Angelo Pricolo reports on a first for pharmacists and some vulnerable patients alike
On a chilly Friday winter’s morning in Melbourne, it was time to start a new episode in this pharmacist’s life and inject hope into the life of some local patients.
Long Acting Injectable Buprenorphine (LAIB) can now be subcutaneously injected by the pharmacist to chronic addiction patients in Victoria.
LAIB is quickly being established as an effective alternative treatment for opioid addicted patients. The preferred formulation is a one-month depot injection and two pharmaceutical companies using slightly different technology have developed this.
Indivior has the sublocade® injection in two strengths 100mg/0.5mL and 300mg/1.5mL. Camurus has the buvidal® injection 64mg/0.18mL, 96mg/0.27mL and 128mg/0.36mL (as well as 4 less commonly used weekly formulations).
Both are simple to inject subcutaneously (like insulin or clexane) although their duration of action can be unpredictable initially. The monthly injection may in fact need to be administered after two to three weeks. Usually the doctors’ advice suggests that if the patient is beginning to withdraw it is time for the next dose.
To administer LAIB pharmacists in Victoria must first complete a vaccination course and then complete a short on-line training for the two LAIB products. Of course to inject at the pharmacy an appropriately approved consulting room must also be in operation.
Buprenorphine is a very different drug to methadone so swapping between the two drugs may not always be appropriate or successful. Unfortunately we have seen some patients change to LAIB to take advantage of the convenient half-life or sometimes the cheaper price without thoroughly considering the different pharmacology of these two compounds.
The transfer from methadone to buprenorphine is further complicated when it involves higher doses of methadone. Usually doses of 20-30mg are manageable but attempts at upwards of 50mg even as high as 80mg presents barriers and success rates are lower even with inpatient stays.
Until now only clinics with doctors or nurse practitioners could administer LAIB and they would charge a Medicare item for their reimbursement, so patients could receive the treatment for free. Anecdotally though we are hearing that some doctors are claiming a MBS item and charging the patient an additional fee of up to $65 in some NSW clinics.
Rose McCrohan, a nurse practitioner at Uniting ReGen, has administered LAIB to patients but is keen to involve pharmacists in the process. She has been an advocate for pharmacist prescribers also and sees a way forward with LAIB.
“I had a discussion with the rehab today about this (the pharmacist administering LAIB) becoming the normal process for future people on the program,” she says.
So what will it cost to get your LAIB shot at the pharmacy? Discussion in pharmacy circles has so far produced a fee of somewhere from $30 to $50.
As we know both methadone and buprenorphine for the treatment of opioid addiction are classed as S100 drugs. The pharmacy receives these free of charge so the patient contribution is the full fee available to the pharmacist.
Until an MBS item number is allocated to pharmacy this will not change.
Swapping to the long acting version of buprenorphine from the sublingual formulation is straightforward. The main issue could just be around reaching steady state quickly and avoiding any withdrawal symptoms.
But potentially pharmacy would be eliminated from the loop as clinics directly access LAIB from the drug company.
No pharmacist would ever stand in the way of a better patient outcome just to protect his or her place in this treatment. But consideration must be given to the importance of relationships forged and counselling given by pharmacists involved in opioid replacement for close to half a century. So keeping pharmacists involved may have a huge upside for patients too.
Another factor to consider is the real time prescription monitoring system SafeScript. Although this is not yet employed Australia-wide, it will be soon.
Bypassing the dispense/administer function of the pharmacist has meant that SafeScript does not always catch the event for all health practitioners to see as doctors have been using LAIB without writing a prescription.
The two LAIB formulations also have different storage requirements. Sublocade® only has a shelf life of one week if stored at room temperature. As a result a fridge-safe has been developed to store the depot, which will not suit all pharmacies but Indivior can be contacted to assist.
Cohealth is a non-for-profit community health organisation located in the inner Melbourne suburb of Collingwood. Through the co-operation of two GPs Dean Membrey and Paul MacCartney, a relationship has been forged with pharmacy colleagues.
The introduction of LAIB has interestingly increased GP workload at Cohealth and many other Drug and Alcohol clinics around the country. Where stable patients were visiting their doctor every 3-6 months, those who swapped onto the depot injection now needed monthly visits.
Dr Dean Membrey reflects, “We have been swamped by extra patient visits, many of which have not required anything other than their next injection. It will be great if we can develop a system where the pharmacy can lessen our workload and stay involved by administering LAIB to our patients.”
Giving the injection was a simple procedure, subcutaneously delivering the very small volume. The liquid does cause some pain after administration that varies depending on the patient and usually starts a couple of minutes after the injection. It is more uncomfortable than very painful from all accounts and it usually passes in 10 -15 minutes.
The intention is to forge better links with doctors and patients so that administration at the pharmacy becomes as normal as picking up a prescription. As such it does not resemble a fragmentation of care but in fact a reinforcement of the Australian model that has seen pharmacy play a pivotal role in treating addiction for almost 50 years.
Angelo Pricolo is an addiction medicine pharmacist and former National Councillor of the Pharmacy Guild of Australia.