Delivery of Opioid Pharmacotherapy

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Procedure for Delivery of Opioid Replacement Therapy to State‑Operated Quarantine Facility or Private Residence

Purpose of Procedure

Opioid Replacement Therapy (ORT) is used in the treatment of opioid misuse disorder. In usual circumstances, ORT is administered in a pharmacy or other health setting, with dosage supervised by the dispensing agent or another health professional, as per the Tasmanian Opioid Pharmacotherapy Program (TOPP) Policy and Clinical Practice Standards.

This Procedure is to be used in the event that a person receiving ORT cannot attend a pharmacy or other dispensing site due to infectious disease pandemics or outbreaks, or circumstances related to these, such as vulnerability to infection or illness.

This Procedure applies to the delivery of ORT by a pharmacy or their agent, or other provider contracted by the Tasmanian Alcohol and Drug Services, or the Department of Health Mental Health, Alcohol and Drug Directorate.

This Procedure does not apply to the delivery of ORT by other agents (which may include family members, friends or carers).

Introduction

Opioid replacement therapy (ORT) is used in the treatment of opioid misuse disorder. In usual circumstances, ORT in Tasmania is administered in line with the TOPP Policy and Clinical Practice Standards, which outline eligibility, prescribing and dosing requirements and other matters relevant to the administration of ORT.

In usual circumstances, ORT is dispensed by a pharmacist with medication dosage supervised by the dispensing agent, in a pharmacy or other health setting.

There may be situations and contexts in which a person cannot attend a pharmacy to receive their ORT dose. In these circumstances, there are several options available to the prescribing and dispensing agent(s). These include takeaway doses, and delivery of ORT to a State‑operated quarantine facility or private residence.

Decisions regarding these options must be made in line with the TOPP Policy and Clinical Practice Standards, consider any relevant Clinical Practice Guidelines or directions issued by the ADS Clinical Director, and be authorised by the patient’s prescriber.

The Royal Australian College of Physicians (RACP) have released the Interim guidance for the delivery of medication assisted treatment of opioid dependence in response to COVID-19: a national response, which outlines some considerations and recommendations for ORT administration in the context of the COVID‑19 pandemic.

In this document, the RACP recommend that ORT delivery to a private residence is undertaken by two staff members, and that at least one of these should be a health professional, such as a pharmacist, nurse or doctor. In the context of a person receiving ORT in State‑operated quarantine, it is unlikely that two people will be required to undertake delivery.

The RACP interim guidance document also highlights that community pharmacies may have existing mechanisms for home delivery of medications that can be utilised for this purpose, and that these should also be followed for ORT delivery wherever possible. This includes compliance with any relevant legislation, regulations or policy regarding the prescription, dispensing, storage or transport of medication.

In Tasmania, this includes, but is not limited to, the Poisons Act 1971, Poisons Regulations 2018, The Poisons Standard, the Tasmanian Opioid Pharmacotherapy Program Policy and Clinical Practice Standards.

Roles and Responsibilities

All parties must:

  • Comply with any COVID‑19, influenza or other infectious disease protocols or instructions required or recommended by the Federal or State Governments, or their Agencies, as relevant. This includes physical distancing, practise of any hygiene measures and use of personal protective equipment (PPE), if recommended or required, and following instructions and protocols as required by any particular delivery setting (for example, State‑operated quarantine), and compliance with infectious disease plans (for example, COVID‑safe workplace plans).

The prescriber will:

  • ensure compliance with relevant legislation, regulations and policy, including the Poisons Act 1971, Poisons Regulations 2018, The Poisons Standard, the TOPP Policy and Clinical Practice Standards, and this document
  • liaise with the patient receiving ORT, the ADS (on an as needs basis), and the dispenser and/or delivery agent(s) as required by the TOPP Policy and Clinical Practice Standards, and this document
  • review delivery of ORT as relevant to delivery context
  • as soon as practical, notify the Clinical Director ADS of any determinations of eligibility for delivery of ORT to private residence or State‑operated quarantine, and communicate the details of the dispensing agent

The dispenser and delivery agent(s) will:

  • ensure compliance with relevant legislation, regulations and policy, including the Poisons Act 1971, Poisons Regulations 2018, The Poisons Standard, the TOPP Policy and Clinical Practice Standards, and this document
  • liaise with the person receiving ORT, the ADS (on an as needs basis), and the prescribing, dispensing and/or delivery agent(s) as relevant, as required by the TOPP Policy and Clinical Practice Standards, and this document
  • communicate anything required to the prescriber, ADS, Department of Health Mental Health, Alcohol and Drug Directorate and/or relevant authorities, as appropriate. This may include communicating missed dosages to the prescriber, or breaches of quarantine to the Public Health Hotline.
  • review delivery of ORT as relevant to delivery context
  • ensure that any relevant registrations, licenses and/or insurances relevant to the delivery of ORT are valid and current (including, but not limited to, professional registration, vehicle registration, driver’s license and vehicle insurance).

The ADS will:

  • liaise with prescribing agents, dispensing agents and delivery agents as required to provide continuity of care for Tasmanians requiring the delivery of ORT to State‑operated quarantine facilities or private residences
  • liaise with prescribers, State‑operated quarantine services, the Agencies responsible for these facilities, or their agents or delegates, and dispensing and delivery agents, to provide continuity of care for persons requiring ORT in State‑operated quarantine.
  • Provide authorisation for clinically appropriate prescription variation as relevant (for example, daily dosing), in the instance of an unplanned interstate transfer where the patient’s care is transferred from another jurisdiction to the ADS, provided that the ADS has the capacity to provide service to the patient. It is acknowledged that it is in the interests of the health of both the individual and the public to continue care for interstate residents and / or returning Tasmanian residents whilst in State-operated or private quarantine facilities, and the ADS’ ability to do so will be dependent on the service’s capacity as assessed at the time of request. Care will be provided in line with the TOPP Policy and Clinical Practice Guidelines, including daily dosing in the first instance.

The Mental Health, Alcohol and Drug Directorate (the Directorate) will:

  • maintain the Procedure for Delivery of Opioid Replacement Therapy to State‑Operated Quarantine Facility or Private Residence (this document)
  • receive invoices relevant to the approved instances of home delivery and reimburse dispensing and delivery agents in line with these, and the fees and rates outlined in this document
  • monitor expenditure related to the home delivery program
  • communicate with ADS and other prescribers as required, to fulfil the above points.

Process

Eligibility for delivery:

Wherever possible, ORT should be dispensed according to usual protocols and practises, as outlined in the TOPP Policy and Clinical Practice Standards, including consideration of clinical and other eligibility criteria for ORT, as articulated in Section 5 - Assessment for entry into the Opioid Pharmacotherapy Program. Usual practice for ORT dosage takes place in a pharmacy or health setting, but there are situations in which ORT dosage in these settings may not be possible. These include:

  1. A patient requiring or receiving ORT is in State‑operated quarantine as a requirement of infectious disease protocols
  2. A patient receiving ORT has significant vulnerability to the infectious disease and is self‑isolating at a private residence as a precautionary measure (e.g. during an infectious disease outbreak). This precautionary measure must be supported by the medical practitioner responsible for treating or managing the condition that causes, or results in, the vulnerability, and communicated to the ORT prescriber.
  3. A patient receiving ORT is required to self‑isolate at a private residence for reasons including, but not limited to:
    • returning from interstate or overseas;
    • potential exposure to infectious disease requiring isolation or quarantine;
    • confirmed exposure to infectious disease requiring isolation or quarantine;
    • waiting for diagnostic test results regarding infectious disease requiring isolation or quarantine if diagnosis is confirmed; or
    • confirmed infection of infectious disease requiring isolation or quarantine.

    Note – eligibility to self‑isolate at a private residence is determined by State and Federal Government legislation and policy and associated approvals.

Approval of ORT delivery:

Delivery of ORT to a State‑operated quarantine facility or a private residence must be approved by the patient’s prescriber, with consideration given to the TOPP Policy and Clinical Practice Guidelines and any relevant directions issued, or provided, by the ADS (for example, interim instructions in place relating to the pandemic or infectious disease outbreak).

Subject to service capacity, the Clinical Director ADS (or delegate) will approve variation of prescription and/or delivery of ORT for patients who are required to quarantine due to transferring from other jurisdictions, and who do not have prescribing arrangements in place prior to arrival.

Delivery by third‑party agents

The prescriber must consider whether there is an appropriate third‑party agent available to collect ORT from the dispensing site and deliver to the patient, prior to approval of ORT delivery by a pharmacy. Delivery of ORT by a pharmacy should only be approved only if there is no suitable third‑party agent.

Examples of an appropriate agent include a partner, family member, friend or carer nominated by the patient, where the prescribing agent is satisfied that there are no risks involved in delivery, transport or storage of ORT, such as medication diversion.

Variation of prescription

After approval of ORT delivery to State‑operated quarantine facility or private residence, the prescriber will collaborate with the dispensing agent to execute variation of dispensing and delivery of ORT.

The authorisation mechanism will be completion of the Delivery of Opioid Replacement Therapy Billing Form by the prescriber (available on the DoH website). This will then be sent to the dispensing agent for completion.

Delivery of ORT

Delivery of ORT must follow the process for the relevant setting, as described below in “Process for ORT delivery”.

Review of ORT delivery

There is a requirement for the prescriber to review the appropriateness of ORT medication delivery and prescription variation. This should occur on a case by case basis in consultation with the prescriber and patient receiving ORT, with the understanding that dosing in a pharmacy or health setting is the preferred method of medication administration, and that delivery of ORT outside these settings should be the last option. These reviews should be communicated to the dispensing agent as soon as practical.

At the end of the delivery period, or at the end of each review period, the dispensing or delivery agent will send the completed Delivery of Opioid Replacement Therapy Billing Form to the Directorate. Any planning regarding the transition of a person from State‑operated quarantine to the community should consider ORT requirements for the individual and any potential implications associated with the sudden cessation of ORT.

The following periods are suggested for the review of ORT prescription variation involving delivery of medication:

GroupSuggested Review Period
People in State-operated quarantine facilitiesAfter two weeks
People returning to Tasmania and self-isolating at a private residenceAfter two weeks
People self‑isolating due to vulnerability to relevant infectious diseaseDetermined in consultation with practitioner responsible for treating or managing medical vulnerability
People self-isolating due to potential exposure or infectionAfter test results received
People self-isolating due to confirmed diagnosisOn a weekly basis, considering State and Federal requirements for testing, isolation and quarantine

Billing

The Directorate will pay a fee per occasion of service, which includes dispensing, delivering and observing dosage of ORT. The Directorate will reimburse transport costs associated with delivery at the Australian Taxation Office motor vehicle expense rate,  as at 1 July 2020. Rates can be found in the table below.

The dispensing agent should contact the Directorate to discuss transport if the total return travel time by the shortest practical route from the dispensing site to the delivery site is greater than one hour.

The dispensing and/or delivery agent will be required to claim any other eligible benefits or reimbursements from the relevant body, Agency or organisation (for example, Pharmaceutical Benefits Scheme).

This must be recorded in the Delivery of Opioid Replacement Therapy Billing Form, and submitted to the Directorate, with proof of authorisation from the prescribing agent.

Delivery SettingFee for ServiceTransport reimbursement
State-operated quarantine facility$5072 c per kilometre
Private residence$7572 c per kilometre

Process for ORT delivery

ORT Delivery to State-operated quarantine facility

  1. The prescriber will approve delivery to the State-operated quarantine facility, following the process described above. In the instance of unplanned interstate transfers, the Clinical Director ADS (or delegate) will assess the need for and capacity to provide service.

The prescriber will complete the Delivery of Opioid Replacement Therapy Billing Form and send to the dispensing agent, as the authorisation mechanism for dispensing and delivery of ORT to State-operated quarantine facility.

  1. The dispensing agent will dispense the medication in accordance with any relevant legislation, regulations and policy.
  2. The delivery agent will transport the medication to the relevant State‑operated quarantine facility, using the shortest practical route, and ensuring compliance with any relevant legislation, regulations and policy. If the dispensing agent and delivery agent are not the same, the dispensing agent will ensure that the delivery agent is aware of, and equipped to comply with, relevant legislation, regulations and policy.

    Note – only one person is required for delivery of ORT to State‑operated quarantine.

  3. The delivery agent and the person receiving ORT must follow any measures to reduce risk of infection that are required or recommended by the Australian or State Government and the State‑operated quarantine facility, such as physical distancing, personal hygiene, and where relevant, PPE.
  4. The delivery agent must transfer possession of the ORT directly to the medication recipient. The delivery agent must not transfer possession of ORT to the recipient through other agents, stand ins or intermediaries.
  5. Prior to transfer of possession, the delivery agent must sight photo identification of the person receiving the medication. The identification must match the details provided by the prescriber. If the person receiving ORT cannot produce photo identification, the delivery agent must sight multiple forms of identification, to ensure they are satisfied that it is the intended recipient.
  6. The delivery agent will observe the dose as follows:
    • Subutex / Suboxone: Delivery agent to observe ORT recipient place dose in their mouth (no close checking of mouth).  Any takeaway doses must be taken inside by the ORT recipient.
    • Methadone: Delivery agent to observe ORT recipient swallow dose, and then hold bottle upside down to demonstrate full dose has been taken.  Any takeaway doses must be taken inside by the ORT recipient.
    • If there are any diversions from the above, the delivery agent must record details and notify the dispensing agent as soon as practical. The dispensing agent must notify ADS and prescriber as soon as practical.

    Note – Supervision ORT dosing has been temporarily relaxed, due to the risks associated with infectious disease pandemics or outbreaks.

  7. The ORT recipient must record on the billing form that they have received their dose, with both parties ensuring compliance with all relevant infectious disease protocols.
  8. The delivery agent must then leave the quarantine facility.

ORT Delivery to private residence

  1. The prescriber must assess eligibility for delivery of ORT to a private residence as described in this document. If satisfied the patient is eligible, the prescriber may approve delivery of ORT to a private residence.
  2. Once eligibility has been approved, the prescriber will confirm this with the patient receiving ORT, and communicate:
    1. That delivery of ORT to a private residence will be time‑limited, and subject to regular review (using the review criteria and timeframes described in this document)
    2. The patient and delivery agent have responsibility to comply with any infectious disease instructions or protocols relevant at the time of delivery, and provide information of where these requirements can be found
    3. Safe storage of any takeaway doses provided
    4. Responsibility to use the medication as prescribed, including preventing medication diversion
  3. The prescriber will complete the Delivery of Opioid Replacement Therapy Billing Form and send to the dispensing agent, as the authorisation mechanism for delivery of ORT to a private residence.
  4. The dispensing agent and/or the delivery agent will communicate with the person receiving ORT to confirm that their prescriber has approved home delivery for a limited time, and that there are certain requirements that need to be met. These requirements may be used as input into risk assessments usually undertaken as part of medication delivery to a private residence. These may include:
    • Whether there is mobile phone reception at the property and which network(s), as the delivery agent will need to call the person receiving ORT to confirm they have arrived
    • Who else lives at the location
    • Matters relevant to accessing the property including, but not limited to:
      • parking availability,
      • pets – presence, location, restraint etc.,
      • road quality and safety
      • anything else relevant to the delivery context.
    • Any relevant infectious disease‑related matters including, but not limited to:
      • Infectious disease protocols currently recommended or required by State or Federal Governments, such as physical distancing, PPE, hygiene protocols, COVID‑safe plans etc.
      • Other protocols required to prevent or minimise the spreading of infectious agents.
  5. The dispensing agent will dispense the medication in accordance with the above, and in compliance with all relevant legislation, regulations and policy.
  6. The delivery agent will transport the medication to the private residence, using the shortest practical route, ensuring compliance with any relevant legislation, regulations and policy. If the dispensing agent and delivery agent are not the same, the dispensing agent will ensure that the delivery agent is aware of, and equipped to comply with, relevant legislation, regulations and policy.
  7. The delivery agent must transfer possession of ORT directly to the prescribed person. The delivery agent must not transfer possession of ORT to the prescribed person through other agents, stand ins or intermediaries.
  8. The delivery agent will sight photo identification of the person receiving ORT before transfer of possession occurs. If the person receiving medication cannot produce photo identification, the delivery agent must sight multiple forms of identification, to ensure they are satisfied that it is the intended recipient.
  9. The delivery agent (on behalf of the dispenser, if not the same) will assess the person receiving ORT to determine whether the dosage should be administered (as per normal dispensing practice), consistent with the requirements of the TOPP Policy and Clinical Practice Standards.
  10. The delivery agent will observe the dose as follows:
    • Subutex / Suboxone: Delivery agent to observe ORT recipient place dose in their mouth (no close checking of mouth).  Any takeaway doses must be taken inside by the ORT recipient.
    • Methadone: Delivery agent to observe ORT recipient swallow dose, and then hold bottle upside down to demonstrate full dose has been taken.  Any takeaway doses must be taken inside by the ORT recipient.
    • If there are any diversions from the above, the delivery agent must record details and notify the dispensing agent as soon as practical. The dispensing agent must notify ADS and prescriber as soon as practical.

    Note – Supervision ORT dosing has been temporarily relaxed, due to the risks associated with infectious disease pandemics or outbreaks.

  11. The medication recipient must record on the billing form that they have received their dose, with both parties ensuring compliance with all relevant infectious disease protocols.
  12. The delivery agent must then leave the property.

Considerations for all delivery settings:

  • The dispensing and delivery agent(s) must ensure delivery times are consistent with the requirements for regular dosing articulated in the TOPP Policy and Clinical Practice Standards.
  • If delivery is delayed for any reason, the dispensing and/or delivery agent must contact the person receiving ORT delivery as soon as possible.
  • If there is any reason that dosing cannot be observed, the delivery agent must communicate this as soon as possible to the dispensing agent, who must communicate this to the prescriber.
  • If delivery is prevented for any reason, the delivery agent must contact the dispensing agent as soon as practical. The delivery agent must return the medication to the pharmacy, and the dispensing agent must ensure relevant records are kept regarding return of the medication. The dispensing agent must communicate non‑delivery or dosing to the prescriber as soon as possible. In this event, the prescriber will liaise with all parties required to ensure continuity of care.
  • If the person receiving ORT is not provided with their dose on or around the time agreed, the person receiving ORT must communicate with the prescriber, who will liaise with all parties required to ensure continuity of care.
  • If there are any concerns about public health or infectious disease matters (for example, quarantine breaches), the delivery agent should communicate with the Public Health Hotline (1800 671 738) as soon as practical. In the instance of State‑operated quarantine facilities, the delivery agent should notify both the Public Health Hotline and the facility as soon as practical.

Click here to access the Delivery of Opioid Replacement Therapy Billing Form