3 Key Recommendations for Safer Opioid Agonist Therapy in Community Pharmacy

A patient talks with a pharmacist before receiving their opioid agonist therapy.


Opioid agonist therapy (OAT) can put patients at risk of harm. Like compliance packaging, OAT is a high-risk process. 

Medications used for OAT include buprenorphine-naloxone, methadone, and extended-release morphine. Most patients and clients take these types of medication once daily. Some patients ingest these medications at the pharmacy and others take doses at home.1 

Methadone is a high-alert medication. It is also one of the top medications reported in harmful medication incidents. 

Most incidents involving OAT in Manitoba occurred during dispensing and administration. Community pharmacies submitted similar reports for both methadone and buprenorphine-naloxone. 

Incident Example from the National Incident Data Repository for Community Pharmacies 

A patient’s dose of buprenorphine-naloxone was reduced. At the pharmacy, the old higher dose was inadvertently dispensed. The patient ingested the higher dose. They only recognized the error after reading the label for the take-home doses.  

Potential contributing factors 

  • OAT dosing is often highly individualized. This adds complexity to OAT processes. 
  • Copying a previous prescription can lead to confirmation bias. Confirmation bias means that we are more likely to perceive what we expect. We are also less likely to perceive information that contradicts our expectations. In this case, there could be an inability to perceive a change in the prescription.

3 Key Safety Recommendations for Safer Opioid Agonist Therapy in Community Pharmacy

You can make OAT processes in your pharmacy safer today. Here are three simple tactics for providing safer OAT:

1. Develop a template for communication with the prescriber about dose changes. Include clarification of the previous and current doses.

2. Implement a policy to inactivate discontinued prescriptions on a patient’s profile before, or immediately after, entering the new prescription.

  • Create a copy of the new prescription for the log of witnessed and take-home doses to allow for review prior to dispensing and/or administration. Start a new log with each new prescription.


3. Address the patient by their full name and ask the patient open-ended questions about their medication:

    • “What is the name of your medication?” 
    • “What dose are you on?”

Before you give the medication to the patient, repeat the medication name and dose back to them for confirmation. 

OAT is a complex and high-risk process. Simple changes to your policies and procedures, training, and practices can improve safety in your pharmacy. For additional information about safely preparing, dispensing, and administering OAT, please see the Opioid and Opioid Agonist Therapy category of the CPhM resource library and the Opioid Agonist Therapy and Patient Safety section at the following link: https://cphm.ca/practice-education/shared-learning/  

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