Methadone costs ‘not fair’


Leading doctors and the PSA’s Chris Freeman have called for full Federal Government subsidy for methadone treatment, as concerns over opioid dependency grow

Out of pocket costs for people accessing opioid replacement therapy can make it hard for some patients to take their medication consistently, warns Dr Chris Freeman, national president of the PSA – leaving them potentially vulnerable to relapse.

His comments follow a piece in newsGP in which prominent doctors called for a full federal government subsidy for the medication, in the light of not just concerns about illicit opioids, but medicines such as fentanyl and morphine.

newsGP’s Doug Hendrie spoke to Dr Simon Holliday, the rural NSW GP and methadone service provider who first challenged Health Minister Greg Hunt about the cost of accessing the service, at a GP conference in 2017.

Dr Holliday, who has still not had his questions about the “hidden” costs of the service answered by the Department of Health, told Mr Hendrie that the lack of full subsidisation for the service is a “gross omission based on fear, stigma and moralising”.

“We know that opioid-substitution therapy is very evidence-based and highly cost effective,” he told newsGP.

“For every $1 spent on opioid-substitution therapy, there is $7 in benefit for the community.
 
“This very simple change could make an impact on everything from mental health outcomes, indigenous health outcomes, parenting, returning to work, unemployment and crime rates.
 
“Fear and shame are not the way to make evidence-based policies.”

newsGP also spoke to John Ryan, CEO of the Pennington Institute, who has previously called for full subsidy of the methadone program and who said that people were “generally without resources” after a serious problem with dependency, and who often left the program due to its lack of affordability.

He warned that people with dependencies are now moving to stronger opioids, including fentanyl and morphine, to self-medicate in a “cost-effective” manner due to the lack of dispensing fees involved in receiving these.

Dr Hester Wilson, Chair of the RACGP Addiction Medicine Specific Interests network, also supported the subsidy call.

“Given this is a group of people who quite often struggle to make financial ends meet, it would make sense for the Government to support the cost of pharmacy dosing,” she said.

She pointed out that patients who have been able to access free dosing at public clinics, where this exists, are generally shifted to community pharmacy after being stabilised, allowing the clinics to take on more patients.

A spokesperson for the Health Department said that this year’s Federal Budget, handed down on April 2, includes $268 million in funding for Australians with drug and alcohol issues, including $7.2 million earmarked to increase access to naloxone.

PSA’s Chris Freeman later told the AJP that this latter announcement was a “drop in the ocean” and called for “genuine investment” in access to naloxone, as well as methadone and bupropion.

“It’s not adequate,” he said. “If the Government, or incoming government, is genuine about saving lives lost to overdose or illicit substances, they would commit a significant amount more to enable those patients to access naloxone through community pharmacy in a subsidised way.”

He pointed out that having access to naloxone is not only important for people using illicit opioids or misusing licit ones, but also those taking opioids regularly and appropriately under medical advice.

The Australian Greens are taking a plan to the 2019 election which would fund dispensing fees for patients using methadone; party leader Senator Richard Di Natale outlined this policy at the 2018 Pharmacy Guild Parliamentary Dinner, and reiterated it during the recent launch of the PSA’s Pharmacists in 2023 report in Canberra.

“We were pleased when Senator Di Natale presented at the launch of Pharmacists in 2023 and made the commitment that the Greens would seek to fund opioid replacement therapy through community pharmacy,” Dr Freeman told the AJP.

Senator Richard Di Natale speaks at the PSA's Pharmacists in 2023 report launch.
Senator Richard Di Natale speaks at the PSA’s Pharmacists in 2023 report launch.

“We look at this from a harm minimisation perspective.

“People who are in receipt of opioid replacement therapies like methadone or bupropion are very vulnerable. These people have an addiction, and are seeking medical treatment to try and overcome that.

“It’s not fair for that group of people, who are vulnerable, to have to find out of pocket costs to fund that.”

Dr Freeman said that in his personal experience, patients have had to consider forgoing that therapy as they may not be able to afford it in any given week or month.

“This puts them at risk of reverting back to using, because if they can’t afford these costs, but they’ve got access to illicit substances they may have been using, they may use that instead.

“Sometimes that can cause relapses to occur, if there’s a break in treatment,” he said. “So this is a serious problem.

“Most of the out of pocket expenses aren’t large, but over the lifetime of treatment they can add up for an individual.

“Many of these people, because of their illness, many not be working, so money is tight for them.

“However it’s also not fair for community pharmacy to pay the bill either. It’s a clinical service which pharmacies are providing, which is highly valued, and there’s good evidence to show it does assist in the management of opioid addiction.

“So community pharmacy shouldn’t have to fund it. This should be considered like any other medical treatment which is covered through the PBS. These people have a medical need; they’re being prescribed this treatment; therefore from an access point of view there should be funding to support that nationally.

“We’re glad to see organisations like the RACGP come out in support also, as we’ve been advocating for funding for this for quite a period of time through the broader harm minimisation space.”

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8 Comments

  1. Karalyn Huxhagen
    13/04/2019

    Addiction programs require more than AOD programs. In treatment of ICE addiction there is a complex arrangement of antipsychotics and AOD therapy. The best programs in my location are live in rehabilitation programs. How do we improve funding for all of the medications needed? The use of antipsychotics in withdrawal programs is not PBS funded. Should all GPs be encouraged to be AOD prescribers? At best we are applying bandaids to a serious growing issue

    • Peter Crothers
      13/04/2019

      I agree that we shouldn’t over-simplify something that is really quite complex Karalyn but reducing the cost burden of OAT is relatively low-hanging fruit and would have an immediate impact. In my town only an estimated 30% of people needing the service are being treated and a major barrier is cost. Mitigating the cost won’t result in 100% access, because there are other issues like lack of prescribers and AOD caseworkers, but locally we believe it could quickly double the number of people in treatment. That would be huge. It would also have flow-on effects that might help in dealing with the wider issues.

  2. Nicholas Logan
    13/04/2019

    Hopefully the RACGP and AMA get on board this worthy project.

  3. patrick Mahony
    13/04/2019

    I am please the subject of Opioid Substitution Program (OSP) is being debated.
    We have many clients. We more than three decades of experience. Many successes, a few failures, including suicides and several comments from ill-informed customers.
    My major concerns in this article are;
    Dr Simon Holliday statement that the funding is a “gross omission based on fear, stigma and moralising”, is only partly true.
    In practice, most pharmacists involved in this service do not have this problem. Many new clients have been allocated to the program and require a formal but open structure. It is important for them to develop these new skills and confidence. We are generally the first health professional to have contact with a client released from an institution. The AOD consultation with the client is usually some two weeks later.
    Dr Halliday also stated potential clients who are outside the system are accessing “other substances such as Fentanyl and Morphine”. We have identified is that Pergabalin and Diazepam are the much more accessible fully funded (CTG) and more insidious substances.
    Many of OSP clients still have these issues. Doctor and pharmacy shopping are a big issue. Pergablin with its 56 capsules supply (plus 5 repeats) is the most accessible and most abused.
    We have contracts with our clients which requires all these items also be on “staged supply”. We also insist that the Methadone/Bupropion prescriber be the only GP to prescribe (or approve) such items. The hospital clinics cannot provide these additional services.
    Dr Hester Wilson statement speaks about the need to “support the cost of pharmacy dosing”.
    With respect this is only part of the issue for the client and for the pharmacy. Cost is not limited to the actual dosing process;
    • Access to the service is a most important issue.
    o Opening hours are critical to clients who have jobs.
    o Location is important to everyone which may be impacted on transport, parking and mobility.
    • Privacy and social issues are also important.
    • Acceptance, understanding and support are very important issues. Community pharmacists see their clients more frequently than any other member of the health team. We know when they are unwell.
    • Infrastructure is critical to acceptance. Clients should be treated the same as any other pharmacy client with respect and dignity. The reciprocal treatment is also part of the discipline required. We also find that separating the “fiscal” contact from the “pharmacist” contact is important.
    Community pharmacy is providing this service at minimal charge to the client. Except for the actual cost of the OSP medication, there is no funding. Equipment, security, hygiene services and consumables are all paid for by the community pharmacy.
    Like most community pharmacists involved in the process, we don’t do this for the remuneration alone. We do it as part of the community service. Funding must address all of these elements.

  4. Thomas Lake
    13/04/2019

    It’s a great program. GP practice nurses are also well placed to further broaden the service offering and would be MBS covered.
    Keep up the good work.

  5. Thomas Lake
    13/04/2019

    ps. been providing OSP freely for over a year. The paper work is overwhelming and not worth the pleasure of making a difference. Also, it attracts exposure to authoritative review and audit that not even the most particular record keeper wants. I some times ask myself why I’m doing it? Everybody else has already made that comment to me….All pain, no gain, and the clients don’t even appreciate it.

  6. Thomas Lake
    13/04/2019

    SA’s Chris Freeman later told the AJP that this latter announcement was a “drop in the ocean” and called for “genuine investment” in access to naloxone, as well as methadone and bupropion.

    Umm, Bupropion is more like smoking cessation (and off-label anti-depressant). Perhaps the other bup is a better initiative?

  7. Michael Abelman
    15/04/2019

    Evidence based studies have shown substance use disorder to be a chronic relapsing condition. Where the substance is opioid, fear, stigma and moralizing prevent rational decision making. Consider the $s spent on sugar, nicotine and alcohol medication assisted therapy. Also, that long term inappropriate prescribing and subsequent diversion of opioids for period pain, headache, osteoarthritis and back pain has contributed to the majority of overdose deaths.Psycho-social assistance within pharmacies with an appropriate consultation area should also be considered. The relief for ambulance services, emergency departments, hospital admissions,the police, the courts, homelessness, AOD and family welfare services makes this funding decision a no-brainer.

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