Friday Five (December 22, 2021)

This edition of the Friday Five features important Council meeting updates, an announcement from the President, and an OAT update

Announcement from Wendy Clark and CPhM Council

On behalf of the Council of the College of Pharmacists of Manitoba (CPhM), I wish to inform you that Susan Lessard-Friesen, Registrar and Chief Executive Officer (CEO), has announced her pending retirement, effective May 31, 2022. Susan has served as Registrar and CEO since 2016. Prior to taking on the leadership role, she held various positions at CPhM, accruing over 26 years of regulatory experience and dedication to the practice of pharmacy.  She has been a valued and dedicated leader as well as an integral part of the success in regulating pharmacy practice in Manitoba. Susan has applied her expertise, perspective, and diligent efforts to guide the College in its pursuit of safe, ethical, progressive, and patient-centred pharmacy care. 

Early in the New Year, Council will initiate a search process to recruit the next Registrar / CEO of the College of Pharmacists of Manitoba.   

The Council looks forward to working with Susan in 2022 to ensure a smooth transition of leadership. 


Wendy Clark 

President, College of Pharmacists of Manitoba 

December 10, 2021 Council Meeting Updates: 

1) Important Compounding Updates and Information 

  1. Currently pharmacy managers can self-declare the provision of sterile compounding as a pharmacy care service to the College of Pharmacists of Manitoba (CPhM). With this declaration, pharmacy managers have the option to note this information on their pharmacy’s online profile and it may be publicly accessible to all registrants and the public. CPhM Council has approved an expansion of the opportunity to self-declare the provision of compounding to include Sterile and/or Non-Sterile NAPRA compliantcompounding. This declaration can occur at any time and will be included as part of the license application and renewal process moving forward. College staff are working to refine the declaration process and CPhM website to accommodate this request. An update will be provided to registrants once the process is operational.  
  2. The NAPRA Model Standards for Pharmacy Compounding (NMSPC) of Hazardous and Non-Hazardous Sterile Preparations provide pharmacists and pharmacy technicians with the minimum criteria to compound hazardous and non-hazardous sterile preparations.  CPhM Council approved the NMSPC of Hazardous and Non-Hazardous Sterile Preparations in 2018 and pharmacies and pharmacy professionals providing sterile compounding services must fully comply with these standards as of January 1, 2022.  Any specific exceptions to the implementation of these Model Standards for a pharmacy must be approved by Council directly. 
  3. CPhM Council has approved an extension of the exemption for the drawing-up of comfort care medications for Palliative Care patients in a setting that does not meet the NAPRA  Model Standards for Sterile Compounding. The extension will begin on January 1, 2022, with Council to review the exemption again prior to the new expiry date of January 1, 2023.  It should be noted that the guidance below has been updated from what is currently in effect and should be thoroughly reviewed prior to utilising this exemption.  Any pharmacy or pharmacist that is considering this exemption must be complaint with the following requirements: 

When deciding if the service should be provided:  

  • The patient must be registered with the palliative care program.  
  • The medications should be non-hazardous and the manipulation be low risk (as defined by NAPRA) and prepared from a commercially available sterile source only.  
  • The preparation should be only a single manipulation (i.e., pre-filling a syringe).  
  • All possibilities of training a caregiver or family member to draw up medication should be exhausted first before contemplating this option.  
  • The physician determines that this is the only viable method of effective treatment of the patient and the prescription indicates “for emergency use”.  
  • The benefit vs. risk favors rapid access to the medication.  

 Once the decision has been made to provide the service:  

  • The patient or agent must sign a waiver/release form to acknowledge the preparation is from a non-compliant facility “for emergency use only”.  
  • The product should be monitored for signs of potential contamination at draw-up, and further education should be provided to the patient’s agent to monitor before administration.  
  • Preparation should take place in a designated compounding area following the standards for preparing immediate use preparations (see NAPRA Model Standards for Sterile Compounding).  
  • The compounder must don minimum personal protective equipment (PPE) including but not limited to sterile gloves (or gloves that have been disinfected with sterile alcohol) and a medical grade mask.  
  • The preparation must be performed by a pharmacist or regulated pharmacy technician.  
  • The preparation is limited to a 2 day supply that must be labelled with a maximum beyond use date of 48 hours from the point of preparation.  
  • The non-compliant pharmacy is limited to supplying a maximum of 6 days (three occurrences under this exemption).  
  • Supply of medications beyond the limits must occur from a NAPRA compliant facility. The pharmacy must refer the patient to a compliant facility or obtain medications prepared from a compliant facility. 
  • The product must be stored appropriately at the pharmacy and education provided to the patient’s agent on storage at home.  

It is important that before a pharmacist pursues the above exemption, they must make every effort to seek the services of, or refer a patient to, a pharmacy that can provide sterile compounding that meets the NAPRA Model Standards fully. This is best practice and in the best interest of the patient and their safety.

2) Important Practice Directions Updates and Opportunity for Stakeholder Feedback 

The Prescribing and Dispensing Practice Direction has been updated and was approved by Council at the December 10, 2021, meeting. The amended practice direction is now in effect and has been posted on the College website here. 

Additionally, Council approved the release of the following three amended practice directions for stakeholder feedback: 

Please review the draft amendments and provide your feedback by email to by February 22, 2022. For information on the consultation process and providing feedback, please review the Policy Statement on Practice Directions. 

3) Updates to the Opioid Agonist Therapy (OAT) Guidelines for Manitoba Pharmacists 

The CPhM OAT Guidelines for Manitoba Pharmacists have been updated and were approved by Council at the December 10, 2021, meeting.   

Updates include but are not limited to: 

  • Mention of the availability and coverage of generic methadone products; 
  • Dilution requirements for generic methadone products; 
  • Additions to recognized buprenorphine/naloxone training programs to align with CPSM/CRNM; 
  • Additional information around policy and procedure manual content; and 
  • More information around overdose response. 

All pharmacists dispensing OAT must review the updated Guidelines.   

Discontinuation of OAT 101 Introduction to Clinical Practice Workshops 

The Opioid Agonist Therapy (OAT) 101 Introduction to Clinical Practice Workshops have been provided by the College of Physicians and Surgeons of Manitoba (CPSM) in partnership with the College of Pharmacists of Manitoba (CPhM) and the College of Registered Nurses of Manitoba (CRNM) since 2016.  Currently, any pharmacy providing methadone for OAT must have at least one trained pharmacist that has completed this two-day workshop. Pharmacists dispensing buprenorphine/naloxone for OAT can also complete this workshop.  

CPSM collaborated with Manitoba Health and Seniors Care in the fall of 2017 to apply for a federal Substance Use and Addictions Program (SUAP) grant to fund a joint effort to increase the availability and delivery of OAT services throughout the Province of Manitoba over 4.5 years.  Much of this funding was used for provision of the OAT 101 Introduction to Clinical Practice Workshop.  This funding will be coming to an end and the last OAT 101 Workshop will be offered in June 2022 

CPhM is incredibly thankful for CPSM’s willingness to make these invaluable learning opportunities interprofessional.  This collaborative approach enriches discussions during the training process and ensures that all physicians, nurse practitioners and pharmacists completed training with the same high standard of knowledge and insight into the collaborative approach to treatment that best serves Manitobans.  

Pharmacists who have contemplated completing the OAT 101 Workshop in the past should register for one of the upcoming sessions to ensure they are able to complete it while it is still available.  Please see the CPSM website for information on upcoming dates and registration for the remaining offerings. 

Pharmacists should continue to read the CPhM Friday Fives and Newsletters for future updates on methadone and buprenorphine/naloxone training requirements. 

Call for Award Nominations 

The College is now accepting nominations for the 2022 College Awards.  If you or a pharmacist you know has made a noteworthy contribution to patient care and safety or the practice of pharmacy, please consider submitting a nomination or application for one of the awards listed in the College Awards brochure 

The College has created award submission guidelines for your consideration prior to forwarding your nomination to the College’s Awards & Nominating Committee.    

Young Leader Awards  

The Young Leader Awards celebrate the efforts of up to ten leaders in pharmacy practice. The recipients will receive a plaque to commemorate their contributions to the pharmacy profession and a $500 cash prize.  

The awards are open to recently licensed pharmacists (practicing one to five years post-graduation) and to pharmacy students (interns) in their final year of study who have made a professional contribution to patient care, the pharmacy profession or amongst their colleagues and peers at the University of Manitoba’s College of Pharmacy.  

If you or someone you know meet these criteria, please submit a nomination or application package including the nominee or applicant’s Curriculum Vitae and a summary of their activities and contributions within pharmacy practice or within the University of Manitoba’s College of Pharmacy.   

The deadline for nominations or applications is Friday, January 14, 2022.  Please send submissions by email to with the subject line “Attention: The Awards & Nominating Committee – CPhM Awards”.

CPhM Office Holiday Hours  

The College of Pharmacists of Manitoba will observe the following holiday schedule:  

  • Closed at 12:00 noon Friday, December 24 through Tuesday, December 28, 2021  
  • Open 8:30 a.m. to 4:30 p.m. Wednesday, December 29 and Thursday, December 30, 2021  
  • Closed at 12:00 noon Friday, December 31, 2021, through Monday, January 3,2022  
  • Regular office hours resume on Tuesday January 4, 2022, 8:30 a.m. to 4:30 p.m.  

Please be reminded that the CPhM office remains closed to visitors and continues to operate as a virtual office due to the COVID-19 pandemic.  All services continue, however adjustments in service delivery and delays may occur.    

Documents may be left in the black deposit box to the left of the main entrance.  Email is the most efficient means by which to contact staff. A staff directory can be found here:  

Thank you for your kind attention and cooperation. 

Upcoming Events & Professional Development Opportunities   

CSHP Together Conference
January 29 – February 6, 2022
Register here 

Palliative Care Pharmacy – Micro-Credential Program
February 4 – March 18, 2022
Register here