Date: 8 April 2019
Harm Minimisation seems like a mantra we should all adopt in life. It’s a common-sense philosophy that extends beyond providing pharmacotherapy for opioid or nicotine addiction. Yet, although we are knocking on the door of 2020, it still is not accepted in mainstream pharmacy in Australia. It’s fair to say that the stigma we see attached to the patients and to the treatments is partially to blame. Whether we are talking about vaping or opioid replacement, we are reducing harm, but for some, it is the cure that seems more offensive. In addition, we have a funding model that makes accessing treatments difficult for the most vulnerable and needy in our community.
Looking around the world at medication-assisted treatment for opioid dependence (MATOD), there are many differences in the way it’s delivered. Australia stacks up well for the most part — although the way we discriminate based on cost to the patient is a major obstacle to treatment. Various research papers have shown MATOD available for free or as low as $1 per day, all the way up to some private clinics in Sydney charging up to $100 per week.
In Ireland there are about 1,800 pharmacies, and about 40% of those dispense methadone and buprenorphine. This percentage is similar to Australia, except in Ireland they are available free to the patient and the pharmacy is paid per patient. The pharmacy also receives grants to improve shop layout and staff training in an attempt to optimise patient outcomes. Providing assistance to the pharmacy changes the face of MATOD as it encourages participation and improves the quality of care.
It’s interesting that in Ireland there was little or no political or public resistance to the listing of MATOD as a fully funded treatment. It was not a political football used to win votes. There was no hesitation based on possible bad press, rather a decision based on best available evidence, cost effectiveness of treatment and a strong sense of public health prioritisation.
Daragh Connelly, the president of the Irish Pharmacy Union (IPU) said: ‘Typically, the pharmacy will be approached by a patient, family or the police to get the service started. Most importantly, there is great access as pharmacists have really got behind the service and there are no geographic gaps.’
Interestingly, he goes on to say, ‘Unfortunately, with so few GPs engaging, there are huge areas of the country where initiation and prescribing is a train or bus ride away to the city.’
Across the globe in the USA the cost of treatment varies greatly from state to state. Medicaid, a joint federal and state program that helps with medical costs for some people with limited income, does not cover methadone costs very well. Costs for the patient can typically be US$8–15 per day.
Dr Michelle Lofwall, a psychiatrist working in Kentucky says, ‘The cost of buprenorphine is often covered by insurances, public and private, but the reimbursement to physicians is very poor from Medicaid so it is very hard to find a willing prescriber. A common cost is probably about US$100 per week in many places.’
Back in Australia, weekly and monthly buprenorphine depot injections will soon have an impact on patients and clinicians, and challenge current models of care. The depot means less contact with health professionals and may also alter cost structures in a way that could influence treatment selection.
It’s clear that the omnipresent variables that affect outcomes for patients revolve around cost, access (mainly to prescribers) and stigma. It’s a delicate balance and we need to learn from international experience as we try to improve the patient outcomes in Australia. The three factors interrelate and the result is the patient experience. Singularly the most important and least complicated to improve in Australia is the cost to the patient.
We could allow our already partially fragmented system to continue to erode so that state and territory politics form policy in pockets and patients try to adjust to the conditions dictated to them. The Irish model has laid the groundwork for equality and access, and although it is a system struggling with the universal problem of attracting prescribers, it is a long way from the challenges seen, for instance in the USA.
The PBS is the vehicle we have in Australia that can ensure equality of treatment for patients requiring MATOD. We do not need to reinvent the wheel, the PBS can accommodate, and it will improve directly and indirectly the holy trilogy: cost, access and stigma.
For methadone and buprenorphine to be transferred to the general section of the PBS schedule, (from the S100 section where it is currently) a submission to the PBAC would be required. As the items are already listed as pharmaceutical benefits, this may not require a major PBAC submission concentrating on the clinical efficacy and clinical benefits. It would result in an increase in expenditure, so it would need to include an economic analysis to justify the increased expenditure.
The decision is ours to make as a community. Continue to watch our system fragment and leave the vulnerable behind, or use the structure that has benefited so many for so long. Come on PBAC, you can do it!
Article reproduced from In the Know issue #64 with permission.
Contact: Angelo Pricolo, Addiction Medicine Pharmacist
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