National changes to the way opioid replacement treatments are dispensed may only be minor for WA, but it has gone some way to break the stigma.
Eric Martin reports
Australia now ranks third, behind the US and Canada, for the highest rate of lethal opioid overdoses, a figure that has climbed steadily by 3.5% each year over the past two decades, reaching 5.38 deaths for every 100,000 in 2019.
According to the Illicit Drug Reporting System (IDRS), half the nation’s 2020 opioid-related deaths involved heroin, followed by natural and semisynthetic opioids such as codeine or morphine at 32%, with more than three quarters of these overdoses occurring at home.
For many years, the taboo nature of the topic, not to mention the public outcry at the suggestion of locating treatment services locally, meant that commitments to upgrade the funding model for opioid dependency treatment (ODT) medicines have been neglected.
However, from 1 July this year, changes to how ODT medicines were listed under the Community Access Program meant that patients for the first time have gained a PBS co-payment for up to 28 days’ supply, with the amount paid contributing towards their Safety Net threshold.
Dr John Edwards has been one of the State’s leading frontline experts in treating addiction, particularly opioid dependency. Medical Forum discussed with him the pros and cons of the changes, especially given the unique situation in WA, which already dispenses ODTs from pharmacy depots.
“This is the biggest thing that’s happened in the past 30 years for opiate replacement treatment, and it’s got a lot of positive implications and it’s got some negative ones. But I think across the board, it’s a positive thing, going against the stigma and normalising the way that opiate addiction is handled,” he said.
“This is turning buprenorphine, the Subutex, Suboxone and methadone into a normal medication that is on the PBS and is managed just like everything else.
“There’s been efforts from those working in opiate maintenance programs to try to change the process because it has been very unfair that it is the only medical condition where the end user bares the cost of the of the treatment daily.
Right thing to do
“The political drive has been very strong for this to go ahead, and it is needed to be. Whoever is behind it is very courageous and I want to thank them.”
Dr Edwards said that generally, most of his patients were on health care cards, but for some who were on methadone, which was common, their outgoing expenses could be as much as $500 a month.
“It was the dispensing which attracted charge and the pharmacy was charging it every day, and while it’s been seen as an unfair condition for years, no one’s been willing to change it,” Dr Edwards said.
All the research that has been done in the past 30 years on methadone programs has shown that the main reason that people drop out is the cost, both financially and in terms of the effort required to maintain that dose every day.
“This treatment is recognised as one that saves the community money,” Dr Edwards said. “It has been researched over and over, at multiple sites and in multiple projects, that show a dollar spent on this type of program saves the community between $7 and $10 in terms of general costs.
“This schedule has been shown to be the gold standard, the best management for a person with opiate dependence, particularly long-term opiate dependence where detox doesn’t work, and they have a history of dangerous, long-term use.”
Patients can continue to be prescribed their ODT medicines from their current medical or nurse practitioner and access ODTs from their current dosing site, but in an equally momentous change, from July 1, additional private dispensing or dosing fees can no longer be charged by community or hospital pharmacies.
The PBS issued a statement that patients would not have to pay “additional out-of-pocket costs for activities associated with the preparation of in-pharmacy or take-away doses of methadone liquid, buprenorphine sublingual tablet and buprenorphine and naloxone sublingual films.”
It said a community pharmacy program for ODT medicines would be established, including on-site pharmacist administration of injectable buprenorphine, and that it would introduce a nationally consistent payment for ODT services provided by community pharmacists.
Historically, the dispensing charge was the financial basis for the treatment clinic model popular across the Eastern States, as well as a financial incentive for WA pharmacies to participate in the program.
Crisis in NSW
“There were big differences between States how things were done with the biggest contrast being between NSW and WA,” Dr Edwards explained.
“In WA, virtually everybody who is on a program was dosed in a community pharmacy, but in NSW there are a lot of public and private clinics where a person would see their doctor, but it is also where they got their dose, provided free by the NSW government.
“There will be major upheavals in NSW. I think they have got valid concerns about how they will manage in the long term, and the changes have caused an outcry because public clinics relied on those dispensing fees to stay viable.
“If they shut down, it would recreate so many issues that we thought were already dealt with – it would be a disaster to do that with nothing in place and they may have to change their model to something more like WA.
“The issue would be that because it hasn’t run that way in NSW, community pharmacies won’t have the expertise, the network, or the ability to provide this service straight away, let alone having the will to do it.”
Dr Edwards said that under the old system, WA pharmacies were provided with methadone or buprenorphine, Subutex and Suboxone, and the GP would write a non-S-100 script that allowed for a certain length of treatment.
“You might write that script for one month, two months, three months, or even two days, and the script would have state authorisation. The pharmacy would receive the methadone or buprenorphine at zero cost under the S-100, and they would dispense it and charge the person their $5 to $7,” he said.
“The methadone was distributed in a liquid, diluted in water and the patients drank it in the pharmacy, supervised by the pharmacist. There were some provisions for takeaway doses, while the buprenorphine was either a tablet or a strip, both of which were dissolved in the mouth – there was no injecting.”
The new depot preparations, which are monthly injections, will be administered by the pharmacist or an approved person in the same way that Australians can get a COVID or flu vaccination.
“A person on a health care card will pay the $7 for a standard prescription, but somebody who’s not, will have a single payment of $30 once every 28 days,” Dr Edwards said.
“Much of the process will happen the same way and the level of state authorisation will not change – the only difference is it moves from S-100 to the standard PBS and people will now also be eligible for safety net payments.
Impact for GPs
“I think it is going to be a bit harder because the scripts will have to be written with exact quantities, stating just how many tablets or how much liquid is to be given within the 28 days, but in the past, we have often written scripts that allowed some variability.
“The other potential issue is that patients will only be allowed to collect their medication from the depots once every four weeks on the PBS system, yet some of them don’t last four weeks and they’re expensive – more than $300 each round. Potentially, there’s going to be associated holding costs for pharmacies if they’re looking after their customers.
“However, we have used the depots for about three or four years now in WA, or at least my practice has, and it’s turned out to be a real game changer in terms of the quality of treatment that people receive, their safety, and the freedom that they have – such as a much better ability to travel to work.”
Dr Edwards believed that there was a great deal of public misconception about the opiate replacement treatment program.
“Although some patients are chaotic people who are struggling and might match the ‘stereotype,’ most are not, and you wouldn’t pick them in a crowd,” he said.
“People on methadone or other opiate replacement therapies are often working, raising families. They might be teachers or police officers and you would never know because they have moved on from their illicit use and got their life together.
“And that is the whole point of it. That is why it is so useful – they can move on with their life without having to cope without the opiate replacement.
“The most common reason that people become dependent on opiates is because of trauma. Early life trauma impacts 80% or 90% of the people that I would see and, oftentimes, it has such an affect that they cannot manage without the opiate.”
Dr Edwards believed that GPs have a crucial role to play in helping to combat Australia’s opioid dependence.
Normalising
“In the same way that a GP might have a handful of people on a depot antipsychotic, where they would see the pharmacist once a month for an injection – managing someone on a depot-based opiate is no harder than that,” he said.
“There is a bit of training and red tape, but it’s not that difficult to manage those steps and depots have proven themselves – they’ve been around long enough that we understand how to use them and how easy they make it for a GP to manage a patient needing opiate replacement.
“GPs do much more difficult things and, personally, I have found that it has been one of the most gratifying things I have done in medicine. The people that we deal with really do get better, you can see those changes over time, and they are a group who are incredibly grateful just to get care. They have often been chased off from other providers’ places.”
“My practice looks after about 800 people on this program, which represents a quarter of the total number of participants. Although I am a specialist in the area, we just cannot take more people, even though we would if we could, and there is a huge demand that is currently unmet.”
However, Dr Edwards also believed that having an awareness that dependence could be a problem with opioids, it was just as important not to be afraid of prescribing them.
“One of the worst things to happen is that a lot of GPs won’t prescribe opiates at all anymore – they’re scared off it, no matter the level of need,” he said.
“We now know that long-term chronic pain, like mechanical pain, is not well served by prescribing opiates but, sometimes, for a person who is dealing with overwhelming or unbearable emotional distress, opiates are the only thing that keeps them going.
“Giving an opiate replacement provides a safer situation where they can get their life in order and not have to live in the illicit world, not have to spend all their money, and not have to take risks.
“They no longer need to associate with drug dealers and can normalise their lives, starting to better manage their trauma once they have developed that resilience and improved their emotional strength. Then they are in a position where they can deal with the physical addiction – and sometimes that takes years.”