Opioid agonist treatment and trust in the community pharmacy setting: a qualitative study of perceptions and experiences

Abstract

Background

Opioid agonist treatment (OAT) in New South Wales Australia involves prescribed consumption of methadone or buprenorphine formulations and is commonly accessed through community pharmacies. People with a history of drug use often feel mistrusted and this can deter them from starting or staying in treatment. This study sought pharmacist and consumer perspectives to understand how treatment engagement can be best supported.

Objective

To explore consumer and pharmacist experiences of OAT services, identifying the social and structural elements that enhance or impair treatment and professional satisfaction and analyzing how these are influenced by trust.

Methods

Semi-structured interviews were conducted in 2021–2022 with 10 pharmacists and 15 consumers. Transcripts were analyzed using a realist thematic approach.

Results

Burdensome fees, pharmacy service problems, and system opportunities were generated as themes of subjection, and socially inclusive care and person-centered approaches as themes of connection. OAT consumers felt more inclusion when pharmacy practices did not differentiate or demean them and when pharmacists communicated in a personable and caring manner, and pharmacists recognized these aspects as contributing to greater professional fulfillment and less service problems.

Conclusion

OAT delivery in community pharmacies provides opportunities for greater social inclusion, particularly when trust and fairness are demonstrated.

Keywords:

• Opioid agonist treatment
• community pharmacy
• qualitative research
• trust
• methadone
• buprenorphine

Introduction

Opioid agonist treatment (OAT) has been shown to be effective in reducing mortality and health harms related to opioid dependency and illicit drug use, in improving quality of life, and in providing relief to people with related ongoing pain and distress (Brown et al., 2004; Burns et al., 2009; Järvinen, 2008; Sordo et al., 2017). Fears and experiences of drug use-related discrimination and mistrust within health care settings can impede treatment uptake and continuance (Biancarelli et al., 2019; Hammarlund et al., 2018; Muncan et al., 2020). Treatment retention is critical as the risk of overdose-related injury or death increases sharply if treatment is stopped (Pearce et al., 2020; Wakeman, 2016).

OAT is offered within many community pharmacies in New South Wales (NSW) Australia, starting in the 1980s primarily as a harm reduction response to curb blood borne virus transmission related to heroin injecting, and treatment uptake has continued to expand over time (Australian Institute of Health and Welfare, 2023; Caplehorn & Batey, 1992). Treatment retention in NSW is relatively high, with half of those initiated found to continue or re-engage in OAT over a 20-year period, and OAT is estimated to have reduced overdose deaths by 53% and other mortality by 27% in the same timeframe (Chaillon et al., 2022). In 2022, 65% of NSW OAT consumers were dosed in community pharmacies with an average of 13 people per pharmacy, the median age of consumers was 45, and 53% were receiving methadone (Australian Institute of Health and Welfare, 2023).

Treatment is initiated and monitored by a public clinic or private prescriber and involves brief ongoing encounters with a pharmacist to access oral doses of methadone (full opioid agonist) or buprenorphine (partial opioid agonist) formulations. These are consumed under pharmacist supervision, and additional doses may be provided as takeaways, i.e. for the consumer to self-administer on subsequent days, contingent on prescriber authorization (NSW Government, 2020; NSW Ministry of Health, 2018; Winstock et al., 2010). Consumers have identified takeaway access as highly-valued in that it enables greater autonomy and is a strong indicator of clinician trust (Treloar et al., 2007). Pharmacists are responsible for maintaining records related to prescriptions and dose provision, ordering medications and storing them securely, measuring liquid doses, supervising consumption, and collecting dispensing fees (NSW Government, 2020). This service model is recognized as reducing government costs and increasing access to treatment for many, particularly for those in rural areas (Australian Institute of Health and Welfare, 2023; Lea et al., 2008; Ritter & Chalmers, 2009; Wood et al., 2019).

At the time when the study was conducted, pharmacists would set fees to cover their costs in OAT dispensing (e.g. $40 a week), which were generally required to be paid by the consumer upfront. The medication was provided to pharmacists at no cost under a federal scheme (NSW Government, 2020). Additionally, in early 2020 rules around prescriber treatment authorization and monitoring were relaxed in response to COVID-19 public health measures that aimed to reduce interpersonal contact. For many consumers this meant they could have remote or less frequent prescriber appointments, urinalysis requirements were dropped, and takeaway dose provision was increased (NSW Ministry of Health, 2021).

Qualitative studies of pharmacist experiences in OAT dispensing internationally have highlighted the importance of professional competence, clear guidelines, and integrated care coordination, and have shown how deficiencies in these can impair service uptake and quality (Carlisle et al., 2023; Chaar et al., 2013; Yadav et al., 2019). Pharmacist service satisfaction has been linked to having engaged relationships with customers and a positive attitude toward the service (Chaar et al., 2013; Fatani et al., 2019). Service difficulties included busy workloads, insufficient training and support, clinical role constraints, as well as challenges in balancing professional obligations with business operations (Fatani et al., 2019; Le et al., 2018; Le & Hotham, 2006; Yadav et al., 2019).

Qualitative studies involving OAT consumers have generally shown pharmacy dispensing to be favored over clinic dispensing because it reduces treatment restrictions and increases privacy. Benefits include greater personal resources and improved ability to address overall health needs, but there were concerns regarding travel preclusions, dispensing costs, and stigma (Carlisle et al., 2023; Harris & McElrath, 2012; Neale, 1998; Treloar et al., 2007). Furthermore, consumers have described not being afforded the same level of trust and personalized care as other pharmacy customers (Carlisle et al., 2023; Harris & McElrath, 2012; Neale, 1998).

Insufficient trust was a recurrent finding within the literature and was applied as a frame to discuss the findings of this study. Trust can be defined as dispositional or relational; as either a willingness to share with, place confidence in, or be vulnerable to another person or entity (Rousseau et al., 1998), or as an attribute of social relationships that display these characteristics. Trust is also understood to underlie the systems of cooperation and mutual dependence that produce social structures and institutional authority (Cook & Santana, 2020). This study aimed to qualitatively explore and compare consumer and pharmacist perceptions and experiences of OAT services, identifying the social and structural service elements that enhance or impair treatment engagement and professional satisfaction and analyzing how these are influenced by trust.

A note on terminology: ‘Consumer’ is used to refer to people who receive opioid agonist treatment. ‘OAT customer’ is sometimes used when referring to a consumer in the pharmacy setting (i.e. where their role is as a customer to their pharmacist); and sometimes pharmacists refer to OAT consumers as ‘clients.’

Methods

Research design

This study recruited pharmacies from different geographic locations within NSW. It was designed to facilitate an in-depth focus on service experiences, allowing for differences that may arise from locational characteristics while controlling for jurisdictional differences in policy and practice. Interview questions were developed with the aim of eliciting thoughts and experiences with reference to pharmacy OAT provision, as well as illustrating strengths, limitations, and opportunities in the service model. Interview guides (see Appendix) were developed in consultation with people who have experience as OAT pharmacists or consumers. Pilot interviews (three pharmacists and three consumers) were conducted to generate feedback and refine the wording and content. The author conducted pharmacist recruitment, consumer eligibility screenings, informed consent processes, interviews, transcribing, coding, and theme generation, and conferred with the broader study team to refine the data collection and analysis processes. Ethics approval was obtained from the Human Research Ethics Committee at UNSW (HC200836). The data and methods were assessed using the Standards for Reporting Qualitative Research (O’Brien et al., 2014).

Recruitment

A purposive sampling strategy was utilized, aiming for a diversity of pharmacy locations within NSW (Campbell et al., 2020). Pharmacy locations were categorized as city (i.e. Sydney), rural (i.e. small towns in riverine or bushland areas), or remote (i.e. isolated small towns in semi-arid inland areas). Recruitment did not extend to larger towns. The author sent emails and then visited pharmacists, providing them with study information and requesting they provide recruitment slips to their OAT customers. Pharmacists were followed up if they expressed interest, and OAT consumers communicated their interest by phoning or emailing the author. Eligibility criteria were to be a pharmacist who has delivered OAT community pharmacy services in NSW or a person that has been a community pharmacy OAT consumer in NSW, to have good English language skills, and be aged over 18. Recruitment began in February 2021 and finished in March 2022, ceasing when the study team determined that sufficient data had been obtained to generate useful findings and comparisons (Vasileiou et al., 2018). All pharmacists and all but one consumer who were informed of the study went on to later participate.

Data collection

Potential participants were informed that the research involved answering questions about their experiences with dispensing or receiving opioid agonist treatment in community pharmacies. The researcher clarified that they did not have a background in pharmacy or the biomedical sciences and described the social science research approach as primarily focused on perceptions, experiences, and relationships. Interview locations and formats were determined by participants and aimed to reduce participation burden, support open dialogue, and minimize COVID-19 transmission risk. Each interview began by audio recording a verbal consent that was filed separately to the interview audio file. Interviews ran for between 15 and 90 min, with the majority around 30 min. Consumer participants were provided with AUD $20 cash after interview completion; pharmacists did not receive remuneration due to resource restrictions.

Data analysis

Pseudonyms were ascribed and transcripts were de-identified, checked and corrected, re-read, summarized, and inductively coded (extracting key messages as categorical labels) (Thomas, 2006) using QSR NVivo software (version 12.7.0, 2019). The analytic technique applied was realist thematic analysis. It utilizes realist ontology and relativist epistemology (i.e. understands that people generate different observations and knowledge about things, and holds that these things do exist independently of the people that perceive of them) to find contextual explanations for observed social phenomena (Bhaskar, 2016; Stutchbury, 2022; Wiltshire & Ronkainen, 2021). Initial codes were organized into nascent experiential themes that described the viewpoints of participants in reference to the processes, limitations, and benefits of pharmacy OAT, and to consumer and pharmacist characteristics that influence these. Experiential themes were then refined and reduced with respect to the study aims. Inferential themes (i.e. conceptual categories derived by grouping experiences) were generated by reading across the experiential themes, aligning recurrent or related observations within broader categories that described problems and opportunities within the treatment model. Dispositional themes (i.e. postulated tendencies that could explain or resolve the described experiences) were then developed through retroductive analysis, which involved collating the inferential themes into terms that described potential explanatory properties produced from the interpreted data (Stutchbury, 2022; Wiltshire & Ronkainen, 2021).

The transcripts were then reflexively reviewed with reference to the generated themes to ensure thoroughness and validity, and themes were further reduced and refined. Coding and theme generation were discussed and developed with the study team. In the findings that follow, each dispositional theme is followed by summarized interview data that explains its context. Inferential themes structure the description and analysis of the data and contain woven references to the (non-labelled) experiential themes within them. Pharmacist and consumer data and interpretations are presented alongside each other to explore their similarities and produce mutually beneficial knowledge, rather than reify an assumption of opposed interests.

Findings

Participants

Audio-recorded, semi-structured interviews were conducted with 15 consumers receiving OAT and 10 pharmacists in rural areas of the Northern Rivers (n = 13), metropolitan Sydney (n = 11), and one remote area (n = 1) between February 2021 and March 2022. In person recruitment was interrupted for half of 2021 due to COVID-19 related restrictions. All but one consumer were currently receiving OAT from a community pharmacy (the exception had transitioned to depot buprenorphine injections at a public clinic). OAT consumers had all previously received methadone at some time, and most had attended more than three pharmacies. Of the 14 consumers who were still receiving pharmacy OAT, all were receiving takeaways and visited their pharmacies between four times a week and once a month. Forty percent of both pharmacist and consumer participants were female, and 60% were male. Further participant details are provided in Tables 1 and 2.

Table 1. Pharmacist participant characteristics (n = 10).

Pseudonym	Gender	Age	Pharmacy location	Years OAT service	No. on OAT^a	Interview date (D/M/Y)	Interview location	Interview length
Daniel	Male	70s	Rural	>40	50	26/02/21	Pharmacy	0:18:29
Christie	Female	30s	Rural	10	20	05/04/21	Phone	0:23:34
Heather	Male	60s	Rural	>40	5	12/04/21	Café	0:20:44
Stuart	Female	80s	City	>40	70	19/04/21	Phone	1:30:04
Paul	Male	50s	City	11	30	16/06/21	Pharmacy	0:29:32
Warren	Male	60s	Rural	>40	15	30/06/21	Phone	0:48:14
Sabina	Female	20s	City	1	30	01/07/21	Phone	0:31:19
Michelle	Female	60s	Remote	>40	20	02/07/21	Phone	0:37:27
Malcolm	Male	60s	Rural	31	20	30/11/21	Phone	0:20:41
Blake	Male	30s	Rural	14	20	30/11/21	Phone	0:17:19

^aEstimated number of OAT customers at time of interview, or at last time of OAT service.

Table 2. Consumer participant characteristics (n = 15).

Pseudonym	Gender	Age	Pharmacy location	Current OAT type	Years of OAT	Interview date (D/M/Y)	Interview location	Interview length
Naomi	Female	50s	Rural	Methadone	>20	26/02/21	Park	0:45:11
Shaun	Male	50s	Rural	Biodone	>20	04/03/21	Park	0:39:03
Timothy	Male	40s	Rural	Methadone	>20	15/03/21	Café	0:14:48
Stephanie	Female	40s	Rural	Biodone	10	15/03/21	Café	0:19:34
Beth	Female	50s	City	Methadone	>20	25/03/21	Café	0:28:39
Kendra	Female	40s	City	Subutex^a	14	22/04/21	Park	0:34:54
Bree	Female	40s	City	Methadone	1.5	18/06/21	Park	0:20:40
Josie	Female	40s	Rural	Methadone	20	23/11/21	Park	0:34:48
Ethan	Male	50s	Rural	Methadone	8	26/11/21	Home	0:30:34
Matthew	Male	60s	City	Buvidal^a	5	09/01/22	Park	0:40:25
Sophia	Female	50s	Rural	Suboxone^a	18	05/01/22	Home	0:47:12
Adam	Male	50s	City	Methadone	20	22/02/22	Café	0:28:44
Rick	Male	50s	City	Methadone	20	24/02/22	Park	0:26:04
Simon	Male	60s	City	Methadone	3	25/02/22	Home	0:32:29
Jaden	Male	40s	City	Biodone	20	28/03/22	Café	0:28:22

^aIndicates buprenorphine formulations.

Pharmacists reported an average of 28 concurrent OAT customers (median = 20; range of 5 to 70), and five pharmacists had provided OAT to seven of the interviewed consumers. Half of the pharmacists had been delivering OAT since its initial rollout in the 1980s. Consumers represented a narrower age range than pharmacists. Nine participants disclosed their current dispensing fees, with figures that ranged from a low of $20 a week (pharmacist at a rural pharmacy) to $50 a week (consumer at a city pharmacy). Themes generated from the interview data are presented in Table 3.

Table 3. Dispositional, inferential, and experiential themes about pharmacy delivery of opioid agonist treatment, generated from consumer and pharmacist interviews.

Dispositional themes	Inferential themes	Experiential themes
Subjection (A) Conditions that cause someone to be controlled or to feel powerless against	Burdensome fees (A1) Pharmacy service problems (A2) System opportunities (A3)	Costly Restrictive Discriminatory Static Disempowering
Connection (B) A human disposition or need to relate with other people and to feel respected and included within social environments	Socially inclusive care (B1) Person-centered approaches (B2)	Non-differential processes Personable communication Individualized care Promoting community health

A. Subjection

Although recognizing that opioid agonist treatment enables a better quality of life overall (compared with illicit opioid use), consumers and pharmacists identified a range of ways in which OAT systems and services limit treatment satisfaction and produce perceptions of unfairness among consumers. Treatment initiation and its transfer or continuance in pharmacy settings were described as being tightly regulated and controlled by prescribers and health policies, and pharmacists noted how this restricted their dispensing behaviors. According to participant accounts, prescriptions expire within one to three months, takeaways are restricted and necessitate pharmacy attendance on stipulated days (restricting movement), supervised consumption within pharmacies is commonly required, and some of the processes and rules instituted by pharmacies are perceived as discriminatory. Pharmacists generally understood these as measures to prevent dose diversion (i.e. selling or providing to others), to facilitate medical and pharmacist oversight of consumer health (i.e. in observing consumer presentations), and for service efficiency and viability. However, as consumers are subject to these rules continually, and as treatment may continue indefinitely, they described the restrictions in the treatment system as onerous and disempowering. Although much consumer dissatisfaction was expressed in reference to OAT policies, medications, and prescriber behaviors, the analysis below only focuses on the problems they identified within pharmacy practices.

A1. Burdensome fees

Dispensing fees were considered to be a major source of consumer hardship in receiving treatment and were the primary cause of conflict with consumers for pharmacists. Some pharmacists found it a challenge to provide the service in a financially viable way, and some consumers struggled in maintaining pharmacy OAT because the cost was too high.

Most of them pay their way, but […] the lady I spoke about with the mental illness, she’s behind. But I’m not prepared to stop supplying her. (Warren, pharmacist, rural)

Most of them they’ve got, they’ll give you some payment and they’re still back in 2010 or something like that (laughs). Like that’s just a, it’s a bit of a joke. But as long as they pay something we’re happy. (Malcolm, pharmacist, rural)

Pharmacists noted that dispensing fees are included in the shelf price of all other medications, and they were aware that consumers had negative perceptions about being charged extra or more than other customers. Indeed, consumers described the dispensing fees as discriminatory and even predatory, assuming that pharmacists must be making considerable profit in providing the service as ‘they can charge as much as they like’ (Naomi). They described numerous inconsistencies in the way that they were charged compared to other customers. For instance, Sophia was being charged daily dosing fees for monthly supplies of Suboxone® (which do not require pharmacist preparation) and Matthew complained that ‘if you miss a day, you still pay for that day’s dispensing.’ Some consumers also explained that their limited resources and treatment options further contributed to the inequity and powerlessness that they felt with respect to the dosing fees.

I’m paying fifteen percent of my income to the pharmacist. […] I know the government subsidizes him so, you know, he’s doing quite okay out of it. And it seems to go up every six to twelve months. (Shaun, consumer, rural)

A2. Pharmacy service problems

Problems that consumers identified within pharmacy OAT interactions and processes included being treated unfairly and not being trusted or having means of dispute. Furthermore, these perceived deficiencies in consumer agency and procedural transparency were seen to generate suspicions about pharmacist conduct at times. Pharmacists also found some policy restrictions to be encumbering and unfair for consumers and were frustrated when consumers had negative perceptions of the service or did not comply with their treatment regime. Both described the service itself to at times be wearying in its regularity and monotony. These problems are described in more detail below.

Vulnerability to unfair or discriminatory behavior by pharmacy staff was a source of frustration and despair for consumers, as shown by this quote from Naomi in reference to being wrongly accused of unpaid services, ‘we have no recall, we can be ripped off, we can be treated so badly but we have to take it on the chin.’ Unhappiness with the commercial dispensing model extended to feelings of mistrust, with some suggesting that pharmacists were motivated by greed and acted in unethical ways with respect to the service. Rick explained that his pharmacist only accepted upfront cash payments for his methadone and only provided handwritten records, but allowed him to use his bank card and get electronic receipts for other transactions—he felt they were receiving financial benefit from not properly declaring their OAT income. Beth also noted her pharmacists didn’t give receipts, and Naomi said the same of a pharmacist that wrongly accused her on multiple occasions of unpaid dosing bills. Some consumers felt that there were discrepancies in the strength of doses at times, possibly indicating corrupt conduct.

There’s ‘done from some chemist that is stronger than ‘done from other chemists. So, I guess I wonder who monitors the ongoing strengths of methadone in pharmacies? […] If somebody chose to it could be quite lucrative to, you know, to siphon some off on the side and sell that. (Stephanie, consumer, rural)

Consumers described being afraid of potential dispensing errors by the pharmacist because of concerns that they may not be trusted and it would reflect badly on them.

There’s just this sort of automatic assumption that you would be the one that had made a mistake, […] that you also might be, you know, bullshitting them. (Sophia, consumer, rural)

Policy restrictions within the NSW opioid treatment program created problems for pharmacists. They described the recording requirements as laborious and the lack of ability to engage their clinical decision-making skills as unfair for consumers at times. Problems often arose with respect to expired prescriptions, and prescribers could be difficult to contact to resolve these, which at times led to conflict or consumer distress.

There’s all these rules in the program […] how to record it, how to do it […] but there’s no recognition that um, you know, you do have a moral obligation as well, to your client. And sometimes a tiny little rule like a, a variation in a dose, a takeaway regime or something because they’re working a day, […] there’s no flexibility there. (Heather, pharmacist, rural)

[OAT consumers] don’t have an understanding of the, the law, ah with, about prescriptions. […] There might be five takeaways [authorized] with only three in a row maximum. […] They don’t understand that when the prescription runs out that, that I can’t do anything. (Warren, pharmacist, rural)

Michelle described an encounter that occurred when she was working as a pharmacist in a large regional town and was visited by an OAT consumer who was just released from prison. He was in need of his dose and came to her after being turned away from the nearby public clinic (as they had not been accepting new consumers for some time). Her account illustrates the ways systems can fail OAT consumers, as well the efforts that some pharmacists go to in supporting treatment continuance.

[The corrections officers] released him from jail knowing, told him to go to the clinic knowing the clinic wouldn’t see him. And then wouldn’t give me the [prescription]. So I spent four hours ringing every [doctor] in town that had prescribed um, methadone, that I could think of, to try and get it through. (Michelle, pharmacist, remote)

Pharmacists also expressed frustrations related to some consumer behaviors and perceptions of the service, but noted that the service requires more restrictive processes due to the controlled nature of the medication. They explained that consumers are not aware of all that is involved in dispensing OAT, including the amount of work they have to do, the degree of clinical responsibility that they carry in providing the service, and the difficulties they face in maintaining efficiency, financial viability, and medication safety.

Some [OAT customers] are not coming in a hundred percent regularly. […] There’s a lot of recording involved. […] Ordering takeaway bottles [and the different OAT formulations], keeping your stock control right, it gets a bit, gets convoluted. (Malcolm, pharmacist, rural)

A more general dissatisfaction with the service was the monotony intrinsic to (what is predominantly) a maintenance program. The treatment model is highly bureaucratic, requiring onerous record checking and data entry, and consumer engagement generally consists of minimal, frequent, possibly unsatisfying encounters. As Michelle describes, ‘it’s what the job consists of most the time, I think. Paperwork!.’ Pharmacists experienced the service as repetitive yet effortful, and as lacking in opportunities to apply their clinical skills.

Whether the patient or the pharmacist, it’s persistence […] doing the same thing, ch-ch, ch-ch (makes swiping movements, laughs). And basically not much ah, not so much clinical—and you don’t want any interventions anyway, right? You want them to be stable. […] Sometimes I did think about oh, should I just quit or should I just keep going. You see? Yeah you do, you do feel bored. (Paul, pharmacist, city)

A3. System opportunities

The consumer accounts described so far have shared a common sense of subjection that influences their overall perceptions of pharmacy OAT delivery. However, there were some instances where consumers described acting in ways to benefit from the commercial nature of the treatment model, particularly where they had the opportunity to choose between pharmacies (which can occur in more urbanized locations).

Because they’re a capitalist business you can negotiate price with them. I have done that over the years, […] when I’ve gone down to weekly [pick ups] I actually negotiated it down, and then this time I went to monthly so I managed to negotiate it down even more. Although the chemist I was with didn’t do that so I found one that would. (Kendra, consumer, city)

I was able to like pick my own chemist which was really important to me. […] I felt comfortable going there because he, there was no stigma attached to being on any um, opioid substitute treatment through that chemist. You never got a lecture about ‘don’t steal from me.’ You never got a lecture about hours and stuff, which has happened years ago to me, when I was on methadone. (Matthew, consumer, city)

The relaxation of takeaway restrictions and increased pharmacy OAT provision due to the COVID-19 pandemic provided the opportunity for many people to have more control of their time. It also led to reflection on the unnecessary nature of many program restrictions, giving hope that the enabling policy changes made could remain and more could be made in future.

[Now] I go in one day a week, which has just made the most enormous difference. Like, you know, it enabled me to study again. It just, it gives you freedom. It allows you to lead a pretty, a normal life. (Stephanie, consumer, rural)

[Going to see their prescribing doctor], it’s expensive to do. It’s a day to get there and back. […] Now they’re doing them via videolink through the hospital. That makes a big difference [and] it looks like they’re going to keep that going. ‘Cause there’s no need for them to go down. Maybe once a year if you have to, but shoot, every two months? It’s a nightmare! (Michelle, pharmacist, remote)

B. Connection

Most consumer participants had received OAT from numerous pharmacists, and many were able to give examples of good and poor interactions. They reflected on personal qualities of pharmacists that they appreciated, such as friendly communication, kindness, and remembering personal details that they had shared, and felt hurt when pharmacists’ displayed behaviors of disdain, mistrust, or dismissiveness. Some credited their pharmacist’s behavior as contributing to their treatment effectiveness and to a sense of being accepted and encouraged in their motivation to stay in treatment. Within the simple, frequent dosing encounter, pharmacists became an important social support for some consumers, especially those in smaller towns or who experienced persistent social exclusion.

B1. Socially inclusive care

Compared with public clinics, consumers appreciated the social inclusiveness of the pharmacy setting and service processes, stating ‘it’s a normal atmosphere’ (Naomi) and ‘it’s a bit more dignified than rocking up to a clinic every day’ (Matthew). Pharmacies offer greater convenience in being located closer to residences or places of work, and having longer operating hours, as ‘most of them are open at least eight hours a day. They’re also open on Saturday, whereas a lot of clinics aren’t’ (Adam). Their provision of takeaway doses also offered more control over the timing of medication consumption. For example, Kendra noted that she prefers to take her Subutex® dose at night (as it helps her sleep and enables her to go to work without looking affected from it) but this would not be possible if she was required to have supervised dosing. Most importantly, the interpersonal engagement at a pharmacy was considered better; ‘you just get treated like a human being’ (Bree), compared with ‘when you go up to the clinic […] it’s like a cattle call’ (Naomi).

When asked about what makes a good treatment experience in pharmacies, the overwhelming response from consumers was having non-differential processes, where the staff treat you as ‘another customer’ (Sophia) or ‘not like […] a criminal’ (Stephanie). This was consistent with what pharmacists thought OAT consumers appreciated; they responded with ‘being treated like a normal person’ (Christie) or ‘a normal customer’ (Paul). The dynamic of reciprocity was salient in the service relationship, with consumers predicating their engagement behavior on their pharmacist’s attitude and actions, as described by Rick, ‘show me a bit of respect […] and I’ll show you more than that.’ This reciprocity was also reflected by pharmacists:

It doesn’t matter if they’re on the program or not, we treat everybody well. And if you treat them well, you will have less problems and they’ll be fine. And we have no troubles with our [OAT customers]. (Michelle, pharmacist, remote)

Pharmacy rules and processes, including differential systems that separated and delayed OAT consumers, induced or reinforced perceptions of stigma and were barriers to creating more supportive clinical encounters.

Like when other people walk in and that. Sometimes they push you to the side and serve them first, and make you wait and that. (Rick, consumer, city)

Another aspect that was central to consumer service perceptions was the level of privacy afforded to them. Most preferred a private space (i.e. a clinical room) over counter-dosing, but some were not overly concerned in taking their dose at the counter if their pharmacist was discreet and did not make them wait. For instance, Naomi didn’t like having to drink her methadone in front of other customers (‘I feel like I’m on show’), whereas Beth was fine with counter-dosing but didn’t like that her pharmacist waits for non-OAT customers to leave before providing it to her (‘it sort of feels like they’re hiding us, that they’re embarrassed about us’). Pharmacists were conscious of these issues too, with some describing how they facilitated greater privacy.

I built a new pharmacy and designed the dosing area to be semi-private, which I am really happy about. (Daniel, pharmacist, rural)

Consumers appreciated feeling acknowledged by pharmacists, and engaging in friendly conversation, as this helped to allay perceptions of stigma.

They sort of go, not beyond their duty, and they acknowledge you with a smile and, and they become friendly. So you feel comfortable […] rather than, you know, they look at you and then look away. (Simon, consumer, city)

The importance of developing caring and personable clinical relationships was mentioned by many participants, but this was particularly stressed by pharmacists in rural and remote areas, reflecting the more familiar dynamics and the reduced privacy and anonymity in smaller towns compared with cities.

We rise and fall with them. […] There’s always some connection. […] They are like family, because they are regular, regular to the pharmacy. (Warren, pharmacist, rural)

We just treat them like they’re friends. We just want them to be, to be comfortable coming in here. (Blake, pharmacist, rural)

While consumers described their current pharmacists as operating in a personable, or at least respectful manner, they usually had stories of being treated in a discriminatory or unkind manner by other staff or at other pharmacies.

People just give us a wide berth. Staff don’t want to talk to us. (Naomi, consumer, rural)

The pharmacist was a good bloke, but [the other staff would] say stuff about you, they’d look down their nose [at you]. (Ethan, consumer, rural)

Consumers were also subject to stigma or harassment by other customers or people in the vicinity of pharmacies. Christie, Stuart, and Paul described instances where people had made disparaging comments about their OAT service and they responded by explaining that OAT consumers had an equal right to access health services. Pharmacists were also aware that people felt gratitude simply in being able to receive OAT from them and were nervous about possible threats to service continuance.

B2. Person-centered approaches

While noting the high demand on the pharmacists’ work role at times, consumers were sensitive to behaviors that made them feel invisible or unwelcome, particularly as they were frequent and enduring customers. Having a friendly rapport contributed to the development of trust over time, which was seen as important in preventing and reducing the impacts of potential conflict.

Being friendly is probably the most important thing, just establishing relationships, I think. And then when things go wrong um, you can work them out easier. […] A few weeks ago all my [takeaway] doses were one and a half ml under. […] They checked their stuff and they couldn’t work out why. Um, but because we had a good relationship they believed me, they knew I wasn’t lying. And I believed them. (Beth, consumer, city)

Pharmacists were sensitive to the perceptions of OAT consumers and described the importance of giving them time and attention where possible. New pharmacist Sabina noted that consumers appreciated when ‘we listen to them’ but that ‘sometimes we do run out of time.’ Warren noted, ‘when I was by myself it was a problem in coordinating [OAT consumers] amongst the other workflow’ but hiring other pharmacists meant he could prioritize their engagement. Pharmacists also described the use of record-keeping software and automated pumps for methadone dispensing as useful in saving time.

Limits on takeaway doses was an issue that pharmacists identified ‘causes arguments and conflict’ (Stuart). While some pharmacists believed that they were unable to deviate from the takeaway allocations on prescriptions under any circumstances, others did admit they ‘bent the rules occasionally’ (Stuart) and had provided extra takeaways or organized medication drop offs where there were extenuating circumstances, which were reflected in consumer accounts.

I was in court and couldn’t get to, couldn’t get to the pharmacy to pick up my takeaways, so he actually packaged them up and left them at the ticket office in the [local] train station. (Matthew, consumer, city)

When I’ve been sick and I’ve had issues with my back or my leg or something, I couldn’t leave the house and the pharmacist has actually brought it over for me. […] Other times when I’ve been in hospital they’ve always checked to make sure [I’ve gotten my doses]. (Josie, consumer, rural)

Two pharmacists described going to extra lengths to accommodate or dispense OAT to people who had been cut off by flood water.

[OAT consumers come in] saying, ‘I need my takeaways, it’s going to flood.’ We just ring the doctor and he will okay us to give them a few extra takeaways to get them through. […] In floods, we’ve had to, we’ve got the mailman to do it. [On one occasion] I had to give it to the [State Emergency Service] to put in a boat and then throw it out to [a woman who was stranded in her home]! (Malcolm, pharmacist, rural)

We actually got […] maybe twenty, thirty extra clients over a day or two or three. Because their pharmacies were flooded. And um, it was really hectic and because we, we basically had to liaise with the prescribers and the [public clinic], and we just got them all dosed. (Christie, pharmacist, rural)

Pharmacists described these efforts as an extension of their professional responsibilities to their community as a whole, that ‘you want to help out other people in your community’ (Blake), and as particularly positive in that they prevented consumer distress or illness at critical times. Having good rapport and open communication with consumers was also described as important, as it enabled pharmacists to observe and support consumers in achieving wellbeing improvements over time, and to feel a sense of professional and personal satisfaction in this.

At first when people come in they can be so sick and so, just struggling with life. And then you watch them, you know, they get jobs, they get houses, […] they’ve gone on to do great things. (Christie, pharmacist, rural)

Not all pharmacists felt they were adequately included in consumer care coordination. This was described as engendering safety concerns, service difficulties, and professional dissatisfaction.

We’re never involved with any of the management of the clients as such, and yet we play—we see these clients every day. Every day. But you know, they bring in a script for ah, from other doctors for um, meds that obviously would interact. […] We see escalating doses, antipsychotics, but […] we’re not involved in that. And I think that’s a shame. (Heather, pharmacist, rural)

Finally, consumers and pharmacists both appreciated the opportunity to be asked about their thoughts, experiences, and perceptions. Pharmacists remarked upon their lack of knowledge regarding the experiences of consumers generally and wanted to know more about ‘what the consumer wants’ (Christie) and ‘what good we’re doing in this […] because we can’t improve anything or change anything until we know’ (Warren).

It’s just been tittering along. […] I’ve been doing it for fourteen years, I don’t think anyone has ever asked how the program is going for anyone, or anything like that. So, I think it’s such an important sort of program that it’s always good to see what’s working, see what isn’t. Get it right. (Blake, pharmacist, rural)

Consumers wanted more understanding from pharmacists and within the OAT system of the difficulties that they face in accessing treatment, and for service improvements that better support their agency and individuality, including expanding pharmacy provision and learning from consumer experiences.

They need to expand it […] into more chemists and educate a lot more [doctors] about it if they want it to work the way it is supposed to. (Adam, consumer, city)

I like things like this, you know, because you’re taking my information and hopefully it will do some good for others. (Rick, consumer, city)

Consumers also wanted more information about treatment options, including research on the long-term health effects that the different treatment formulations may have, and ways of accessing OAT in emergency situations or where mobility becomes impaired due to age or injury. Overall, pharmacists and consumers thought that improvements to the treatment model need to be informed by consumer experiences, which infers a need for better feedback systems at the local pharmacy level, as well as in broader policy reform.

Discussion

This study set out to explore and compare consumer and pharmacist experiences of OAT services, aiming to identify the social and structural elements that enhanced or impaired treatment and professional satisfaction within the pharmacy setting, and how these could contribute to service improvements. The interview data were collated into dispositional themes of subjection (i.e. conditions and experiences of being socially controlled and restricted) and connection (i.e. conditions and experiences of being socially included and positively regarded). It was found that burdensome fees and pharmacy service problems (including dispensing inconsistencies and onerous requirements) created conditions of subjection, but the system did have some capacities for increasing consumer autonomy. Pharmacy OAT was also found to be more socially inclusive and person-centered service approaches increased feelings of connection, leading to enhanced interpersonal trust and satisfaction with the service model. Trust was identified as an overarching influence, with institutional mistrust of OAT consumers coded into system restrictions and interpersonal mistrust expressed through discriminatory practices.

Recommendations to standardize and subsidize dispensing fees at a level that reduces consumer hardship, maintains service viability, encourages more pharmacists to offer the service, and increases treatment accessibility, reflects findings of prior research (Chaar et al., 2013; Fatani et al., 2019; Le & Hotham, 2006). Since the study was conducted, dispensing fees are now federally standardized and subsidized under the Pharmaceutical Benefits Scheme, with consumers paying a maximum of $30 for a 28 day supply (Australian Government, 2023). This change addresses what participants described as one of the most negative aspects of pharmacy OAT and a salient source of perceived discrimination. It is expected to make a significant improvement to treatment engagement and satisfaction, which will be essential to determine in future research.

Pharmacists faced burdens in dealing with service problems which included unhappy customers, liaising with prescribers, and the bureaucratic or repetitive aspects of their dispensing role. They also felt restricted in engaging their clinical skills and in feeling professionally fulfilled with the service, in ways similar to what has previously been described in the literature (Chaar et al., 2013; Yadav et al., 2019). However, the issues that consumers raised around suspicions of OAT misconduct in pharmacies, and their calls for greater system transparency and for support to address their vulnerability to inequitable or unethical practices, are distinctive findings. It invokes the lack of power that OAT consumers have in health services broadly, and demonstrates how the lack of trust afforded to consumers by the treatment system is reflected back in their perspectives of pharmacy services, and can lead to concerns regarding the institutional authority that pharmacists hold (Treloar & Rance, 2014; Treloar et al., 2016).

The public health focus of the pandemic has provided the opportunity to reconceptualize OAT as essential primary healthcare and reducing barriers to it as important and effective in improving community health and wellbeing (Krawczyk et al., 2021; Steele & Acheson, 2022). Changes made during the time of COVID-19 emergency measures generated a range of international evidence and advocacy to relax some of the more restrictive aspects of the service model beyond the pandemic (Brener et al., 2021; Harm Reduction International, 2020; Krawczyk et al., 2021; Lintzeris et al., 2022). The experiences of participants in this study were consistent with other research in showing no adverse impacts and significant personal gains related to these changes. However, since September 2021 governmental advice to increase pharmacy provision and access to takeaways has been rescinded (NSW Health, 2023), so the opportunity to embed these service changes appears to have passed.

Findings under the theme of connection explain how the socially inclusive nature of pharmacy settings can help minimize the salience of prejudicial cognitions about OAT, but this depended on the dosing processes and behavior of staff. Indiscreet supervised consumption processes, long wait times, discriminatory rules, and being spoken to in a patronizing manner were found to produce feelings of anger and shame. These occurrences increased consumer perceptions of subjection and stigma, in similar ways to what has been described by other qualitative research (Anstice et al., 2009; Harris & McElrath, 2012; Le & Braunack-Mayer, 2019; Matheson, 1998; Notley et al., 2014; Vishwanath et al., 2019; Wood et al., 2019).

Person-centered approaches, that demonstrated positive regard toward OAT consumers, were aligned with greater service satisfaction and feelings of interpersonal trust and care. Examples were given of pharmacists going beyond the standard service encounter to help consumers in times of emergency or distress, alongside more ordinary observations of gradual improvements in consumer quality of life. Whether extraordinary or common, these instances illustrated the care and concern that pharmacists can have for their OAT customers and the essential support they can provide in OAT consumers’ lives (Caruana, 2024). While some pharmacists wanted more involvement in consumer care coordination, this was not expressed by consumers or reflected in consumer studies, which describe wanting more treatment privacy and autonomy than clinician collaboration (Anstice et al., 2009; Damon et al., 2017; Holt, 2007).

The perspectives and experiences of consumers and pharmacists aligned with each other in many ways: both experienced limited autonomy and support, could be unsatisfied with treatment encounters, had concerns related to costs, and wanted system improvements to increase consumer engagement and service viability. In exploring the service relationship more deeply, misapprehension and a lack of connection emerged as characteristics that diminished satisfaction. Both parties felt that the other did not fully understand them: for pharmacists this involved the limitations of their professional role and what they do behind the scenes to provide and maintain OAT services (Fatani et al., 2019; Le et al., 2018; Yadav et al., 2019); for consumers this involved the treatment burdens and stigma they endure (Anstice et al., 2009; Carlisle et al., 2023; Matheson, 1998). As the power held in this professional relationship is heavily weighted toward the pharmacist, it is the consumer that is most encumbered with the consequences of being misjudged, mistrusted, and mistreated (Harris & McElrath, 2012), as demonstrated in consumers’ accounts.

The broad themes of subjection and connection are linked by the concept of trust and represent opposing aspects of trust. On one side, experiencing satisfying and effective ongoing health care service relationships is predicated on establishing trust, which requires both parties to recognize each other’s competence (whether personal or professional) and their efforts in acting responsibly toward the other (Hall et al., 2001; Thorne & Robinson, 1988). Reciprocal interpersonal trust involves dynamic, self-reinforcing processes that are initially enabled through respectful communication and are strengthened through consistently demonstrating positive regard over time (Koorsgaard, 2018; Thorne & Robinson, 1988; Treloar et al., 2016). The findings here highlight how socially inclusive care and person-centered approaches within the dispensing encounter support the development of trust, and can lead to service experiences that emphasize connection and mitigate against perceptions of discriminatory or differential treatment.

On the other side, the onerous, inflexible, and inequitable aspects of OAT policies and pharmacy processes have been shown to be structured by mistrustful attitudes toward OAT consumers as a group, and are experienced by consumers as sources of systemic discrimination (Fraser & valentine, 2008; Harris & McElrath, 2012; E. F. Madden et al., 2021; Neale, 1998). Here, the structural mistrust that is coded through service regulations and processes reflexively produces consumer mistrust of the treatment system (A. Madden et al., 2008; Treloar & Rance, 2014). To improve this at a regulatory level, constraints on consumer OAT engagement could be lessened. A more enabling approach was shown to be effective in the wellbeing benefits that consumer participants attributed to COVID-19 emergency measures (including telehealth prescribing, greater access to takeaway doses, etc.), and is supported by other evaluations (Brener et al., 2021; Lintzeris et al., 2022; Steele & Acheson, 2022).

To improve perceptions of subjection and mistrust at the service level, future research could investigate mechanisms that enable consumers need to be understood and heard, alongside pharmacists, in making practice improvements and in policy reforms (Neale, 1998; Treloar et al., 2007). To start, pharmacists could encourage consumers to give direct feedback about the service, and professional organizations (e.g. The Pharmacy Guild, in NSW) could promote systems for enabling feedback as a part of quality improvement processes. This study demonstrated that including the voices of both consumers and pharmacists produces a more critical and comprehensive overall view, including identifying distinct and aligned challenges. Implementing similar processes in an ongoing manner may help in creating more responsive service improvements over time.

Importantly, pharmacy OAT was generally seen by the study participants to be a necessary and effective service model. Compared with OAT clinics, consumers considered it to be more socially inclusive and enabling of individual agency (particularly in pick-up and consumption timings). As this has also been shown in research from the UK and Canada (Anstice et al., 2009; Matheson, 1998; Neale, 1998), community pharmacy OAT delivery should be considered in jurisdictions that only offer clinic-based OAT services (such as the USA) as a means of reducing opioid overdose mortality and harms, particularly in locations where access to OAT is scarce (Calcaterra et al., 2019; Joudrey et al., 2020).

These findings contribute unique knowledge on OAT service provision through exploring the aspects that support greater treatment engagement and satisfaction for both consumers and pharmacists in-depth, by recruiting participants with diverse characteristics including geographic location, and in analyzing participant information with the goal of generating mutually beneficial knowledge. For instance, both consumers and pharmacists saw that more personable engagement styles within service encounters enhanced positive perceptions and reduced conflict, whereas processes that openly differentiated OAT consumers from other pharmacy customers detracted from this. It also identified structural and social dimensions of OAT delivery in community pharmacies, with subjection and connection theorized as being as formative conditions for the OAT service experiences described and their linkage through the concept of trust as enabling opportunities for improvement.

Limitations

The study was carried out in NSW and discussed components of its OAT system, which may differ from other jurisdictions. Interviews were undertaken in the second year of the COVID-19 pandemic; service particulars were intermittently changing according to governance adaptations which may have had an extraneous influence on participant service perceptions. Pharmacist sampling involved self-selection biases, and author biases with respect to the purposive method. Consumer recruitment was contingent on pharmacists’ actions to make information available about the study, which constrained broader participation and likely involved selection biases. The restricted, supervisory involvement of other researchers in collecting and analyzing the data limits the rigor and trustworthiness of findings. Consumer participants were all middle-aged people who had mostly been receiving OAT over a long time; newer and younger consumers may have different service experiences and perceptions, as may people who had left treatment. Participating pharmacists mostly showed positive attitudes toward OAT and wanted to contribute their professional expertise, so their accounts may not be representative of pharmacist perspectives more widely.

Conclusion

The delivery of opioid agonist treatment in community pharmacies provides opportunities for consumers to achieve greater social inclusion, but a lack of structural and interpersonal trust engenders experiences of subjection and impairs treatment engagement and satisfaction. While it is important for regulatory barriers and burdens to be addressed, pharmacists can support greater inclusion and connection in their delivery of OAT services by demonstrating non-differential processes and person-centered, responsive care.

Acknowledgments

This research was developed in consultation with Loren Brener and Joanne Bryant, who provided advice and support in reference to the research design, data collection and analysis, manuscript development, review, and editing. Thanks to Jude Byrne for consultation advice with respect to the study design and interview guide questions, and to William von Hippel for advice and PhD supervision. Thanks also to all the consumer and pharmacist participants who generously gave their time and knowledge for this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of the research and its ethical restrictions supporting data is not available.

Additional information

Funding

TC is supported by a UNSW Scientia PhD scholarship. The study was funded by the UNSW Faculty of Arts, Design & Architecture Higher Degree Research Essential Costs of Research Funding Support.

Appendix

Interview guide: interpersonal dimensions of opioid pharmacotherapy in NSW community pharmacies

Introduction

Thank you for making the time to speak with me today. I am Theresa Caruana, from the Centre for Social Research in Health at the University of New South Wales. I am conducting a research study exploring issues and experiences of opioid pharmacotherapy treatment in NSW community pharmacies. We are collecting information from Opioid Treatment Program pharmacists and consumers to help understand what makes the service effective and how it may improve outcomes for people receiving treatment.

• This interview is about your experiences and thoughts in reference to opioid agonist treatment in community pharmacy settings.

• There are no right or wrong answers, and feel free to say as much as you like.

• You do not have to answer any questions that you do not wish to, and you are free to take a break or end the interview at any time.

• If you decide during the interview or afterwards that you no longer wish to participate, let me know and I can delete any information collected.

• Do you have any questions before we start?

Interview guide – pharmacists

1. Screening questions (short answer)

   1. Are you currently practicing as a pharmacist in NSW? (Yes/No)

      1. [If yes] How long have you been practicing as a pharmacist?

      2. [If no] How long were you previously practicing as a pharmacist?

   2. Do you currently deliver opioid pharmacotherapy services?

      1. [If yes] How long have you delivered OTP services in community pharmacies?

      2. [If no] How long did you previously deliver opioid pharmacotherapy services in community pharmacies?

   3. In a sentence or two, can you please briefly describe your experience as a pharmacist and in delivering opioid pharmacotherapy services.

      • Prompts: i.e. methadone and/or buprenorphine, number of pharmacies, volume of customers, any other jurisdictions, highest position achieved, any other roles, etc.

2. Interview questions

   1. What is your understanding of the purpose of opioid pharmacotherapy?

   2. How did you gain your understanding of this purpose?

   3. How are opioid treatment program clients different to other customers?

   4. What service changes have you made to better manage opioid treatment program clients?

   5. What aspects of your service have opioid treatment program clients responded well to? (e.g. efficiency, privacy, friendliness, etc.)

   6. How have you tailored your service approach to your customer preferences and needs?

   7. What aspects of the opioid treatment program are hardest for pharmacists to comply with?

   8. What aspects of the program are hardest for your customers to comply with?

   9. What barriers to people receiving treatment do you see?

   10. What barriers to pharmacists providing opioid treatment program services do you see?

   11. What improvements do you think could be made to help address any of the barriers or difficulties that you have raised?

   12. How do you feel about the negative depictions of opioid pharmacotherapy? (by the community, the media, etc.)

   13. Have you experienced negative reactions from others in reference to your role in providing opioid pharmacotherapy services? If so, please describe this.

       As this interview will assist in the development of further research with opioid pharmacotherapy pharmacists and customers in NSW:

   14. In the context of people’s experiences in delivering or receiving opioid pharmacotherapy in pharmacies, what would you be interested in finding out more about?

3. Demographic questions

   • We are almost finished, but I wish to ask you a few demographic questions.

   • What year were you born in?

   • What is your gender identity?

   • What best describes your ethnic or cultural identity?

END OF INTERVIEW

Interview guide – consumers

1. Screening questions (short answer)

   1. Are you currently receiving methadone or buprenorphine in a community pharmacy? (Yes/No)

      1. [If yes] How long have you received this treatment?Is this in NSW? (If no, state which jurisdiction)

      2. [If no] How long did you previously receive methadone or buprenorphine for?Did you receive services in a community pharmacy setting?Was Is this in NSW? (If no, state which jurisdiction)

   2. How many pharmacies have you received methadone or buprenorphine in?

   3. How many pharmacists do think that you have received opioid pharmacotherapy services from?

   4. In a sentence or two, can you please briefly describe the details of your opioid pharmacotherapy treatment history.

      • Prompts: i.e. methadone and/or buprenorphine, frequency of dosing, access to takeaways, number of episodes, service settings, etc.

2. Interview questions

   1. What is your understanding of the purpose of methadone/buprenorphine treatment?

   2. How did you gain your understanding of this purpose?

   3. What were your goals in receiving treatment?

   4. How did your experience in treatment meet these goals?

   5. What have been some of the positive aspects of receiving treatment in a pharmacy setting? (in comparison to a public clinic, etc.)

   6. What have been some of the negative aspects of receiving methadone/buprenorphine treatment in a pharmacy setting?

   7. What do you think makes a good treatment experience in a pharmacy setting?

   8. What are some of the qualities that you appreciate in a pharmacist who delivers methadone/buprenorphine treatment? (efficiency, privacy, friendliness, care, knowledge, etc.)

   9. Have you felt comfortable to request health advice or other health services from your treating pharmacist? Please describe why/why not.

   10. Do you feel that your treating pharmacist always treated you with respect? Please describe why/why not.

   11. Describe any barriers to receiving methadone/buprenorphine treatment, or staying in treatment, that you have experienced.

   12. What aspects of your treatment do you find the most difficult?

   13. What improvements do you feel could be made to opioid pharmacotherapy services in pharmacies, to help address any of the barriers or negative experiences that you raised?

   14. Have you experienced negative reactions from others in reference to your treatment? If so, please describe this.

   15. Do you take steps to prevent other people from knowing about your methadone/buprenorphine treatment? If so, please describe how and why.

   16. How do you feel about the negative depictions of opioid pharmacotherapy treatment? (by the community, people who use drugs, the media, etc.)

       As this interview will assist in the development of further research with opioid pharmacotherapy pharmacists and consumers in NSW:

   17. In the context of people’s experiences in delivering or receiving opioid pharmacotherapy in pharmacies, what would you be interested in finding out more about?

3. Demographic questions

   • We are almost finished, but I wish to ask you a few demographic questions.

   • What year were you born in?

   • What is your gender identity?

   • What best describes your ethnic or cultural identity?

   • How would you describe yourself to another person, in a sentence or two?

END OF INTERVIEW