Background: Approximately nineteen million individuals in the United States are diagnosed with a substance use disorder (SUD), including many veterans enrolled in the Veterans Health Administration (VHA). The prevalence of SUD within the veteran population has been steadily increasing, resulting in increased utilization of substance abuse services, such as buprenorphine programs for opioid dependence. As this population grows, there is an increased need for multidisciplinary services. Clinical psychiatric pharmacists do not have prescriptive authority for buprenorphine, but can play a vital role in outpatient buprenorphine programs.

Description of Innovative Service: The clinical psychiatric pharmacist is involved in many aspects of the outpatient buprenorphine program. There are over 100 patients enrolled in the buprenorphine program at the White River Junction Veterans Affairs Medical Center (WRJVAMC). The clinical pharmacist devotes approximately ten hours per week to the program, which includes dispensing the medication, monitoring lab values, patient counseling and random medication counts. A spreadsheet is maintained and updated weekly to monitor doses, refill dates and urine toxicology results. The clinical pharmacist is also involved in the dispensing process in the outpatient pharmacy; this allows for open communication between the clinical pharmacist and patient.

Impact on Patient Care: The clinical psychiatric pharmacist has been involved in the outpatient buprenorphine program at the WRJVAMC for approximately two years. Prior to this, the program included less than 100 patients, pharmacy wait times were over sixty minutes and early refills were frequent. Since clinical pharmacy involvement, the pharmacy wait time is approximately 30 minutes or less and early refills are infrequent. Patient satisfaction has also significantly improved. The clinical pharmacist has helped open the lines of communication between the patient, the pharmacy and the prescriber.

Conclusion: Substance use disorder programs, such as buprenorphine programs, can benefit from clinical pharmacy involvement. Even with limited prescriptive authority, clinical psychiatric pharmacists can play an important and active role in outpatient buprenorphine programs.

Approximately nineteen million individuals in the United States are diagnosed with a substance use disorder (SUD), including many veterans enrolled in the Veterans Health Administration (VHA).1,2 The prevalence of SUD within the veteran population has been steadily increasing. Between 2008 and 2010, the total number of veterans diagnosed with a SUD has increased by up to 38%, with alcohol and cocaine use being most common.3 This has resulted in increased utilization of substance abuse services, such as buprenorphine programs for opioid dependence. As this population grows, there is an increased need for multidisciplinary services. At the White River Junction Veterans Affairs Medication Center (WRJVAMC), the total number of buprenorphine prescriptions filled between 2007 and 2012 increased by greater than 2000%, directly supporting clinical pharmacy involvement (Figure 1). Clinical psychiatric pharmacists do not have prescriptive authority for buprenorphine, but can play a vital role in outpatient buprenorphine programs.

FIGURE 1:

Total Buprenorphine fills 2007–2012 at WRJVAMC

FIGURE 1:

Total Buprenorphine fills 2007–2012 at WRJVAMC

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The outpatient buprenorphine program at the WRJVAMC currently treats 122 patients, 93% males and 7% females. The average daily dose of buprenorphine is 16mg and the preferred formulation is the sublingual film strips. The interdisciplinary team consists of three psychiatrists, four addiction therapists and one clinical psychiatric pharmacist. The clinical psychiatric pharmacist is involved in many aspects of the outpatient buprenorphine program. The clinical pharmacist devotes approximately ten hours per week to the program, which includes dispensing the medication, monitoring lab values, patient counseling and random medication counts. The clinical pharmacist assists with the dispensation of buprenorphine, which includes processing and verifying the prescriptions and patient counseling at the outpatient pharmacy. This allows for open communication between the clinical pharmacist and patient. The clinical pharmacist also maintains a spreadsheet and updates it weekly to monitor doses, refill dates and urine toxicology results. This is a useful tool for not only the treatment team, but also the outpatient pharmacy in the absence of the clinical psychiatric pharmacist. In an effort to minimize buprenorphine misuse and diversion and to better monitor medication adherence, the clinical pharmacist conducts two random strip counts each week and documents the encounter in the patients' medical record. Each patient is given a minimum of twenty four hours to present to the clinic with their buprenorphine strips.

The clinical psychiatric pharmacist has been involved in the outpatient buprenorphine program at the WRJ VAMC for approximately two years. Prior to this, the program included less than 100 patients, pharmacy wait times were over sixty minutes and early refills were frequent. Since clinical pharmacy involvement, the pharmacy wait time is approximately thirty minutes or less and early refills are infrequent. Patient satisfaction has also significantly improved. The patients were asked to complete a patient satisfaction questionnaire regarding their overall experience at the outpatient pharmacy before and after the clinical pharmacist involvement (Table 1). Prior to clinical pharmacy involvement, approximately two-thirds of the cohort rated their overall experience with the outpatient pharmacy as “poor/fair”. Following clinical pharmacy involvement, two-thirds of the cohort rated their overall experience as “good/excellent”. Additionally, as the wait time decreased, the overall satisfaction with the pharmacy wait times significantly improved. Through these patient-centered services, the clinical pharmacist has helped open the lines of communication between the patient, the pharmacy and the prescriber.

TABLE 1:

Patient Satisfaction Questionnaire Results

Patient Satisfaction Questionnaire Results
Patient Satisfaction Questionnaire Results

Substance use disorder programs, such as buprenorphine programs, continue to grow and can benefit from clinical pharmacy involvement. The needs of each individual program should be assessed to determine the most appropriate roles for the pharmacist. Even with limited prescriptive authority, clinical psychiatric pharmacists can improve patient care and clinical outcomes in buprenorphine programs.

1.
SAMHSA
. (
2010
).
Results from the 2009 National Survey on Drug Use and Health: Mental health findings
.
Office of Applied Studies, NSDUH Series H-39
,
No. SMA 10-4609. Retrieved September 12, 2013, from http://oas.samhsa.gov/NSDUH/2k9NSDUH/MH/2K9MHResults.pdf
2.
Raisch
DW
,
Fye
CL
,
Boardman
KD
,
Sather
MR.
Opioid dependence treatment, including buprenorphine/naloxone
.
Ann Pharmacother
.
2002
;
36
(
2
):
312
21
.
PubMed PMID: 11847954
.
3.
Saxon
,
A.J.
Returning veterans with addictions
.
Psychiatric Times
.
2011
;
28
(
7
).