It would be “fantastic” if more pharmacists were willing to provide opioid replacement therapy, says leading researcher
Latest data estimates that 40.5 million people across the world were dependent on opioids in 2017, with opioid dependence the third most impactful substance use disorder after tobacco and alcohol, in terms of contribution to morbidity and mortality.
Fatal opioid overdose is a major adverse outcome increasing in Australia and other countries.
Meanwhile opioid agonist treatment can be “highly effective” in reducing illicit opioid use and improving multiple health and social outcomes, according to research led by UNSW’s National Drug and Alcohol Research Centre (NDARC) in The Lancet.
This includes reducing overall mortality as well as rates of overdose, suicide, HIV, hepatitis C virus and other injuries.
However while there is strong evidence for opioid agonist treatment and other interventions, coverage is low – even in high-income countries.
“Coverage of interventions to prevention of opioid-related harms to health is woefully inadequate in most countries,” say the researchers.
While Australia has better availability of evidence-based interventions than most countries, there’s a lot more and a lot better work could be done in that area, says lead researcher Professor Louisa Degenhardt, Deputy Director at NDARC.
“One of the best examples is opioid agonist treatment – methadone or buprenorphine – which is obviously a treatment for opioid dependence but also has multiple benefits in preventing other harms,” she tells AJP.
Concerns about stigma and discrimination can act to dissuade people from seeking treatment.
“More people could have access to treatment. The way in which treatment is delivered can be quite restrictive for patients.”
Professor Degenhardt, along with co-authors, point out that limiting access to unsupervised dosing is a barrier to treatment entry and retention.
“In rural and regional areas it can be extremely difficult to access treatment. When it is available, the emphasis on supervised dosing means that many people have to travel considerable distances to receive their medication.
“Even when someone’s pharmacy or clinic might be nearby, the fact that people need to attend everyday can be quite limiting in terms of flexibility for work, family and just life,” she says.
“What’s clear is that we need to improve ways to make treatment more attractive, more accessible and easier to stay in, because one of the best ways people can benefit from opioid replacement therapy is to stay in treatment.
“The easier we make that and the more palatable way we make that the better off they will be.”
Professor Degenhardt encourages pharmacists to get involved.
“It would be fantastic if more pharmacists were willing to provide this treatment. We know that some aren’t, and in rural and regional areas, they could be a really important and very unique source of treatment access in smaller towns where there aren’t clinics.”
In addition to increasing access to unsupervised dosing, she says extended-release formulations of buprenorphine could have the capacity to enhance treatment capacity across the country.
One of these has been approved and subsidised, while another is being currently considered by the TGA.
“This could help overcome some of the issues of access and acceptability, and for some reduce the feelings of exposure to stigma, because there is less requirement for regular attendance at clinics and pharmacies,” she says.
Tackling stigma is another important dimension.
“Concerns about stigma and discrimination can act to dissuade people from seeking treatment,” says Professor Degenhardt.
It can also “act as a daily unpleasantry when people are attending a clinic, making them feel uncomfortable, either from people outside the clinic, within the clinic or just the general experience of going.”
Restrictions on opioid prescribing need to go hand-in-hand with widespread availability of effective treatments, urge Pamela Das and Richard Horton in an accompanying Lancet comment.
“Restrictions on opioid prescribing for pain need to be accompanied by the rapid expansion of opioid agonist treatment for people with opioid dependence,” they say.
Such restrictions implemented in the US, without ensuring widespread availability of treatments, have meant continuing high demand for opioids in the country including heroin and fentanyl.
See the full Lancet article here