Pharmacotherapy Issued August 2011 The effectiveness of pharmacotherapy 1 in reducing harm is supported by indisputable evidence including sources from the World Health Organisation (WHO). In Victoria, the pharmacotherapy system is in a severe state of disrepair and has not been supported to cater for the current burgeoning levels of need, which became evident following the heroin glut around the turn of the century and the reduced availability of heroin resulting in increased programmatic uptake. The system requires reform with an emphasis on access, workforce development, equity and costs. Introduction The Victorian pharmacotherapy system is currently in crisis and in dire need of reform. This system is based on voluntary participation from pharmacists (dispensers) and general practitioners (prescribers), with the number of dispensers and prescribers not increasing commensurately with the growing community need. Four key themes underscore the limitations of the system being: access, workforce development, equity and cost. Victorian Alcohol and Drug Association (VAADA) Position Paper: Pharmacotherapy This position paper will provide a brief overview of the Victorian pharmacotherapy system and outline areas requiring reform to ensure that harms associated with substance use are minimised. The evidence supporting the efficacy of pharmacotherapy is very strong with the program reducing significant harm to the community and enabling thousands of Victorians to experience improvements in health. A joint position paper from the World Health Organisation (WHO), the UN Office of Drugs and Crime and UNAIDS (2004:2) asserts that substitution maintenance therapy 2 is one of the most effective treatment options for opioid dependence. The position paper lists the benefits of substitution maintenance therapy (pharmacotherapy): Reduces HIV risk factors (and other blood borne viruses); Reduces heroin use; Reduces mortality; and Reduces crime (2004:2). 1 This Position Paper refers exclusively to the prescription and use of methadone, buprenorphine and the combination of buprenorphine and naloxone to meet service users physical opioid needs. 2 Substitution maintenance therapy, pharmacotherapy maintenance, opioid substitution therapy and opioid replacement therapy are some of the terms which are used to describe the treatment or maintenance of people dependent on opioids with pharmaceutical opioids. In this position paper, we will use the term pharmacotherapy unless quoting directly from another source.
It should be noted that methadone is an essential medicine listed by WHO (WHO 2011). Further, the Victorian Department of Health 3 (2006:8) asserts that pharmacotherapy also enhances social responsibility and productivity, as well as stabilising the patient s life and reducing chaotic drug taking. Finally, Chalmers et al (2009:ix) and Ritter and Chalmers (2009:2) note that pharmacotherapy is cost effective given the resultant savings in health, law and order and social expenses which would be accrued in its absence. Pharmacotherapy in Victoria The pharmacotherapy system was developed in Victoria in 1972 and was delivered to a small number of service users through specialist clinics (Rowe 2008:34). Up until the mid 1980s, abstinence was the overarching goal of drug treatment and it was only with a growing awareness of HIV and other blood borne viruses that harm reduction began to achieve prominence and pharmacotherapy became a major response to heroin use (Ritter and Chalmers 2009:3). Currently, specialist clinics support prescribers and dispensers, and provide secondary consultations or advice as appropriate. The current pharmacotherapy model, although suitable for the mid 1990s, has not grown commensurately with the rapidly increasing number of program participants (with service users more than doubling in the 11 years from 5,334 in 1998 to 12,576 in 2009 (Australian Institute of Health and Welfare 2010:10) to well over 13,000 as of January 2011 (McDonough 2011)). Moreover, current levels of demand impact adversely on the program which is struggling to keep up and thus there is a need to increase the capacity of specialist pharmacotherapy services to provide assistance to prescribers and dispensers. The overburdening of this program has resulted in a highly fragile and tenuous model of service delivery, with the treatment of large numbers of service users adversely impacted upon when, for instance, a participating dispenser or prescriber closes down. VAADA is of the view that the current system is under resourced and cannot cater for the huge demand and thus is unable to maintain and build on the benefits evident with this style of treatment; therefore significant reform of the system is necessary. VAADA contributed to the Victorian Pharmacotherapy Review and highlighted a number of challenges facing the system. A summary of these challenges which have been detailed in the VAADA State Budget Submission 2010/11 (2009:30 1), are as follows: a general shortage of prescribers and dispensers; a skewed distribution of those prescribers across Melbourne and rural and regional areas; costly dispensing fees for both clients and service providers; limited succession planning for existing prescribers; limited addiction medicine support; limited planning and integrated care for clients, particularly for clients with complex needs; 3 The Department of Human Services oversaw the preparation of the document, Policy for Maintenance Pharmacotherapy for Opioid Dependence; however, the Department of Health is now responsible for managing Pharmacotherapy policy. 2
limited specialist pharmacotherapy providers; and lack of alternative models for pharmacotherapy. These, in many cases long standing, system deficiencies facing the Victorian pharmacotherapy system can be characterised under four interrelated themes being, access, workforce development, equity and cost, which are detailed below. Access There is a need to ensure that pharmacotherapy services are available to all members of the public who require them, irrespective of locale and financial situation. The capacity of service users to participate in public life should not be impinged upon by their participation in the pharmacotherapy program. Ready and timely access to pharmacotherapy is a deciding factor for participation. Logistical and geographical factors are significant for a number of service users, especially those residing in rural and regional areas. This is made more poignant in light of the limited number of prescribers. The tyranny of distance, combined with inflexible dosing times (Ritter and Chalmers 2009:35), may be an overwhelming factor for some service users with familial and employment obligations who do not have ready access to a motor vehicle. The rising population and expansion of Melbourne s growth corridors require appropriate infrastructure to enable timely access to pharmacotherapy. This may be problematic as the voluntary system of GPs and pharmacists nominating to respectively prescribe and dispense creates a lottery for emerging communities regarding the proximity of supporting prescribers and dispensers. It should be noted that even brief gaps in service can result in the relapse and the attenuation of hard fought wins for service users. The pharmacotherapy system reform must account for rising populations and growth areas and deliver contingencies which plug gaps in service. Related to the rising population is the inertia of prescriber levels. There have been significant challenges in encouraging GPs to prescribe resulting in a small number of prescribers, some with a large number of pharmacotherapy service users. VAADA is concerned as system stability is entirely reliant on the prescribers capacity and willingness to prescribe pharmacotherapy. Thus, retirement, illness or even vacations can have a devastating effect on the stability of pharmacotherapy service users. In many cases, the system is unable to cater for such inevitable circumstances. VAADA has been informed by some AOD treatment agencies that a number of prescribers are fairly senior in years and are potential candidates for retirement, which, when it occurs, will decimate the system. Ritter and Chalmers also note this threat to the system (2009:17). Many of the challenges evident with prescribers are also evident with dispensers. The average number of pharmacotherapy service users per dispenser in Victoria has increased from 26 (2006) to 29.2 (2010) per dispenser (AIHW 2011:39). Dispensers interface, often daily, with pharmacotherapy service users. In the case of conflict between dispensers and service users or lack of payment (dispensing fees will be discussed below under equity and costs ) the service user can be refused pharmacotherapy. This can result in significant challenges for the service user to remain on the program, as the old pharmacy is unlikely to provide a positive reference to assist the service user to 3
locate another dispensing pharmacy (Ritter and Chalmers 2009:20) and especially in the face of the strained resources evident with the growing number of service users per pharmacy. Also there may not be another dispenser within close proximity. There are a number of solutions to these problems which should be considered. These include providing incentives to GPs and pharmacists as well as exploring the feasibility of allowing AOD nurse practitioners to prescribe in certain cases. Further reforms could include implementing alternate means of dispensing and increasing the accessibility of take away pharmacotherapy. Research has indicated that the provision of take away pharmacotherapy increases program retention (Ritter and Chalmers 2009:35), which is analogous with a reduction in harm to the community and service user. Further means of strengthening the system could involve increasing the level of support to prescribers through improved access to pharmacotherapy specialists and/or attaching AOD case managers to pharmacotherapy services as a further support to prescribers and dispensers. Case management services could be provided in a tiered approach, with increased support depending on the level of patient complexity. This would involve having all prescribers linked with a local AOD service and, with appropriate resources, the AOD worker would support the prescriber and provide the case management functions for those patients requiring this level of intervention. Finally, with reference to rural and regional service users, consideration could be given to more accessible models of service delivery. Workforce development Given the paucity of prescribers and dispensers, there is a need to ensure the continuity of quality service provision within a climate of exponential growth in service need. This relates to recruitment and incentives for prescribers and dispensers, and also bolstering AOD service systems to have capacity to provide support. Some of the key themes which underscore the challenges facing the diverse workforces involved in the delivery of the pharmacotherapy program relate to ensuring a high quality of service in light of an increasingly complex service user profile. The increasing complexities evident in client presentations which include but are not limited to comorbidity and poly drug use (including a substantial increase in misuse of pharmaceuticals (Ritter and Chalmers 2009:42)) on top of the difficulties in navigating an increasingly overburdened and stretched sector must be considered. The workforce, ranging from prescribers and dispensers to addiction specialists should be provided with enhanced opportunities for training and support mechanisms (such as clinical attachments) to ensure that they can meet the demands of this increasingly complex client base. In particular, there are only a limited number of AOD specialists supporting a large number of patients; there is a need to incentivise the medical sector to increase the number of AOD specialists. Ritter and Chalmers (2009:58) note that GPs are willing to take on patients presenting with complex and long term issues (such as mental illness and diabetes) and attributes their willingness, in part, to the availability of expert support. Access to addiction specialists must be resourced in a similar manner. Incentivising the pharmacotherapy workforce (as has occurred in NSW with some success (Ritter and Chalmers 2009:57)) is an important means of sustaining this workforce, as is providing expert advice, support and assistance when presented with complex cases. 4
Evidence indicates that the provision of counselling and psychosocial support can improve client outcomes, as long as the provision of this support is voluntary in nature (Ritter and Chalmers 2009:40). Further, the provision of voluntary counselling and support can assist those service users who wish to reduce or transit out of the pharmacotherapy system. Research must be undertaken to ensure that the Victorian pharmacotherapy program has programs and processes which will enable service users to voluntarily exit the system. This will include providing the workforce with appropriate training to facilitate this end. Thus accessibility to appropriately trained and resourced allied health staff should be prioritised. There is a need to provide the resources and infrastructure to enable collaboration between related sectors. An integrated approach to service delivery would enable a seamless referral process to other sectors as required by the service user. This requires strengthening relations, delivering training and importantly the creation of robust and transparent systems. Health and community services external to the AOD treatment sector can impact upon the long term efficacy of pharmacotherapy, including creating environments where there is a reduced likelihood of relapse. For instance, the provision of a portable model of pharmacotherapy which could attend to areas of high demand would reduce service user travel time and expense, which would increase the likelihood of service user retention and therefore reduce the risk of harm. Finally, the provision and resourcing of services which provide for other medical needs is crucial. Equity and cost There are some regions in Victoria where access to pharmacotherapy is greater than others. Moreover, rural and regional service users may be greatly disadvantaged for access related reasons noted earlier. Equity ties into quality of life and capacity to participate in community life which may be adversely impacted upon for some service users, due to system limitations with pharmacotherapy. Finally, dispensing costs may be prohibitive for some service users. As has been illustrated above, there is a skewed distribution of prescribers and dispensers across Victoria, with some regions having more than others. This is not a sustainable for the long term and creates significant disadvantage for pharmacotherapy service users in those regions without these services, or where the limited services available charge high dispensing fees (Ritter and Chalmers 2009:28). Further challenges facing pharmacotherapy service users are the prohibitive dispensing fees. This cost can be a decisive factor on pharmacotherapy service users with limited means, such as those on low income or Centrelink benefits. These fees mount on top of daily travel and living expenses. Many service users on low income or Centrelink benefits will prioritise accessing their pharmacotherapy over food, rent and other basic and essential needs (Ritter and Chalmers 2009:19). Removing dispensing fees would result in a financial burden for dispensers and would therefore likely reduce the number of dispensers, creating further service gaps. However, there are a number of proposals which were included in the Pharmacotherapy Review which should be considered, which involve the Victorian Government covering the cost of these fees or lobbying the Commonwealth to include dispensing fees on the PBS (King, Ritter and Berends 2011:25). 5
In order to better engage with the diverse range of pharmacotherapy clients and provide them with optimal service there is a need to ensure that services are best suited to their needs. On the ground, this translates into specialist pharmacotherapy services both to support prescribers as well pharmacotherapy service users with higher needs, as well as general prescriber and dispensing services, strategically located in regions of high demand or where there are regions with an absence of service. Currently, there are only four specialist pharmacotherapy services in Victoria, all of which are located in urban areas. New specialist pharmacotherapy services must be resourced to have capacity to respond to the broad range of complexities evident with presenting clients. Finally, there is a need to ensure that the services are tailored to changing demand. This relates to changing demographics and how Victoria s pharmacotherapy participation statistics in part vary from the national trends. For instance it is evident that there is an increase of younger service users (aged 34 years and younger) and modest decrease in older service users which is contrary to the national trends (see AIHW 2011:35 (table A4) and AIHW 2010:35 (table A5)). Figure 1 below highlights the number of pharmacotherapy service users from each age group with reference to the AIHW statistics from both the 2010 and 2011 data collection reports. Figure 1 NUMBER of pharmacotherapy service users 3500 3000 2500 2000 1500 1000 500 0 <25 25 29 30 34 35 39 40 44 45 49 >49 2009 2010 AGE of service users Further research must be undertaken to map these diverse trends and ensure that programmatic activity matches contemporary community need. 6
VAADA s Recommendations Reform of the Victorian pharmacotherapy system is an urgent priority. The following recommendations require expeditious implementation: 1. The Victorian Government reform the pharmacotherapy system in order to cater for the growing demand; 2. The Victorian Government commit to implement those findings from the Victorian Pharmacotherapy Review which improve the range of systemic and capacity issues besetting the Victorian system. 3. The Victorian Government commission research and pilot alternative pharmacotherapy models in addition to the current GP prescriber model, including options for training additional nurse practitioners to prescribe. 4. The Victorian Government undertake research to identify effective means of assisting pharmacotherapy participants who voluntarily elect to exit the program. Pharmacotherapy participants should not be compelled to exit the program but should be provided with the means to do so if requested. 5. The Victorian Government develop strategies to increase access to take away pharmacotherapy while minimising the risk for diversion. 6. The Victorian Government develop strategies to improve access for pharmacotherapy participants who reside in rural and regional areas; this may include a mobile outreach service. 7. The Victorian Government strengthen the pharmacotherapy workforce through the provision of: o Incentives to GPs and pharmacists to respectively prescribe and dispense; o Training to prescribers; o Better access to addiction medicine specialists for prescribers; and o Enhanced psycho social services when requested by pharmacotherapy participants. 8. Pharmacotherapy training for prescribers should include attending a clinic as well as the provision of mentoring. 9. The Victorian Government plan the deployment of more specialist services, especially dispensing specialist services, and greater usage of community health services and district hospitals to meet the needs of communities in growth areas and in regional Victoria. 10. The Victorian Government subsidise dispensing fees for low income earners (ie. those on a health care card) directly or commit to work with the Commonwealth Government to amend the PBS to include methadone, buprenorphine and buprenorphine/naloxone combinations alongside other medications in Section 85 of the National Health Act 1953. 11. The Victorian Government undertaken further research to map Victorian demographic trends to ensure that programmatic activity matches contemporary community need. Victorian Alcohol & Drug Association 211 Victoria Parade Collingwood 3066 Victoria Australia P: 03 9412 5600 F: 03 9416 2085 info@vaada.org.au www.vaada.org.au 7
References AIHW 2011, National Opioid Pharmacotherapy Statistics Annual Data collection: 2010 report, Drug treatment series no. 12, Cat. no. HSE 109, Australian Institute of Health and Welfare, Canberra. AIHW 2010, National Opioid Pharmacotherapy Statistics Annual Data collection: 2009 report, Bulletin 79, Australian Institute of Health and Welfare, Canberra. Chalmers J, Ritter A, Heffernan M and McDonnell G 2009, Modelling pharmacotherapy maintenance in Australia, Research Paper no. 19, Australian National Council on Drugs, viewed 17 May 2011 http://www.ancd.org.au/images/pdf/researchpapers/rp19_modelling.pdf Department of Health (Victoria) 2006, Policy for Maintenance Pharmacotherapy for Opioid Dependence, Melbourne. King T, Ritter A and Berends L (2011). Victorian Pharmacotherapy Review, Sydney: National Drug and Alcohol Research Centre. McDonough, M 2011, Pharmacotherapy in Victoria: From Policy to Practise, VAADA Conference 2011, viewed 17 May 2011 http://conference.vaada.org.au/sites/conference.vaada.org.au/files/3.%20mike%20mcdonough%2 0 %20Pharmacotherapy%20in%20Victoria.pdf Victorian Alcohol and Drug Association (VAADA) Position Paper: Pharmacotherapy Ritter, A and Chalmers J 2009, Polygon: the many sides to the Australian opioid pharmacotherapy maintenance system, Research Paper no. 18, Australian National Council on Drugs, viewed 17 May 2011 http://www.ancd.org.au/images/pdf/researchpapers/rp18_polygon.pdf Rowe J. 2004, A Raw Deal? Impact on the health consumers relative to the cost of pharmacotherapy, Salvation Army, Victoria. WHO 2011, WHO Essential Medicines Library: Methadone, viewed 20 June 2011 http://apps.who.int/emlib/medicinedisplay.aspx?language=en&medidname=442%40methadone WHO, UN Office of Drugs and Crime and UNAIDS 2004, substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention, World Health Organisation, United Nations Office on Drugs and Crime, Joint United Nations Programme on HIV/AIDs, viewed 24 May 2011 http://www.unodc.org/documents/hiv aids/position%20paper%20sub.%20maint.%20therapy.pdf Disclaimer While efforts have been made to incorporate and represent the views of our member agencies, the position and recommendations presented in this Paper are those of VAADA. 8