Four major themes emerged, and the analysis revealed several recommendations to improve community pharmacy services for patients living with SUD. The four themes provided insights regarding participants' experiences and perceptions of community pharmacists as health care providers. Also, they summarized the participants' needs that went beyond the pharmacological aspects of treatment. The themes also explained the effect of physical space and the community pharmacy setting on the communication between people living with SUD and pharmacists. Finally, the developed themes described participants' experiences with the services provided by community pharmacists, particularly harm reduction services, such as needle exchange and maintenance therapy of methadone.
Experience of people with SUD in a Community Pharmacy
All participants had notable experiences with community pharmacists due to their frequent visits to community pharmacies that ranged between daily to weekly occurrences. Participants' visits to community pharmacies were mainly to obtain their methadone and HIV medications. They described community pharmacists as the most seen health care provider. They indicated that pharmacists are nearby and have long working hours so they can be reached easily. Paradoxically, pharmacists were described by the focus group participants as the health care providers they would be least likely to seek out when help was needed. They elaborated that pharmacists have a busy work environment and hardly reply to their questions or consultations. However, most participants did not recognize community pharmacists even when they have time, as a source for medical information, counseling, or medical advice.
“Participant A - The pharmacist, I never really thought about going to him for support for anything. I always just thought of him as someone serving me just to get the pills and…And, get out.
Participant B – Get your drugs, and that’s it, yeah.” Focus Group 1
The main issues that shaped participants experiences with community pharmacists are listed as sub-themes:
Lack of time was a core problem often reported by participants. They elaborated that community pharmacists are always busy and do not have time to communicate with their patients. Lack of time for appropriate communication, being too busy, and inefficient multitasking were common themes across all group meetings. In fact, lack of time was the main reason that participants do not seek help and medical advice from community pharmacists. Participants expressed that pharmacists do not have time in their daily routine to provide one-to-one counsel for them.
“Participant A – Probably we don’t go to them, like for counseling or whatever because it seems like they don’t have enough time, [it] seems like they’re so busy.” Focus Group 1
“Participant A – That’s basically the problem, yeah. They’re so busy packaging and looking at their computer.
Participants B – Prescribing.
Participant A – Answering phones for the next prescription. They don’t have time to even look at you. And, then when you do get a chance, they’ll start and then…Oh, excuse me I got to get going.” Focus Group 2
Participants explained that some community pharmacists could be helpful when they have time, but the business model of community pharmacies pushes pharmacists toward profitability. Profitability is mandated by the companies and forces pharmacists to “push drugs” and limit counseling time with their patients, as explained by participants.
“..They have very, very, very little time to spend with patients. As a matter of fact, zero time to spend with patients because their job is to push drugs.” Focus Group 2
“Participant A – All they care about is the money. They just want the money. And they don’t really care.” Focus Group 3
Also, participants articulated that pharmacists are inefficient multitaskers in that they do not have time to properly counsel patients and provide medication-related information in addition to their many other tasks. This was identified by a number of participants. They perceived that the extent to which pharmacists are required to multitask was harmful to patients’ care, resulting in suboptimal services. For example, several participants reported that the concentration of methadone varies from one time to another because pharmacists are multitasking and cannot stay focused on any one task.
“Participant C - Yeah, in [Pharmacy Name and Location], like that’s a constant problem with me too. There’s always a different pharmacist filling [the] bottles. There’s never one person, and it’s never the same. I’m always finding my methadone’s too, too much.” Focus Group 2
“Participant E – You know, instead of having four different pharmacists doing one methadone…you know methadone for all these people, yeah. It’s never constant, and it’s always, yeah, I, I find sometimes that my, my methadone’s too weak and I get that bone rot. Like, you know, cause yeah. And, it, it…” Focus Group 2
Participants believe that the business and profitability pressures of pharmacy operations affected the way health care services are provided in community pharmacies by hiring a few pharmacists and overworking them. According to the participants, community pharmacists are “overworked, underpaid” workers who are pushed by their companies to make a profit. Having this perspective of community pharmacy services affected patients’ engagement with pharmacists. Participants describe pharmacy services as a money-making business that endeavour to maintain power and control over the patients they serve.
“I truly think it’s a power/control issue. Extremely, that’s what it’s become.” Focus Group 3
Participants identified that lack of consistency in pharmacy services negatively affected their experiences in community pharmacies. Participants reported that dealing with a different pharmacist each time prohibits building trust and meaningful relationships with pharmacists. Having different pharmacists providing regular services like methadone, HIV, and Hepatitis C medication prevented the feeling of familiarity with the system and alienated patients.
“Yes, that’s exactly what the problem [is]… There’s always a different pharmacist doing something. Right, one pharmacist for methadone, period. That would be great. That way that pharmacist knows who’s, what, where, how, when and why” Focus Group 2
Lack of consistency in pharmacy procedures was also a concern for participants. For example, it was not clear for participants why some pharmacies would provide them with over-the-counter medications, such as Tylenol One (a medication that contains codeine, an opioid), while other pharmacies would deny it. Similarly, it was upsetting for participants that providing pamphlets with information about their medication and illnesses was not a regular practice at all pharmacies.
“Participant A – You know what is weird…because of my methadone, uh, some pharmacies will sell me ones [Tylenol one], and some other pharmacies will not sell me ones.
Participant B – Yeah, yeah, but, uh, I am wondering how come other pharmacies will sell me them? And, I have asked them too, like, why do you guys do this…like, are you purposely giving me a hard time? Because other pharmacies do it, no problem.” Focus Group 3
“I used to like some of the [Pharmacy Name] pharmacies because they used to have all the pamphlets and everything…all the drugs and all the illnesses…and stuff like that available. Like the one [location of a pharmacy, with street name] doesn’t have it … I don’t know why but they don’t, but the ones on the east side have pamphlets with the ailments.” Focus Group 1
Participants suggested pharmacies should hire more pharmacists to improve services. Participants believed that if pharmacies were properly staffed, pharmacists would have more time to answer questions, improve consistency, and augment the quality of the provided services.
“You know, it’s, it’s constantly like that. That’s why if they got one pharmacist for the methadone, HIV, Hep C, whatever. Then, that pharmacist is just doing that job and able to answer questions for you. Then, that, I would feel much better about all pharmacists. But right now, when go I see my pharmacist, I got no time for them either. Cause, why? They don’t, they look at you, they sneer their nose down at you, or whatever and then have a nice day.” Focus Group 2
4. Positive Encounters:
It was an interesting observation when participants from different focus groups shared positive stories of the same pharmacists. A number of pharmacists -known by name- were able to provide a positive experience to multiple participants. Polite, genuine, friendly, and caring were the main characteristics of the pharmacists who created positive experiences for participants. Participants perceived that those pharmacists sincerely cared, tried to put their health first, and never let them go without the necessary medications.
“Participant A –certain pharmacies are good, like, it depends on the pharmacist. Like, [Pharmacist Name] was an awesome pharmacist…
I – What, what makes [Pharmacist Name], a good pharmacist?
Participant A – Well, his attitude.
Participant B – He cared about people.
Participants A – He actually cared.
Participant C – He, like, he mingled with the people, you know.
Participant A – He never ever let me go without my medication” Focus Group 2
Services from Community Pharmacists
Participants showed a lack of knowledge regarding the scope of services community pharmacists could provide. It was surprising for participants that community pharmacists can provide services beyond dispensing medications. The key service or role community pharmacists provided for them has been limited to the dispensing of medications, namely methadone and HIV medications. However, even the dispensary services were reported as suboptimal because of pharmacists’ inefficient multitasking and lack of time for proper communication.
“I always just thought of him as someone serving me just to get the pills and get out” Focus Group 1
“The only reason, the only reason they use a pharmacist…they go get my, my product.” Focus Group 2
The limited understanding of the role, services, and responsibilities of community pharmacists created a communication barrier for SUD patients when accessing pharmacy services. Not knowing about the services pharmacists could provide discouraged participants from seeking help and other services from pharmacists beyond dispensing medication. When a pharmacist offered additional services such as dose adjustment or medical advice regarding their drug regimen, participants felt annoyed as they believed pharmacists were overstepping their role and delaying the dispensary services. Participants stated that understanding the broad scope of a pharmacist’s role would facilitate information exchange between patients and pharmacists.
“I did not even know that they could do all that stuff because … they never …showed that they could do all that stuff.” Focus Group 3
“And, the pharmacist will sometimes say that, uh, I really do not think you need this medication, or it should be lowered, or something like that. And I do not think that it is their job to be doing that and when it comes to the doctor … I mean, when the doctor prescribes it, they should just be following what the doctor orders.” Focus Group 1
However, once participants became aware of the extent of help community pharmacists can provide, they showed interest in accessing such services if offered by community pharmacists. Some participants indicated that their pharmacy uses posters to promote the different services they can provide. Those participants described the convenience of accessing different services through community pharmacies. Stronger relationships appeared to be formed between patients and pharmacists when patients accessed various additional services via community pharmacy.
“Participant A – Well, like at my pharmacy, they post up posters, like, post up like…
Participant B – What they can do?
Participant A – Things that, what they can do and what, what.
Participant C – How they can help.
Participant A – What they’re there for if it makes it easier than going to a doctor.
Participant B – That’s a lot better.
Participant A – Like, even when I’ve been sick when it happened on a weekend when it hasn’t been a doctor, they can look up stuff that…if they can give me something, they can give me something until I can get to a doctor. I think I’ve been through that system three times already and I think it’s pretty good.
Participants C – Yeah, that’s how [Pharmacy Name] in Winnipeg…when I was in Winnipeg, that’s how they were. Like, they’re very like, you know, one-on-one basis. Like, they care for you. Like, they, they, like they knew when something was wrong with me and they come up to me. Because I have mental health issues. And, so they know, like, I’d be off balance and stuff like that.” Focus Group 3
Participants across all focus groups described one specific Saskatoon pharmacy with a higher number of positive comments as compared with other pharmacies in the vicinity. This pharmacy offered multiple services at one location. The “one-stop-shop” was recognized by most participants for its convenience for patients who do not have transportation. It was the only community pharmacy in Saskatoon that has a unique patient-friendly arrangement, whereby participants were able to receive more services than what a usual pharmacy provides, including access to a nurse practitioner, a doctor two days a week, and a counselor. Also, the pharmacists working in that pharmacy were able to provide a positive experience for most of the participants.
“In my pharmacy, we go [to] my methadone doctor comes there on Tuesday. And, we got them nurse practitioners, and then the doctors do come in, and it’s right in the building. And, then it’s open all week too. Other things like drug things, talk to the counselors there, and…we have all of that [Pharmacy Name].” Focus Group 3
“And, then I told him, we need a one-stop-shop. Quit sending us to the east side cause they’re not going to go. Cause they didn’t feel well. And, then so [Physician Name] cut them off. So, we, we tried to relocate it back to…everything back to [Street Name], but they’re being labeled.” Focus Group 2
The Methadone Program
Enrollment in a methadone program was the predominant reason why participants accessed community pharmacy services. Almost all participants had experience with the methadone program, and those experiences appeared to shape their perspective of community pharmacists. Participants were glad to have the advantage of accessing the program that helped them manage their SUD. However, the way the methadone program was operated generated negative feelings and experiences among most participants. Several participants showed frustration with the idea of methadone as a lifelong commitment. They believed that it creates a power disparity where pharmacists “control how [their] health is right now.”
The negative experiences about the methadone program were centred around pharmacists’ attitudes, pharmacy settings, and unclear procedures.
Although participants reported few positive encounters, most of the participants’ comments were characterized as unfavorable, describing both stigma and discrimination. Participants felt that pharmacists’ attitudes showed prejudice. Those negative feelings were combined with participants' beliefs that pharmacists do not understand the hardship they are going through to stay on the methadone program. They explained the difficult lifestyle they have as drug users and the significant effects of unforeseen events like a death in the family or a house fire. Despite all their sufferings, patients felt that pharmacists did not offer proper assistance and are finding different reasons every time they visit to cut them off methadone. For example, losing methadone bottles, coming late to their methadone appointment, being rude to pharmacy staff have been reasons cited by a pharmacist to refuse to give them their methadone dose. Participants believed that community pharmacists lack sincere compassion and enact barriers because they are on the methadone program.
“Right. And, you got these people looking at you. Oh, you’re on the methadone program. You’re a user. You’re garbage. That’s how you feel because that’s the response you get from all the people.” Focus Group 2
“No, health region helping us. I have some people hitchhiking on the highway, coming to get their methadone because the pharmacist won’t give them a week or two days or three days.” Focus Group 2
Participants also believed that they are being discriminated against and treated differently than other clients because they are engaged with the methadone program. Participants reported that being on methadone or having HIV or Hepatitis C evokes negative attitudes and behaviors from community pharmacists. Participants expressed that pharmacists’ body language changes once they know that a patient is a methadone client. For example, they feel because they are methadone clients, they are ignored, stigmatized, and pushed aside in favour of serving other clients.
“Participant A – We shouldn’t feel discriminated against because we’re sick, you know. And, a lot of these pharmacists do that. They will look at you, …like if they know that you’re Hep C or HIV. Right, they’re automatically, like, there are some that just will not touch you.
Participant B – They’ll get somebody else…
Participant A – Oh, oh, their, their language, … eye appearance.
Participant A – Their facial expression.
Participant B – You can feel it.
Participant A – Yeah, you just…Oh god, you’re here. Ok, well, ok, where is my gloves, where’s my hat and…you know, cover up garb or whatever, you know.” Focus Group 2
2. Pharmacy settings:
Pharmacy settings for methadone patients were described as unwelcoming environments that made them feel uncomfortable, especially with pharmacies that designated a separate entrance and space for methadone patients. Using a different back door and dealing with pharmacists through a glass barrier was an upsetting experience for participants. Participants felt alienated, discriminated against, and stigmatized because they had to access their services differently than other clients. In other pharmacies, the situation is less traumatic, but methadone clients were still treated differently and “pushed” aside to wait, unlike other clients.
“You know…even if they had some pictures up, behind [Pharmacy Name], in the back door…there’s nothing to make that person feel comfortable. You are in the cold; you’re in an enclosed space that’s no bigger than this (Participant indicates the size of the space by tracing it out in the room). With a, with a big plexiglass window and that is all you got. There are no pictures. It is always gross on the floor, and you feel like you’re in a prisoner’s box” Focus Group 2
Participants indicated that despite their negative experiences regarding a particular pharmacy setting or pharmacist’s attitude, they did not have the option of getting methadone from another pharmacy. They were forced by their SUD and their doctors’ referrals to access certain pharmacies. Due to their sickness, they needed to utilize a nearby pharmacy, especially when they did not feel well.
Furthermore, the lack of privacy was reported as a communication barrier by different participants. Participants did not like to discuss and share sensitive information about their substance use with community pharmacists in such a public setting. Also, a few participants felt ashamed when a pharmacist discussed their medications and health concerns where others could hear. This behaviour was perceived as a breach of confidentiality.
Participants elaborated that community pharmacies are very busy, community pharmacists are overworked, and that is why patients may be receiving suboptimal services. In fact, participants recognize how challenging the work environment is in community pharmacies. They explained that pharmacists provide services to a wide range of clients and that some methadone clients are rude and obstinate. They understand how stressful it is for pharmacists to validate the information provided by a SUD patient as some patients may provide misleading information to break the rules. It was recognized that pharmacists’ behavior might be justified based on previous negative encounters with other methadone clients. However, participants felt that pharmacists should not judge all methadone clients negatively and should “treat people how [they] want to be treated” Focus Group 3.
3. Unclear Procedures and Policies
Unpredictability and lack of consistency in the procedures for methadone dispensing was a primary concern for several participants. Various reasons were shared as to why pharmacists may refuse to dispense methadone, such as being late for appointments, being rude to the pharmacist, missing daily methadone doses for a couple of days, and losing carries bottles. The worst scenario was when, according to some participants, pharmacists refused to dispense medications without any explanation. Also, participants reported that pharmacists did not assist participants when they have unforeseen events like travel arrangements to attend an unexpected family funeral. It was not clear for participants what the policies were under such circumstances as pharmacists often lacked consistency in such situations. Participants theorized that pharmacists were prejudiced and enforce policy without caring about their patients.
Participants shared incidents of when they suffered from withdrawal symptoms after receiving their witnessed daily dose of methadone due to inaccurate dosing or because they vomited the dose. Participants explained how they felt abandoned as pharmacists did not help while witnessing their suffering. They explained the pharmacists did not replace their dose until they contacted a doctor. The situation sometimes resulted in the replacement of the methadone dose; however, other times, participants’ doses were not replaced. Participants felt controlled by pharmacists who may find different reasons not to give them their methadone carries – take-home methadone doses - or even their daily witnessed dose. It was upsetting for participants that pharmacists lacked compassion when enforcing policies and regulations.
“They don’t care about the patients. They don’t. It’s all by…based on rules and regulations.” Focus Group 2
“I mean, like, um, for one instance, like, a house of mine burnt and my methadone carries bottles were in the house. They burnt too. The pharmacist on [location] knew about it. Like, it was on the news … I had to pay back sixty dollars for the bottles plus thirty bottles for my replacement drinks.” Focus Group 2
Needs from community pharmacists
Participants' responses aggregated around three main aspects concerning their needs, namely respect, education, and the needle exchange program.
Participants explained that they wanted to receive respectful communication from community pharmacists, similar to other clients. They expressed that they deserved to be treated with respect, politeness, and care and not to be judged because of their SUD. Participants also described that they would appreciate if pharmacists socialized and engaged in friendly exchanges with them. Genuine understanding and respectful communication were the paramount need reported by participants. However, participants also clarified that it might take some time to build trust and form a relationship with them; therefore, the best way to interact with SUD patients is to be professional, polite, and “do not force it.”
“If I [were] a pharmacist, I would look at each individual case separately and would not judge a person if they are having a bad day. I would ask them, are you ok? I would direct them, you know, if you need someone to talk to, here is a number, you can go here. There is a job there, you know. There is a lot of help out there; you just got to reach out.” Focus Group 4
Finally, participants wanted pharmacists to be sensitive to different cultures, languages, and practices, particularly the culture of the Indigenous peoples of Canada. An Indigenous participant described how great the experience would be for an Indigenous patient if a pharmacist showed a sign of cultural admiration.
“They (referring to First Nations peoples) are all flown here to get their drugs. And, they are just, it is intimidating. It is scary as hell, having a pharmacist there, the pharmaceutical company ready to hop on you. They got a whole team of doctors as soon as they get off the plane. Not one of them speaks their language.” Focus Group 2
Participants acknowledged the need to be educated by community pharmacists regarding their medications, such as toxicity, drug-drug interaction, and drug-food interaction. Health information provision and explanations were one of the main topics discussed across all four focus groups. Learning about SUD and understanding the effect of the medications on functionality was reported as an essential need. A pamphlet (print-out) with information about SUD or where to get help was recognized as a great approach to providing information.
“Participants A - But they got to educate people more on…and give them more information about the drugs people are taking. Instead of just prescribing and giving the person their prescription and, you know, go home and take your meds until they are done. And, you know, if they are prescribed Dilaudid or morphine, well, two weeks down the road they are… they have no energy, they are sore, and they are sweating and everything.
Participant B - But they do not understand why.
Participant A – Yeah, they do not understand why because they did not get the information from the pharmacy when they started taking this.” Focus Group 2
“what drugs interact with each other. I think it is a good idea that they should bring it to the drug addict’s attention. Like say, for instance, this seizure medication combined with this medication, if you are abusing crystal-meth, it will do this to you, just a heads-up, I know it is stupid cause drug…people just think that they are drug addicts and they do not care, who cares to let them know, but it’s important because some of us are diabetic or suffering with mental illnesses like depression ” Focus Group 1
Similarly, participants wanted community pharmacists to learn about the difficulties and social hardships they are going through as drug users. Many participants expressed that they wanted pharmacists to understand how hard it was for them to secure basic needs like food, shelter, and transportation. Participants also believed that community pharmacists needed more education and training on SUDs. According to the participants, pharmacists had a knowledge gap concerning SUDs and HIV; thus, they needed to be further educated in order to better serve patients with SUD.
“They do not know what we are talking about when I am discussing my lab results with them. CD4 count, CD4 count, uh…[Multiple Participants’ Voices] CD4 count and your viral load. They did not know any of that. You know, just looked at me. They are real puzzled.” Focus Group 4
3. The needle exchange program:
Several participants described the city’s needle exchange program as a non-effective program because of how it was operated. They elaborated that the operating hours, the quantity of provided syringes, in addition to the limitations of the exchange policy, made the program ineffective when needed. Community pharmacies were not currently providers of the needle exchange program in Saskatoon; however, participants believed they should be. Having community pharmacists involved in the distribution of clean needles would enhance the accessibility of the program, especially on weekends.
“The Health Bus* is done at 11. After 11 and on weekends, you are done. If you do not have a clean rig, well, all of a sudden, you are using one of your used ones. Heaven forbid you would use somebody else’s, but I am sure you would not in this day and age. Or, you are sharpening one of yours. I am it is, it is really quite gross. I could go into it. or [Pharmacy Name] could have it……. could have a mandate of giving out five.” Focus Group 2
* Health Bus is a mobile health initiative in Saskatoon. It is designed to bring health care services to people and is staffed with nurse practitioners and paramedics.