The gap between GPs’ eagerness to delve into the AOD treatment space and engaging in management is rooted in systemic barriers.
Systemic barriers, more so than stigma, are holding GPs back from getting more involved in the alcohol and other drug (AOD) treatment space, an RACGP representative told the AOD inquiry.
Speaking at the inquiry into the health impacts of alcohol and other drugs in Australia in Melbourne yesterday on behalf of the RACGP, Victoria-based GP and addiction medicine specialist Dr Paul Grinzi said that the decline of prescribers – specifically GPs – with competency in prescribing for opioid dependency was a concern.
“There has been, historically, a burden of treatment [for opioid dependency] placed on a generation of GPs who are now peri-retirement,” he said.
“Over the years, a lot of them have generated a large patient base.
“Once they come out of the workforce, that patient base needs to find other prescribers.”
According to the RACGP, only 7% of GPs provide opioid dependency treatment, despite being the major prescribers.
While there has been uptake in education programs for new prescribers, there remains a gap between education and prescribing, added Dr Grinzi.
“I’ve been involved with the Victorian department’s education program for GPs and other prescribers for a number of years, and we’ve had continuing increased uptake of education, so the amount of doctors engaging in the training program certainly hasn’t dropped off.
“But the amount of translation from having been trained to actually prescribing and prescribing in reasonable numbers, there’s a big gap there.”
According to Dr Grinzi, its systemic barriers, more so than stigma, that’s holding GPs back from fully engaging in the space.
“The [federal health] department funded the RACGP to run an AOD education program nationally.
“In being part of the education program, I got to speak to GPs nationally, and particularly the ones … interested in what’s going on, and my experience from having those discussions was [reticence was] more about system barriers [than stigma].
“One GP said, ‘I’d love to be doing it, but particularly after lockdown and covid and all the extra mental health [care that] has been flushed into the system, I can’t deal with more complexity without more support’.”
Dr Grinzi said GPs can often feel under supported, particularly for the cohort of patients that may feel beyond their capabilities but that may not seem eligible for a referral to other AOD services.
“The MBS is very skewed towards shorter consultations in terms of the remuneration for patients with their rebates,” he said.
“For GPs looking to do longer consultations, which this area does require, it is complex.”
It was posed by a member of the panel that, historically speaking, as rebates rise, so too do doctors’ fees.
“You’ve got fair criticism of Medicare rebates,” responded Dr Grinzi.
“I think historically, [the rebate] has fallen so far behind real costs that increases would need to be significant [to compensate].
“I think, hypothetically, if we got to that point, the out-of-pocket costs would stabilise … but we’re unlikely to get there in the current fiscal arrangements of the country… so maybe that’s an area to move away from.”
Able to take a holistic approach as an “expert in juggling various aspects”, GPs can look beyond simply a disorder, like drug or alcohol dependence, and treat the person as a whole, said Dr Grinzi.
“One of the issues with another clinic taking over or initiating [AOD] care, and we’ve seen this with a number of attempts in Victoria, is that a special service may start a patient, for example, on Suboxone treatment for say Oxycodone dependence, and the idea was to stabilise them and hand them back to their GP.
“[But] often there’s a patient barrier there.”
Patients can feel abandoned by their new prescriber, with whom they’ve built a trusted relationship, and are then “dumped” back onto their GP, said Dr Grinxi.
“In starting treatment for a very stigmatised and embarrassing topic for a lot of people, they have to develop a bit of trust and rapport with the service provider.
“If it’s a primary service provider who’s not designed to continue that care longer term, then there’s a mismatch, because now we’re getting people who don’t need that specialist care stuck emotionally to that care.
“I caution around having more clinics to start [treatment] that would be quite short term.”
Most specialist care is not set up to provide long term support, said Dr Grinzi.
While patients might be happy to keep that relationship ongoing, the system would likely become overwhelmed.
“I think we would lose the value of that sector being specialised, and we also lose the value [by labelling AOD] what I call a single organ issue, even though AOD is not an organ, we’re missing that whole person approach.”
Related
In its submission to the inquiry, the RACGP recommended increasing the Medicare rebate for longer level C and D consultations by 20%, with an additional increase for patients in MM3-7 areas, to facilitate longer consultations.
It also recommended a 20% increase in GP mental health MBS item rebates and specific funding for opioid dependency treatment in primary care.
The college also called for a multi-sector approach, incorporation of learnings from domestic and international models to provide inclusive and culturally competent care and education support.
“If we implement inclusive, positive policies, supporting appropriate training and drawing from best practices, we can enhance AOD services for the community and contribute to more equitable healthcare systems and healthier and happier in health of Australia,” said Dr Grinzi.
