Withdrawal is a crisis


depression mental health anxiety population

During the COVID-19 pandemic, it’s vital not to lose sight of the needs of patients on opioid replacement therapy, writes Angelo Pricolo

Withdrawal from heroin is one of the biggest obstacles to recovery from heroin addiction. People who are addicted to heroin often have no greater fear than dope sickness — the street name for heroin withdrawal.

The symptoms can be so severe that individuals going through withdrawal become figuratively paralysed. Being dope sick can confine a person to a bedroom or a bathroom for days.

Withdrawal from methadone or for some even buprenorphine can be just as scary and painful. It makes people behave in a certain way. It creates anxiety and fear. Past experiences inform.

This manifests in different ways. Some isolate and others explode. The fear of being cut off opioid replacement therapy (ORT) is real and we are being confronted with patients struggling with the burden.

Part of our job is to ensure these patients do not feel too anxious while doing our best to continue supply in the face of the adversity we are also experiencing. We need to stay safe and healthy, just like putting an oxygen mask on ourselves before our children on a doomed flight.

In this crazy new world we need good clear messaging, understanding, resources and financial assistance. What are the messages and specific needs?

We should have a clear directive that patients no longer need to sign for dose pick-up as is the case with all other scripts at the moment. Most pharmacies are already applying this for all patients but official advice would be comforting.

Most patients should be attending their pharmacy weekly. There are some patients that need to attend more often (some even less) but the rule should be weekly, not the exception. Script expiry dates should be extended, at least three months for most.

Pharmacists will send patients back to their doctor if their assessment indicates the situation is unsafe. As we always have, we assess the suitability of dosing every time we see patients, which is a lot more often than they see their doctor.

Doses should be written with a dose range. This flexibility empowers patients and also minimises unnecessary visits to a GP. Again, pharmacists will always assess appropriateness and call on their experience and knowledge in making clinical decisions around doses.

More and more patients are finding themselves with less money and this is making relationships at the pharmacy even more strained. Conflict is not a good way to engage patients with ORT. Money is still the main reason for discontinuing ORT.

Every jurisdiction in Australia provides ORT funding to help pharmacy administer the program and keep the charges down for patients. The only exception is Victoria, which is another reason why ORT should receive Commonwealth funding, to avoid these unfair inconsistences.

Regardless of the importance put on ORT, all jurisdictions need to increase financial support to encourage pharmacists to continue their important work in this field. The Australian ORT model is unique and showcased around the world to highlight the community pharmacy involvement.

It is not a glamorous area to work in, it’s hard and we see lots of hardship. Unfortunately most of the work by the front-line pharmacists and assistants goes unnoticed. It is time that this changes, or COVID-19 will start to reveal the cracks.

Takeaway bottles for methadone are re-used for months. We are getting messages that shopping bags should not be re-used once yet ORT bottles fly under the radar.

A plastic amber bottle and childproof lid can cost around 80 cents. At six weekly takeaway doses that’s about $5 per week. Take that off the weekly long-term static fee and add in a healthy bad-debt ledger, pharmacy is bleeding! We need support and resources to keep our patients, communities AND PHARMACY STAFF SAFE.

Inevitably pharmacies will shut and we need plans in place for this. But we can minimise stress on the system with some sensible thinking and implementation of measures that seem obvious. We need Plan B.

Although naloxone has been OTC since 2016, if your pharmacist recommends it the price is prohibitive. We still need a prescription from a doctor to claim though the PBS. Why? Change this now and keep patients safe, it is simple. Pharmacists can provide an extra month of S4 medicines but not a life saving dose of naloxone.

When we look back at COVID-19, which departments and individuals will we call the visionaries? Which initiatives will be hailed as lifesaving? Will pharmacy be left out in the cold to fend for itself again or will it receive the necessary support from the government to survive and keep people healthy and safe?

Angelo Pricolo is an Addiction Medicine Pharmacist and a former Guild National Councillor.

 

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2 Comments

  1. Karalyn Huxhagen
    03/04/2020

    Our local Govt service has loosened the rules to allow patients to pick up larger amounts.

    The private prescriber will not budge and he is not adjusting dose based on the stress and anxiety of the patients. He has actually put his fees up to see them!

    I have been doing QOTP for many years and have never received any govt funding.

    I am hoping the clinic will embrace the injectable formats soon as this should help.

    These patients are a forgotten entity in this crisis

  2. adam needleman
    03/04/2020

    Unfortunately, we have many unstable patients that could not possibly be given a weeks supply at a time . I would be surprised if any non discriminatory ORT program had many candidates for weekly supply.
    The injectable form will not have a large impact as the guidelines state the patient must be stable. This will apply to a relatively small cohort.

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