia email) with an addiction physician
• there is a concern that the patient may have an
opioid use disorder If the patient has an opioid use disorder, develop
and discuss the treatment plan with the patient.
Consider tapering for any patients who are receiving
doses above 50 MED, particularly those whose doses Include the following messaging in your discussion
are over 200 MED. Many patients on higher doses of the treatment plan:
will actually experience improvements in their pain, • options for initiation of buprenorphine or referral to
mood, and function when their dose is lowered. an addiction specialist
• anticipated benefits of the treatment plan, including
Taper doses by no more than 10% of the total daily reduction of pain, prevention of overdose, and
dose every 1-4 weeks. Whenever possible, use improvement in mood, energy level, and function
scheduled rather than as needed (PRN) doses.
Dispense small quantities frequently (as often as For most patients with opioid use disorder,
daily), depending on the patient’s adherence to the initiate buprenorphine or refer the patient to an
tapering schedule. addiction physician for buprenorphine or
methadone treatment.
For patients who are taking high doses, do not
stop the opioids suddenly. Both buprenorphine and methadone have been shown
to dramatically reduce opioid use, crime, and
Abrupt cessation may cause patients who are taking overdose. Buprenorphine can be safely prescribed
high doses to go into severe withdrawal. This may and managed by family physicians.
lead them to seek other sources of opioids, which
puts them at risk of overdose and other harms. If the patient refuses the treatment plan, and will not
attend an addiction clinic, then taper the dose over
1-3 months, with frequent dispensing (as often as
ISMP Canada Safety Bulletin – Volume 16 • Issue 8 • November 29, 2016 3 of 7
PHARMACY CONNECTION ~ WINTER 2017 ~ PAGE 23You can also read
