Opioid dependence changes will take a leap of faith

Patients should benefit overall, but communication has been poor and the changes are unlikely to improve access, clinicians say.

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With just two weeks until a major change to the Opioid Dependence Treatment program comes into effect, GPs and addiction experts say administrative issues remain unresolved but postponement would be “devastating” to vulnerable patients.

From 1 July PBS-listed medications used in the ODT – methadone oral liquid, buprenorphine sublingual tablets, buprenorphine + naloxone sublingual films, and long-acting injectable buprenorphine products – will become part of the Section 100 highly specialised drugs program.

Effectively this means that PBS-eligible patients will pay a co-payment to access their treatment (for up to 28 days’ supply per pharmaceutical benefit prescribed) and the amount paid will contribute towards their PBS Safety Net threshold. It also means dispensing pharmacists will no longer be able to charge an out-of-pocket or gap fee for dispensing the drugs.

Similar to other medicines on the PBS, if different strengths of opioid agonist drugs are prescribed, each strength will attract one PBS co-payment.

The changes seem positive for patients, but what isn’t clear is how the transition from the current program to a post-1 July world will go.

GPs who prescribe opioid-agonist treatment can probably expect a surge in visits from their dependent patients come 1 July.

Sydney GP Dr Brad McKay said the Department of Health and Aged Care had been less than forthcoming in communicating about how the policy change would roll out.

“For example, if I write a script today for three months’ supply, will that script be honoured once 1 July comes around, or will it suddenly be invalid?” he said.

“Are we going to have patients suddenly unable to access their supply? Are we going to have a rush of patients needing new scripts? These are all questions prescribers have, but there has been no communication from the department about this at all.”

“As usual the left hand has not been talking to the right hand.”

Operators of private opioid treatment clinics say they are at risk of closure because of the change, which they say would “displace more than 4500 patients with opioid dependence”.

Professor Suzanne Nielsen, deputy director of the Monash Addiction Research Centre in Melbourne, said the policy change was, overall, a positive one for a vulnerable patient population.

“Even though it’s very close to the launch date, it’s my understanding that there is work ongoing to try and resolve some of these issues,” she told TMR.

“We just don’t have the details yet to know what that’s going to look like. It’s not clear to me in terms of what the funding is going to look like, and how much pharmacists, for example, are going to get paid.”

“We obviously don’t want these payment barriers to be in place for a day longer than necessary. But it has been a very quick implementation.”

“I would expect there’ll be some teething problems. But I think the intention of the program is it’s coming from the right place, there are just a lot of complexities in terms of the different treatment models and how this has been delivered.”

“Most of those treatment models have really come out of necessity, because we just didn’t have enough treatment places in the various jurisdictions, [which is why these] different kinds of clinics have opened up.”

“I would really hope that we can resolve the issues so that they’re not negatively affected.”

At the moment, Professor Nielsen said, it was a “leap of faith”.

“If there was a delay, I think that the negative impact on clients would also be devastating for many patients who have really just been hanging on for this change,” she said.

“Often it’s very day-to-day in terms of coming up with that $5 for a daily dose, and to be told a few weeks out, that you’ve just got to keep paying that fee until the end of the month, and then there’s going to be some relief – that’s really important.

“We know that people miss doses or drop out of treatment, because they just can’t afford what might seem like a small amount, but which adds up.

“I’d like to be optimistic. I know people are really working on trying to resolve this. And I think that it’s all coming from a good place with an excellent intent. But it’s a lot of details to sort out in two weeks,” she said.

One opioid agonist-prescribing GP said that most patients needing this treatment were vulnerable and unable to pay for private treatment, making this new policy a win-win for patients in need.

“The people who are needing these medications are already vulnerable populations,” said Dr Pallavi Prathivadi, a Melbourne GP and researcher at Monash University.

“We are often talking about low-income patients, single parents, co-existent domestic violence, unstable housing, complex family health care needs, children with complex healthcare needs.

“If we are not subsidising vulnerable patients like this, then we’re doing a bad job in this healthcare system.

“There are people that absolutely have capacity to pay privately for care and can drive a privatised pharmacy model. But I don’t think asking our vulnerable patients to do that is reasonable in any way.”

Practical concerns come down to the details of what needs to be on the prescription itself after 1 July, Dr McKay told TMR.

“In New South Wales, at least, I can write a script for methadone, say, that will be for 65mg per day between a three-month spread of dates.

“After 1 July, I have to start thinking about how many millilitres are in a bottle, how many bottles does the patient need. Do I need to get an authority from NSW Health for each script? Do I need to get an authority from Health Professional Online Services?

“None of these things have been made clear.”

According to the PBS information page, prescribers are, and will continue to be, required to comply with state and territory ODT program policies, guidelines and regulations when writing PBS prescriptions for ODT medicines.

“From 1 July 2023, ODT medicines will be Authority Required (STREAMLINED) listings under the Section 100 HSD Program (Community Access).

“Similar to other medicines listed under the Section 100 HSD Program, authorised prescribers participating in state and territory ODT programs will be able to:

• prescribe ODT medicines for PBS-eligible patients, as per the prescription of other medicines under the Section 100 HSD Program (Community Access) arrangements (often for up to 28 days’ supply);
• for methadone oral liquid, prescribe up to a maximum quantity of 4200mg (840 mL) with 2 repeats (the maximum quantity is equivalent to up to a maximum dose of methadone of 150 mg per day for 28 days);
• for sublingual buprenorphine and buprenorphine with naloxone, prescribe up to a maximum quantity equivalent to 32mg of buprenorphine per day for 28 days, with 2 repeats;
• for injectable buprenorphine, prescribe up to a maximum quantity equivalent to 28 days (4 weeks) with 2 repeats.”

Another looming possible problem lies in GPs’ practice software and communication with health departments.

“Just as an example, when fluticasone for asthma was taken away from GP prescribers, there was heavy pushback from GPs and paediatricians and that decision was reversed [in mid-May], right?” said Dr Prathivadi.

“Even though that policy change has been made, [the medical software] is not honouring my fluticasone scripts. I have had to write private fluticasone scripts until that change has been reflected in my medical software.

“So, I am also curious to see what will happen with this ODT change. But I have a gut feeling there’s going to be software issues, potentially.”

For Dr Prathivadi, the problem with the changes to the ODT program are that they don’t help the stark reality that only about 7% of GPs are OAT prescribers.

“All this is doing is making it maybe a little bit more accessible for the patients to get to, but this is not changing provider attitudes. It’s not changing GP prescribing rates,” said Dr Prathivadi.

“Is it going to encourage more GPs to prescribe?

“This may take out some of the bureaucratic requirements [around OAT prescribing], but they haven’t taken out the long training program. They haven’t incentivised prescribing, they have not addressed the fact that GPs don’t want to be known as the methadone prescriber.

“I will be really curious to see if this has a meaningful effect on OAT prescribing rates.”