Novel remote electronic medication supply model for opioid-dependent outpatients with polypharmacy--first long-term case study

Abstract

Background: Patients with substance use disorders grow older thanks to effective treatments. Together with a high prevalence of comorbidities, psychological problems, and low social support, these patients are at high risk for medication non-adherence. Established treatment facilities face challenges to accommodate these complex patients within their setting. Electronic medication management aids (e-MMAs) might be appropriate to simultaneously monitor and improve adherence for these patients.

Case presentation: We report the first long-term experiences with a novel remote electronic medication supply model for two opioid-dependent patients with HIV. John (beginning dementia, 52 years, 6 tablets daily at 12 am) and Mary (frequent drug holidays, 48 years, 5-6 tablets daily at 8 pm) suffered from disease progression due to non-adherence. We electronically monitored adherence and clinical outcomes during 659 (John) and 953 (Mary) days between July 2013 and April 2016. Both patients retrieved over 90% of the pouches within 75 min of the scheduled time. Technical problems occurred in 4% (John) and 7.2% (Mary) of retrievals, but on-site support was seldom required. Viral loads fell below detection limits during the entire observation period.

Conclusions: Continuous medication supply and persistence with treatment of over 1.7 years, timing adherence of more than 90%, and suppressed HIV viral load are first results supporting the feasibility of the novel supply model for patients on opioid-assisted treatment and polypharmacy.

Keywords: Interprofessional collaboration; Medication adherence; Medication management aid; Old age; Substance use disorders.

Fig. 1

Remote-controlled, electronic medication management aid, Medido®, used in this study to dispense the unit-of-dose pouches. Notes: height × width × length, 140 mm × 140 mm × 225 mm. Weight, 1486 g. The inset shows the power cord

Fig. 2

Unit-of-dose pouches with pre-packed oral solid medication from front (a) and back (b). Note: patient’s name and date of birth were concealed for privacy reasons

Fig. 3

Novel medication supply model where the community pharmacy provides unit-of-use pouches (medication roll Mo-Su) with all solid oral medications directly to patient home, except opioids for opioid-assisted treatment (OAT) and methylphenidate (S). The pouches are loaded into a lockable, remote-controlled dispenser that can be programmed according to a patient’s medication schedule. The dispenser records dates and times of medication retrievals and wirelessly transmits them to a server (blue waves). Patients obtain the opioid agonist therapy (S) from the outpatient addiction service (OAS) in regular intervals, at least once weekly, according to local law requirements

Fig. 4

Time of medication dispense for John (659 days) and Mary (953 days) recorded with electronic monitoring. White areas are days with missing electronic monitoring (John, 0.8%; Mary, 4.4% of all days)

Fig. 5

HIV viral load and CD4 cell count of John and Mary. Start of electronic monitoring is marked with an arrow