Opioid pharmacotherapy: barriers to treatment

Angelo Pricolo examines the main reasons patients cease, or don’t access, therapies for opioid dependence… and why many pharmacies don’t offer it

We know that about 50,000 people in Australia currently receive either methadone or buprenorphine to treat their opioid dependence.

We estimate that as many as that figure again could potentially be candidates for these drugs also. With the positive moves in Victoria and other states to move to a real time dispensing system we expect this number to rise sharply.

So could that mean a doubling of patient numbers? Probably not, although it is an alarming thought, as we don’t have as a good a program as many would like.

Are we creating barriers to treatment, and what are they?

Probably the easiest way to establish if we are in fact pushing people away from treatment instead of actively engaging them is to ask some of the current consumers of the service.

Unfortunately the voice of the patient in this sector is not often sought and even less often listened to. If it was, the first step in addressing potential problems is to include more consumers on more advisory panels; we would hear some messages very clearly.

Cost. Cost is the major barrier identified by the greatest number of patients and is the main reason cited for program termination by the majority of pharmacists. 

General PBS listing is the quickest most efficient way to solve this problem. Not the current S100 listing but a change that would bring opioid pharmacotherapy in line with the treatment of other chronic disease states.

We believe this is being seriously considered at the moment although no detail has been officially released and frankly, unless we see detail we have to assume the current momentum will end the same way every other push has ended. Badly for the patient.

There are some clinics in NSW that are charging patients up to $90 per week to receive methadone or buprenorphine, two drugs on the WHOs essential medicines list. If $30 per week is a barrier then $90 is a force field.

It should also be noted that most pharmacies have been charging the base $30 for upwards of 20 years with no increase in fees. Added to the fact that an element of bad debt also exists, there can also be a barrier to offering treatment. Limiting pharmacy involvement means less access and choice for patients.

Pharmacists being forced to extract payment from some patients that have no capacity to pay also poisons a relationship that ideally should be based on trust and support.

So affordability we know is pushing people towards a riskier lifestyle that ultimately is probably going to cost the taxpayer far more than $30 per week!

One might think that fix the dollars and everything else works like a Swiss watch. But if we explore a bit deeper, and we should, we discover there are things we can directly influence that would remove some of the other barriers identified.

We do not have nearly enough prescribers to service the level of need and certainly not enough to treat the potential increase in patient numbers. GPs have not flocked to the rescue despite repeated calls and various measures designed to entice them.

Nurse practitioners have been introduced but again in very small numbers so we need to put the steps in place that will enable pharmacists to prescribe. There will be resistance from the very doctors who refuse to see these patients.

The PSA conference later this month in Melbourne will present a poster detailing pharmacist prescribing and the expected accreditation needed. No prescriber is a barrier to treatment and lack of prescriber choice is just as big a barrier for many.

Also, attitudes and stigma should be addressed with education and training. Later this year at the Pharmacy Assistants Conference in Queensland a session will be run on addiction.

For the first time it has been identified how important the role of pharmacy assistants is in the engagement or disengagement of patients in treatment. As more people better understand how opioid replacement works and its aims, we will see better outcomes.

Medical clinic staff and managers should also be offered such sessions as discrimination occurs at many levels for these patients seeking treatment. Pharmacy is visionary identifying the importance and role of their assistant staff. Congratulations to the Queensland team!

Take away dose availability and delivery of this component is also a major sticking point for many patients. In some states access to take away doses is far too restricted and does not facilitate a return to work or the flexibility to pursue other important interests.

Also the dilution of take away doses must be addressed. In some states take away doses are handed over undiluted and in others they are made up to 200mL with water. Patient preference is usually to add very little water as for some 200mL of liquid causes regular vomiting of doses.

In every other area of practice as health professionals we try our best to keep patients in treatment and hence improve their quality of life. We must strive for exactly the same with opioid addicted patients and in so doing we will save lives and fulfill our professional responsibility. 

Angelo Pricolo is an addiction medicine pharmacist and former National Councillor of the Pharmacy Guild of Australia.

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