COVID-19 Pharmacotherapy Update from the PAMS Service 

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The PAMS Service will continue to operate during COVID-19.

You can contact us by calling 1800 443 844, (free call from landlines, most mobiles, and all public phones).

During the last 4 weeks or so, we have had several calls from pharmacotherapy consumers who are worried about various aspects of the program, given the international COVID-19 pandemic.

We would like to reassure people on methadone or buprenorphine (Subutex) or buprenorphine-naloxone (Suboxone) that:

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1. the supply of these medications can be guaranteed in Australia for the foreseeable future.

2. Pharmacies are ‘essential services’ and are therefore likely to remain open during COVID-19.

3. Importantly, all pharmacotherapy dispensing pharmacies have been encouraged to have plans in place in order to ensure ongoing service delivery in the event the pharmacy had to close for a short period (e.g. due to staff sickness).

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PAMS has developed “Some Helpful Tips for People on Pharmacotherapy Programs”. Given information is changing rapidly during the COVID-19 pandemic, we have now updated and added to our “helpful tips” which can be found here.

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What has changed for Victorian Pharmacotherapy Consumers as a Result of COVID-19?

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New COVID-19 Specific Pharmacotherapy Guidance:  In consultation with several experts, (including PAMS), the Department of Health and Human Services (DHHS) have released an interim guidance which aims to make life safer for Victorian pharmacotherapy consumers and service providers during COVID-19.

Currently, this guidance is in place only in response to COVID-19 and may be removed after the pandemic eases.

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1. Take-Away Doses, (TAD):  We all know we are being encouraged to “stay at home” as much as possible during COVID-19. The less contact we have with other people, (e.g. on public transport, at the pharmacy or in the street), the safer we and our loved ones are likely to be.

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Given this interim guidance is now in place, some people might be eligible for TADs for the first time and others may be able to get additional TAD’s. The new (COVID-19 specific) Victorian TAD policy can be found here. A tool has been developed to help prescribers assess patient eligibility for TADs during COVID-19 which can be found here.

Contra-indications to TADs: Please remember that both your pharmacist and prescriber must be in agreeance before you can get TADs or additional TAD’s.

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There are 4 circumstances when it is not considered safe to have TADs, these are:

1. Recent OD reported with any substance

2. Recent diversion of doses to others, sharing or trading of doses

3. No safe and secure storage facility available

4. Serious and immediate risk of harm to self or others

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Talking to your prescriber and pharmacist about TAD’s/extra TADs: If you feel you would benefit from a TAD review, PAMS staff suggest you consider the following:

• Get yourself a safe, secure storage facility: this can be as simple as finding a secure place, (e.g. a locked drawer or filing cabinet) where your TADs can be safely stored away.

If your TADs are stored safely:

• You are unlikely to lose your dose/doses if your accommodation is burgled,

• Your confidentiality is maintained regarding the program and family members/non-using friends

• Your doses are kept safe from children and even pets!

• There is much less chance of an accidental, methadone-related overdose occurring.

• Remember: having a safe, secure storage facility is a requirement for TADs.

 

• Talk to your pharmacist first – ask if they would be happy to dispense TADs or additional TADs before you talk to your prescriber, (getting the support of your pharmacist is essential).

• Do the “check-list for assessing appropriateness of TAD’s to support continuity of pharmacotherapy during the COVID-19 pandemic” yourself first. This will give you a good idea of what your prescriber might consider when faced with this question. The checklist can be found here.

• Talking to your prescriber: think about the points you want to get across to your prescriber regarding TAD’s and why you feel you would benefit from them.

  • Do you have any other chronic conditions that might make you more at risk of COVID-19 (e.g. history of respiratory problems, immune compromised, living with elderly relatives, are you over 60 years etc).

  • Do you have to travel to the pharmacy on public transport, do you live in rural/regional Victoria with no car and public transport has been reduced etc.

• When talking to your prescriber, try not to demand what you want, instead try to explain the problem, and ask for their input and opinion. Importantly, maintain your cool, getting angry just makes everything worse for everyone!

 

1. 3rd Party Pick-up:  A formalised arrangement is now in place whereby if you must isolate or are unwell and therefore unable to present for an in-store dose, it is now possible to have your dose/s collected by another, (officially authorised) person, referred to as a ‘3rd party’.  If you find yourself possibly needing a ‘3rd party pick-up’, you may want to consider the following questions:

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Who should I choose to collect my dose/s? The ‘3rd party’ needs to be somebody you trust (if it is a person you know). Importantly, there is a requirement the ‘3rd party’ has photo ID. If you do not have a family member or friend who is appropriate to collect your dose/s, then the next option would be to ask a case worker (if you have one), failing this it is possible to utilise a courier company. Importantly, both the prescriber and pharmacist will need to approve of the 3rd party you have nominated.

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Will there be any additional costs to me? Any doses collected by the ‘3rd party’ must be dispensed by the pharmacist as a TAD/s. In some instances, pharmacists charge additional fees for dispensing a TAD (e.g. for a bottle). We would hope there would not be any further cost to the consumer, aside from the usual dosing fees. However, if a courier company is used, they will likely charge a fee for service.

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What, (if any) changes need to be made to my script? Your pharmacotherapy prescription will need to reflect a TAD for each dose to be collected by the 3rd party. As an interim measure this could be a verbal authorisation from the prescriber to the pharmacist, however an actual prescription will need to be supplied as soon as practicable.

How are the doses transported from the pharmacy to me? It is essential for the ‘3rd party’ to understand the need to collect the dose/s from the pharmacy and transport them directly to you, the consumer. Doses should, (ideally) be transported by car as opposed to public transport wherever possible. Under no circumstances should your doses be left unattended, (e.g. in a car) for any period.

Who signs for the doses and how does this process happen? Your doses will need to be signed for at the pharmacy by the 3rd party.

Are there any forms that need to be completed? There are forms available to assist with 3rd part pick-up. Although not mandatory, these documents can assist to formalise the 3rd party pick-up process and outline the various roles and/or responsibilities of all parties involved. These forms can be found here.

We refer to the issue of ‘3rd party pick-up’ when we discuss “what do I do if I have tested positive or need to isolate”, which can be found here.

The actual guidelines on 3rd party pick-up can be found here.

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Prescription Length: Once you are stable on a program, most prescribers write a pharmacotherapy prescription for a month. However, during COVID-19, prescribers are being encouraged to write prescriptions for up to 6 months.

There are a few reasons for longer pharmacotherapy prescriptions during COVID-19, including:

• If your prescriber became unwell, (e.g. had to self-isolate) and there was nobody to write your prescription from the same clinic, a longer script would hopefully allow your prescriber enough time to recover. Providing you do not miss 4 doses in a row, you can likely continue to dose.

  • Hopefully, if your prescriber is seeing less patients face to face due to longer prescriptions, they are less likely to become unwell, 

• Reduced travel to medical appointments, means overall less exposure to other people e.g. on public transport and/or inside the clinic.

• Remember, if you do get a longer script it is likely your prescriber may want to have regular check-ins with you, (these can now be done over the phone or by videoconferencing – see below).

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Tele-health:  Pharmacotherapy prescribers can now bulk-bill patients through Medicare for consultations by phone or videoconference, (tele-health).

In relation to tele-health, PAMS suggest that you consider the following:

• Before your next medical appointment, contact your prescriber’s clinic to find out if they require you to attend in person or if they offer tele-health.

  • If your preference is for tele-health and it is offered by your prescriber, ask if there is anything you need to do, (e.g. is there an application you need to download for a videoconference or tele-health consult?)

• Make sure that your medical clinic have your recent contact details, (mobile phone number, email address and next of kin/emergency contact), store the clinic phone in your mobile phone so you will know if they are calling you.

• Before the tele-health consultation ends, ask your prescriber for the date your prescription expires and when the next consult will be – make sure you have these dates recorded somewhere safe.

• If there is anything that worries you about using tele-health, (e.g. your privacy/confidentiality, understanding of and/or availability of technology etc), please raise these issues with your medical clinic or pharmacotherapy service provider.

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What do I do if I think I might have COVID-19 or may be required to self-isolate?

Opioid Withdrawal and COVID-19: Some of the symptoms of COVID-19 can be a little like opioid withdrawal, therefore it is important not to jump to any rash conclusions.

If you are on a program and think you might have COVID-19 or may be required to isolate, we suggest you follow the steps below, including:

Call the COVID-19 hotline, (PH: 1800 675 398) – they will advise if you need to be tested and provide information on test sites etc.

NEGATIVE COVID19 TEST RESULT - Nothing needs to change

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POSITIVE COVID19 TEST RESULT - 

Call your prescriber’s clinic and tell them you have a positive test result for COVID-19.

• It is likely that your prescriber will allow you to have additional TADs to cover the period you need to isolate.

• Your doses can be collected by a 3rd party, (e.g. a person who is a friend/relative, case worker)

The interim COVID-19 guidelines cover 3rd party pick-up, more information, (including specific consent forms) can be found here.

*We strongly suggest you consider who this (‘3rd party) person might be NB: it must be a person who you trust to collect and transport your doses to you, has photo ID and the pharmacist and prescriber approve of.

Contact your dosing pharmacy and inform them you have a positive test result for COVID-19. that you have spoken to your prescriber and who your nominated 3rd party is.

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If you are  worried or feel you are not able to do this on your own, or if you have any questions, or concerns please call PAMS on  1800 443 844 so we can help guide you through it.

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More Tips for People on Pharmacotherapy During COVID-19

If you have not seen the first lot of tips, they can be found here.

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New Tips for People on Pharmacotherapy:

Stay on your pharmacotherapy program: over the last couple of weeks, some people on methadone or buprenorphine-naloxone have reported to PAMS that they either missed doses or at worst stopped dosing altogether in an attempt to avoid COVID-19 or to keep family/friends safe. In all honesty, this is crazy, you need your dose, (usually daily).

If opioid dependent and not on a program, consider starting treatment: over recent weeks, we have been hearing that supplies of illicit drugs such as heroin are dwindling, quality is decreasing, and prices are increasing. We have experienced an increased demand for the methadone/buprenorphine-naloxone program in recent weeks. In order to prevent the possibility of opioid withdrawal, we encourage you to consider starting/re-starting treatment for opioid dependence, (pharmacotherapy).

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Get Naloxone: as we all know, naloxone is used to reverse an opioid overdose, including a methadone overdose. With an increased amount of methadone TADs and a supply of heroin that is likely fluctuating, the more Naloxone in circulation the better we can respond to an opioid overdose. We strongly encourage you to ask your prescriber for a prescription of Naloxone.

NB: All pharmacotherapy prescribers are being encouraged to provide each patient with a prescription of Naloxone.

If you get more TADs, please look after them: it is very easy for us to forget that just one methadone dose can kill several non-opioid-tolerant individuals. One of the contra-indications to getting TADs is having no safe storage unit. If your TADs are stored safely, there is no chance that kids, teenagers, visitors, (even house breakers) will be able to get hold of them. A pin-code safe can be purchased relatively inexpensively, otherwise a lockable cabinet or drawer can be utilised.

TADs of buprenorphine-naloxone, (Suboxone Film): people who are stable on Suboxone Film may find themselves with a 14-28-day supply of TADs during COVID-19. Please be very careful about ensuring you keep track of your TADs and do not miss the day you are due back at the pharmacy for your next in-store dose.  Missing doses during COVID-19 can be risky as if you miss more than 4 in a row, you will have to be reviewed by your prescriber before you can resume dosing. Complications can occur if your prescriber is

• unavailable, (e.g. due to being unwell),

• reluctant to re-start people via tele-health (if this is all your prescriber offers)

• insisting you see a new prescriber (if you have no history with the new prescriber it might be difficult to get TADs).

Tip,: set an alarm/reminder message on your phone so you do not miss a dose/s at the pharmacy.

Photo ID: Having photo ID is always handy. For example, many prescribers require photo ID at the first appointment and pharmacists often ask for it along with a certified photograph, (colour photo of you signed by your prescriber). If you are required to self-isolate and need to arrange for a “3rd party” to collect your doses for a short period, the 3rd party will require photo ID. It is even possible you may become a nominated 3rd party if an acquaintance must isolate.

Tip: If you do not have any photo ID, we strongly suggest you consider getting it.

Update your contact details: It is easy to miss a call from your prescriber or pharmacist, especially if you do not have their contact details saved in your phone’s ‘contact list’. During COVID-19, it is essential you do not miss an important call such as this, (you might be called to change an appointment time, inform you about tele-health, let you know of a change to pharmacy dosing arrangements etc). Make sure your prescriber and pharmacy have your up to date contact details. We strongly suggest you give both prescriber and pharmacist a second contact person who knows how to find you, especially in case of emergency.

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If you do not yet have an email address, now is a good time to consider getting one – this will only work if you check your email regularly!

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If you can think of anything that we have not covered here or if there is anything you would like to ask us, or if you are experiencing a pharmacotherapy program-related problem you are unable to resolve on your own please do hesitate to contact PAMS on 1800 443 844.