Court Ordered Witnessed Administration of Substances in Pharmacies

1
Court Ordered Witnessed Administration of
Substances in Pharmacies
Stephanie Angobung, Ellen Bartholet, Joyce Ho,
Andrea Sato, Kristin Skiff, Laura Veriga, Sylvia
Wong
2
Problems arising from current standards of
practice

• Without std. protocol, pharmacies do not have
  uniform method of administering.
• No std of practice ensuring that substances are
  swallowed.
• No standard requiring RPhs to ensure complete
  consumption.
• Ex. Pt. may fail to swallow Pt. may hold
  substance in cheek Pt. may not show up.

3
The Proposal

• Establish a protocol for administering
  court-ordered drug therapies.
• To clearly define duties of the RPh that ensure
  successful completion of the therapy ordered by
  the courts.

4
Why?

• There is a defined role for the RPh in
  administering and distributing drugs, as well as
  monitoring a patients drug therapy. RCW
  18.63.011
• Severity for reasoning of tx (i.e. nonadherance)-
  need for clear procedures
• Public Safety

5
Potential Efficacy

• 1st court-ordered therapy for psychiatric
  patients (1989)
• - Showed improved tx for pts.
• - Providers noted improved quality of care.
• - Family members more satisfied

6
Potential Efficacy

• South Carolina and NYC- anti-TB tx.
• -1986-1991 court-ordered TB tx
• -1991- South Carolina had a completion rate for
  TB treatment in 1991 of 96.6 (national average
  of 79 in 1990).

7
Existence of the problem

• Involuntary treatment services (RCW 70.95)
• Need for a standard protocol
• Liability
• Confirmation of consumption
• Communication with the involved parties

8
Goals

• Protocol applicable in most pharmacy settings
• Patient care on daily basis
• WAC 388.805.300
• Increased compliance
• Cost effective standards
• Safety of general public

9
Proposed Protocol

• Pharmacy responsibilities
• Time periods
• Identification
• Observation
• Counseling
• Record keeping
• Information

• Patient responsibilities
• Attendance
• Notification
• Liability
• Signature

10
Social Impacts

• If a court order must be issued, it is the
  intention to uphold their own and the publics
  safety.
• With no protocol, the system as a whole is broken
  and the good intention is lost.
• There is a place for RPhs to ensure the
  effectiveness of this process and the safety of
  the patient and public.

11
Social Impacts cont.

• WDA results in positive outcomes and safety of
  patient, care-givers, family members, community
  and the public.
• Examples
• - Prevent a repeat offender from another
  DUI
• - Prevent an act of alcohol-related
  physical abuse

12
Examples cont.

• Prevent exposure of TB to a hospital worker by a
  non-adherent pt
• Prevent an illegal or hurtful act by a pt.
  Non-adherent to antipsychotics

13
Economics and Impacts

• Pharmacies are allowed to
• charge a dispensing fee for
• services
• Low to moderate impacts

14
Liability

• Must follow WAC 246-878 Good Compounding
  Practice
• Medication is compounded liability falls on
  pharmacists

15
Pharmacy Insurance

• Pharmacists Mutual
• Witness Drug Administration
• Drug administration including immunization, where
  permitted by state law by you as a pharmacist.
• Medication consulting patient counseling and
  those acts or services necessary to provide
  pharmaceutical care.

16
Pharmacy Insurance

• Compounding and labeling of drugs and devices
  (except labeling by a manufacturer, repackager,
  or distributor of non-prescription drugs and
  commercially packaged legend drugs and devices).
  Pharmacy services do not include manufacturing.

17
Pharmacy Insurance

• All other services of a professional nature
  usually and customarily performed by a registered
  pharmacist or qualified pharmacy intern. This
  includes but is not limited to those professional
  services customarily performed by a community
  pharmacist, hospital pharmacist, consultant
  pharmacist, clinical pharmacist, long term care
  pharmacist, or nuclear pharmacist.

18
Pharmacy Insurance

• According to Karen Peterson of Pharmacists
  Mutual, if witnessing of drug administration is
  allowed by the state board of pharmacy, then
  there is professional liability coverage for it
  under the policy language
• Rates would not change based on a pharmacists
  activities.  
• Differences in rates are based more upon a
  pharmacists employment status

19
Alternatives to Proposal

1. Do Nothing Leave current practices as is
2. Collaborative Drug Therapy Management for WDA
3. WDA Procedural Guideline Standard

20
Best Alternative
Criterion/ Alternative Technical Feasibility Political Viability Administrative Operability
1) Do nothing Leave As Is -
2) Collaborative Practice Agreement for WDA -
3) WDA Procedural Guideline
21
Stakeholders

• Pharmacists
• Added responsibilities
• Administration of medications
• Follow a specific protocol, including
  documentation
• Safe consumptioncompounding issue?
• Physicians
• Share responsibilitywould they want to?
• Disulfiramcurrently restricted to treating
  facility and patients physician
• Must evaluate patient every 90 days

22
Stakeholders

• Victims
• Managed program for offenders
• Reduction in future harm (public health issue)
• Law Enforcement
• Police/ Parole officersreduction in crime
  related to medication compliance issues
• Lawyers, Judges, Court Professionalsboth sides
  of issue based on client they represent

23
Stakeholders

• Pharmacy Managersbalance between bottom line and
  role of pharmacy in community
• Othersfeel proposal infringes on rights of
  individuals

24
Resources

• Howard Telson, MD, Bellevue Pilots Outpatient
  Commitment Program. American Association Of
  Community Psychiatrists Newsletter, Vol. 13, No.
  4, Autumn 1999. Available from URL
  http//www.wpic.pitt.edu/aacp/Vol-13-4/regional13-
  4.html. cited 25 Nov., 2003
• 1Approaches to Improving Adherence to
  Antituberculosis Therapy South Carolina and New
  York, 1986-1991. Mortality Morbidity Weekly
  Report. Feb. 1993 42(04) 74-75, 81. Available
  from URL http//www.cdc.gov/mmwr/preview/mmwrhtm
  l/00019521.htm. cited 27 Nov., 2003

25
Resources

• King County Chemical Abuse and Dependency
  Services. Available at lthttp//www.metrokc.gov/dc
  hs/mhd/cdits.htm.gt 26 Nov. 2003.
• Menzin, James et Al. Treatment adherence
  associated with conventional and atypical
  antipsychotics in a large state Medicaid program.
  Psychiatric services 200354719-723.
  lthttp//psychservices.psychiatryonline.orggt 12
  Nov. 2003.
• Kristenson, Hans. How to get the best out of
  antabuse. Alcohol and Alcoholism 199530775-783.