Demographics
Of the 14 participants, 57.1% (n = 8) were female, 50.0% (n = 7) were aged 36–70 years, and 71.4% (n = 10) were white (Table 1).
Qualitative interview findings
Results emerged from the data were consistent with three domains of the PARIHS framework. These findings are organized based on these domains: evidence, context, and facilitation.
Evidence (perspectives on PADMOUD)
The evidence domain concerns participants’ perception of the intervention (benefits and disadvantages of PADMOUD). Participants reported benefits/advantages of PADMOUD for patients, OTPs, pharmacies, and payers.
For patients
PADMOUD was considered a treatment option that could increase access for patients by offering a more convenient setting (pharmacy) and flexible office hours, less waiting time to receive medication, and fewer drug use cues/triggers (e.g., less contact with drug users) to prevent relapse than usual care at the OTP.
Pharmacy participant # 1: “The advantages are access, improved access, improved schedule, flexibly, and decreased triggers.”
OTP participant # 1: “If it’s a 24-hour pharmacy and you’ve got the flexibility of picking up your week’s prescription, whenever you want on the day that it’s due, that creates a lot more flexibility.”
In particular, time was considered a key factor underlying the support for PADMOUD:
Pharmacy participant # 3: “The time factor is probably the most frustrating part of not only their access to treatment and ability to stay adherent and things like that. Everyone struggles with taking more time to do things that all frustrate us. So I think that’s [PADMOUD] a huge thing that make it easier for patients.”
PADMOUD was considered a good option for stable patients, as it would allow patients to step down from a more-structured setting to a less-structured setting where patients could go for their medication at flexible hours, live more normal lives, or maintain regular work schedules:
OTP participant # 6: “For stable patients, it [PADMOUD] possibly would make it easier because they’re not coming into the clinic, and they’re not having to wait in line. Many of them have jobs to get to, so they’re rushing.
OTP participant # 7: This [PADMOUD] would definitely be a draw for them to seek this service. So this is kind of a step down from the higher structure to a lower structure where they can go and not have to worry about the hours. And they just don’t need the counseling twice a month, quite as much as they don’t need nurses to see them in person.”
However, PADMOUD was considered less suitable for non-stable patients with clinical issues that require frequent urine drug screens and/or counseling:
Pharmacy participant # 2: “If a patient was getting more or having more frequent urine drug screens or that kind of thing in a clinical setting, that [PADMOUD] might not be an option in a pharmacy setting, but that could obviously be part of the collaboration between decisions about the physician, what the patient needs.”
In addition, patients would go to multiple locations for their treatment, which would increase the challenge monitoring patients’ compliance with methadone treatment:
OTP participant # 2: “The barriers would definitely be their drug screens and their compliance. I know that they’re going back to the main clinic for drug screening and counseling. So a disadvantage would just be like having to go to multiple locations for their services.”
For OTP/OTP staff
PADMOUD was considered an option to increase OTPs’ capability to treat more patients and reduce OTP staff burden.
OTP participant # 6: “For the methadone clinic, this would help reduce the traffic that comes through for the staff, especially on the weekends. It’s a lot of responsibility to dose all those patients in that short amount of time.”
Although PADMOUD could decrease the OTP’s revenues, PADMOUD was perceived to give the OTP an opportunity to treat more new patients to increase revenues:
Pharmacy participant # 1: “Methadone clinics themselves could decrease their volume and decrease their overall revenue, but it could give them potential opportunities to work with other community providers to decrease or increase their overall volume, which could treat more patients and give them opportunity to continue their revenue, at the same rate.”
Further, PADMOUD was considered to increase the OTP’s burden of communication and record keeping:
Pharmacy participant # 3: “Con [disadvantage of PADMOUD] is associated with increased record keeping in terms of communicating changes and dosing with the pharmacy and making sure they get implemented on a real time manner.”
Therefore, streamlining the workflow processes among OTP staff, patients, and pharmacy staff was considered important to ensure proper operations of PADMOUD (e.g., coordination and communication on record keeping, medication orders/supply, methadone doses, drug screen, and psychosocial counseling):
OTP participant # 5: “What days do the clients have drug screen? It’s very hard to get the drug screens like all of those things that are still necessary, but making sure that it’s streamlined a little bit better where there’s a lot more structure.”
For pharmacy/pharmacists
PADMOUD was considered to increase pharmacists’ skills and promote collaborative opportunities with physicians.
Pharmacy participant # 4: “It [PADMOUD] adds a new skill. I guess it’s also kind of cool to see that you’re helping someone instead of just filling a prescription or checking a prescription and sending it off. You are actually getting that one-on-one patient interaction.”
Pharmacy participant # 2: “I think advantage again, just increasing more collaborative work between pharmacists and physician practices. Just the opportunity to have that kind of role in patient care is a is a big advance for pharmacists.”
Additionally, PADMOUD would increase revenues for pharmacies/pharmacists:
Pharmacy participant # 1: “Most pharmacists are very hungry for medical opportunities and ways to get reimbursed. Like why not also pick up your maintenance medications? So getting that [PADMOUD] also increases the profit for the pharmacies, increases the sync status and the accessibility to the other medications that they’re taking.”
Although participants perceived a potential concern of liability (e.g., issues related to patient relapse or overdose) among pharmacists, liability could be addressed by receiving additional training on assessing and monitoring signs of relapse or overdose problems:
OTP participant # 5: “I think it is a big liability because like I said, relapse. And they [pharmacists] not having a baseline of what the client looks like and not being able to kind of tell if this client is not okay, because they’re going to be the eyes and ears for the clinic between times when they’re not doing their drug screens. So being able to 1) give those pharmacists education and 2) being able to help the pharmacist kind of watch out for some of the warning signs.”
Another issue for pharmacy/pharmacists was the time burden for delivering PADMOUD and identification of pharmacies willing to take on the additional workload and responsibility:
Pharmacy participant # 6: “It just takes more of a pharmacist’s time for them to see the patient and do methadone dosing and just interacting with them would take more time for the pharmacist.”
Pharmacy participant # 3: “I think maybe finding pharmacies that are willing to take on the additional workload and responsibility. I think that’s definitely the biggest barrier to finding the pharmacies that want to take on the additional workload.”
For payers
PADMOUD was considered acceptable to payers (e.g., insurance companies), as it would have lower costs for patients than going to the OTP (e.g., dispensing costs).
OTP participant # 1: “I guess the advantage for the health insurance payers is typically we get paid, you know, like 16 dollars a dose, but at a pharmacy, the usual reimbursement is like five dollars to fill a prescription. So it may be cheaper for them to use a pharmacist as opposed to an OTP.”
Pharmacy participant # 2: “It would be less expensive for insurance companies. There would be some cost benefit from both the provider fees as well as the medication fees.”
Context (capability and intention)
The context domain was related to the perceived capability of pharmacy and OTP staff to implement PADMOUD and the perceived support from pharmacy/OTP staff and payers (e.g., insurance company).
Pharmacies’ ability to implement
Participants perceived that pharmacists would be comfortable and effective in delivering PADMOUD if pharmacists received the right training and had the PADMOUD protocol in place.
OTP participant # 2: “I think they [pharmacists] could be very comfortable at dispensing. It’s all about the team of people you’re working with, communication, as far as training that is available for them and the tools, you know, binders, whatever they need as far as those resources. So if they have a good team, the doctors and everything where they can go back and if they have questions, ask the questions, things like that, I think that will be fine.”
Pharmacist participant # 2: “Pharmacies can be very effective at dosing, dispensing methadone, but it would just require the right types of tools and equipment for that to happen.”
Regarding whether pharmacists and pharmacy staff, in general, would be comfortable with discussing patients’ substance use and treatment, participants also considered that pharmacists would need additional training and resources to help with their skills:
OTP participant # 3: “My experience with pharmacists have been that they don’t know what to do with the people who have the issue [OUD], but they are very willing to share education. I think I’ve seen that more in probably the last 10 years. I’ve just been more aware of the education component with pharmacists. In both small and large pharmacies now, the first thing out of their mouth is, do you have any questions? So I think that they may not know what to do with it, but I think that they have education, they have some stuff they might be able to give somebody to read. So I think they are a little more comfortable with discussing substance use treatment.”
In particular, building trust in relationships with patients would improve pharmacy staff’s skills in discussing patients’ substance use and treatment:
Pharmacy participant # 6: “I guess it would be easier for pharmacy staff to discuss this with the patients as long as patients have more trust in the pharmacist. I guess we are not uncomfortable at all with discussing substance use with the patients if we are building trust and having its familial trust with the patients, ongoing patients, not just new patients.”
OTPs’ ability to implement
OTP programs would be comfortable transferring their patients’ methadone dosing and dispensing to a local community pharmacy when patients were relatively stable and communication procedures between the OTP and the pharmacy were in place.
OTP participant # 6: “What would make them comfortable if it’s the right patient, patients that have definitely demonstrated progression in the program with their opiate use treatment, and the right communication between the pharmacy and the clinic.”
Participants also perceived that pharmacy staff should have received training on PADMOUD and have a proper protocol in place to ensure a smooth transition of patient treatment from an OTP to a pharmacy:
OTP participant # 8: “What would make them feel more comfortable is going to be a nice transition where everyone can kind of understand each other and everything’s kind of passed over smoothly. And all the information is transferred over and we feel like they’re in good hands. And the people who are taking care of them are educated on what the treatment is.”
Perceived support from OTPs
Participants perceived positive support from OTP staff because PADMOUD was considered a good option for stable patients (e.g., a step down).
OTP participant # 3: “The physicians, the counselors and the nurses would support additional options, treatment for our clients. So a step down is something I think that they would see. I definitely think that it should be for patients that are stable.”
Another reason for support was reduced staffing time with stable patients to allow the OTP to treat additional patients (e.g., new or severe patients):
Pharmacy participant # 6: “From staff perspective, I guess it is like less work for them to do this if pharmacy is being used for methadone dispensing.
Pharmacy participant # 4: “It can alleviate some of the in and out of their [OTP] office and the time that it takes away to diagnose other patients and to help their other patients.”
A further reason was to respect patient preference for going to a pharmacy, as it was considered to improve patients’ treatment compliance:
OTP participant # 2: “If the client wants to be there, we have to support what makes them comfortable and compliant with their dosing. The reason was because we were able to see our clients who were successful, the pharmacy based treatment, and being able to hear our clients talk about how much of a relief it was.”
However, some for-profit OTPs might not support PADMOUD due to reduced revenues:
OTP participant # 4: “For clinics that are for profit, that’s going to be an issue. If you’re going to lose money by sending them out, then that’s not going to work.”
Nonetheless, other for-profit OTPs might still support PADMOUD for the reason of helping patients (e.g., improved treatment access):
OTP participant # 8: “The idea is that we can help more people, the better, even if it’s less money in our pocket. As long as we can get people the help that they need and the treatment they need, the right way, we can support. That’s how we function here.”
Perceived support from pharmacies
Participants also perceived positive support from the pharmacy staff because it would meet the needs of the underserved populations and provide additional revenue.
Pharmacy participant # 1: “The majority of pharmacy staff would be very supportive of bringing an alternative revenue to help solidify longevity to provide long term care security for those individuals and also give them opportunities to reach a desperately needed patient population.”
Pharmacy participant # 4: “For the advantage of helping people get off their addiction. It would help the community. Just knowing that they have a place that they can go to get the help that they need.”
Independent pharmacies were perceived to be more suitable than large chain pharmacies in implementing PADMOUD due to extra time required to interact with patients receiving methadone:
Pharmacy participant # 3: “I think more so with the independent pharmacies. They would be a better way to do it or even an independent chain. More so because they have the additional time to interact with that population that it requires, because basically every interaction is almost the same amount of time as like a flu shot; whereas the chains, I think that would be just more of another hurdle for them.”
The Community Pharmacy Enhanced Services Network (CPESN) was considered a suitable network of pharmacies to implement PADMOUD, because pharmacists of the CPESN would have more time available to interact with patients:
Pharmacy participant # 3: “I have heard from different kinds of chains like CVS and Walgreens. I feel like it would be a little bit more difficult to maybe implement that reduced stigma on a companywide level. So maybe like through the Community Pharmacy Enhanced Services Network (CPESN). I think that may be a better route of going with those kinds of pharmacies who also have a little bit more time on their hands to actually forge that interaction and that kind of ties in the pharmacies.
Perceived support from payers
Participants also considered support from insurance payers because PADMOUD would save costs.
OTP participant # 1: “Insurance payers would be fine with it, especially if it would save them money. I think that’s what their focus is going to be. So I would think that they would be supportive of that.”
Facilitation (strategies to address barriers)
Participants provided important recommendations for facilitating the implementation of PADMOUD, including having thought leaders, collaborative agreements, education, pharmacy staff attitudes, pharmacy staffing, technology/workflow, inventory management, and reimbursement.
Thought leaders
Having thought leaders serving as resource would facilitate the setup and operations of PADMOUD.
Pharmacy participant # 2: “Have people, sort of thought leaders, in that could serve as resources or references for groups that are monitoring pharmacies or clinics or physicians who are interested in getting this type of collaboration set up.”
Collaborative agreements
It was considered critical to establish collaborative relationships between the OTP and the pharmacy for PADMOUD and to start with just one pharmacy in order to understand implementation issues before involving with multiple pharmacies.
Pharmacy participant # 3: “Making sure that there is collaboration that exists and maybe starting it off small before it’s completely rolled out with a pharmacy to test out.”
Education
Pharmacist/pharmacy staff training or education on opioid addiction and methadone treatment was perceived to be a primary facilitator to implement PADMOUD.
Pharmacy participant # 2: “The type of support that would be needed to most effectively implement would be definitely education. It would definitely be sort of a different practice that many pharmacies are currently used to. I think feeling like you’ve got education, that you’ve got support, contacts within the physician group to reach out to if there were any questions or something right in the moment.”
Proper training was perceived to be necessary to ensure that pharmacy staff would know how to provide information about addiction/methadone and assess for signs/red flags of drug use issues:
OTP participant # 5: “Training. It’s very necessary for them not to just do something because they were told to, but understanding how methadone impacts the receptors, how methadone treatment works, how it lasts, because if a client asks you those questions, it would be beneficial for them to be able to answer it if asked.
Participants recommended to have a certification program requiring a minimal number of educational hours on addiction and methadone, and to have final support available for supporting such education:
Pharmacy participant # 1: “Perhaps some sort of certification program or minimal number of educational hours manually like CE credits per year to participate.”
OTP participant # 6: “Financial support will probably need to help with the training, help with the staff and help with the overall; maybe remodeling of the pharmacy area to accommodate this.”
Pharmacy staff attitudes towards methadone (stigma)
Stigma towards methadone/addiction among pharmacy staff was considered an important barrier. Participants recommended additional education on PADMOUD for pharmacy staff, including benefits of PADMOUD as well as stigmas issues around methadone.
OTP participant # 3: “There’s a stigma around methadone and the kind of people that are in methadone treatment. It is very important for us to take the stigma off methadone. Being able to transition to pharmacy based, will hopefully alleviate some of that stigma that’s associated with it in the community.”
OTP participant # 8: “As long as people were properly educated on it and the benefits and it is helpful in the difference between methadone and Subutex and the other options out there. I think that would that would make a huge difference.”
Specifically, pharmacists/pharmacy staff were expected to show nonbiased attitudes towards patients:
Pharmacy participant # 6: “So just treating patients like normal people, not judging people, not treating them with judgment on their previous actions.”
OTP participant # 2: “Just continuing with good attitudes and letting them know if they have any questions or they feel uncomfortable because some clients may feel not comfortable and just keep things in because they don’t feel like they are being accepted at the pharmacy.”
Pharmacy staffing
Additional staffing was considered needed to have designated pharmacy staff for PADMOUD.
Pharmacy participant # 1: “The barriers would definitely be pharmacy staffing. Having one or two key individuals that are responsible for working with those that subset of patients. Having at least two people that are kind of a primary point to work with a group.”
Technology/workflow
Updating pharmacy’s computer system and allowing pharmacy staff access to electronic medical records of patients were considered important for facilitating communication and operations of PADMOUD (e.g., monitoring patients’ compliance with drug screens).
OTP participant # 6: “Update the computer technology.”
OTP participant # 4: “If the pharmacy had the same electronic medical record that we did, they could just go into Methasoft and they could put in real time the data that we could see in real time about what happened. Real time communication about all of it, which is not insurmountable in today’s technology.”
In addition, PADMOUD procedures would be incorporated into an existing pharmacy management software (e.g., PioneerRX) to streamline the pharmacy workflow:
Pharmacy participant # 3: “Tools. It would pretty easily be implemented into the pharmacy workflow, at least within PioneerRX as the pharmacy management software.”
Inventory management
Participants also recommended that pharmacies should have the right kind of space and security measures to ensure proper inventory storage and management.
Pharmacy participant # 2: “Definitely the right storage situation to be able to keep the medication separate and secure.”
Reimbursement
Finally, participants recognized that the pharmacy would need to provide PADMOUD to enough patients and receive proper reimbursement (e.g., dispensing fees) in order to have adequate financial support.
Pharmacy participant # 3: “It’s essential that you schedule enough patients and make sure that the reimbursement is at the appropriate level for the dispensing fee so that it makes the full time equivalent of a pharmacist worthwhile for the pharmacy to provide this program.”
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