Issue 12 / 2 April 2012

A LEADING drug and alcohol addiction specialist says only about half the people across Australia who should be receiving opioid substitution therapy were able to find a placement in a treatment program.

Dr Alex Wodak, senior staff specialist in alcohol and drugs at St Vincent’s Hospital, Sydney, said the consequences of not adequately treating opiate addiction were “clear and predictable”, including increased drug overdoses and property crime, and more HIV and hepatitis C infections.

His concerns are particularly reflected in the Hunter New England region of NSW where patients are being told to join waiting lists of up to 2 years to access opioid substitution therapy (OST) programs.

A NSW Ministry of Health spokesperson confirmed to MJA InSight that “non-priority patients” were waiting up to 2 years to access opioid treatment in the Hunter New England region.

While “priority patients” were being accepted for treatment, this included only a narrow set of patients, such as those who were pregnant or HIV positive.

The spokesperson said there had been a 200% increase in the number of OST patients in the Newcastle region in the past 10 years — the largest increase in demand in the state.

Dr Wodak said there should be greater financial incentives to encourage GPs to manage these patients.

Research in the MJA this week looked at patient perceptions of sharing a waiting room with people being managed for opiate addiction. It found patients were much more likely to change practices due to waiting times or price hikes than because some of their fellow patients were attending for OST. (1)

Only 15.9% of the patients said they would be likely to change practices if their practice treated opiate addiction, compared to 28.7% who said they would do so if consistently kept waiting for more than 30 minutes, and 26.6% who said they would do so if fees increased by $10.

The researchers were surprised that a large majority of patients could not correctly identify if their practice prescribed OST.

“These results suggest that GPs’ fears of losing patient patronage if they commence OST prescribing are unfounded and should reassure GPs who are considering prescribing OST”, the researchers wrote.

Dr Wodak said the research was encouraging.

“It suggests the problem of stigma from patients is not as bad as we thought, but we need to encourage more doctors to get involved in this kind of work.”

The lack of GPs prepared to offer OST has had serious consequences in the Hunter New England region where local pharmacist Ms Donna McKinnis said patients were missing out on treatment because of the difficulty of getting onto the treatment program or into local GPs.

Ms McKinnis said she believed GPs were reluctant to manage opiate addiction “because they think their patients are reluctant”.

The problem affected many people who had been receiving OST in prison but were unable to access the medication upon release.

Since late December, Ms McKinnis had been lobbying local GPs to take on more methadone patients. She has succeeded in shifting 10 patients from the methadone clinic into local general practices, freeing up places in the clinic.

She first became aware of the problem when a man released from prison presented to her pharmacy in Newcastle last August unable to access the low dose methadone (4mL) he had been receiving in prison.

Ms McKinnis finally found a GP who would prescribe the methadone after calling the local methadone clinic, prison health services and 14 GPs, plus visiting another three GPs.

“It is frustrating that this was what I had to do. What are we doing to these people? What do we expect will happen to them?”

She said that the patients’ inability to access their medication “would not be happening if they were diabetic”.

McKinnis recalled the case of a man recently released from prison who was unable to access the large methadone dose [20mL] he had been receiving.

“He managed to last a week before it all got too much and he went in search of drugs.” She said something went wrong and he was now back in prison facing serious criminal charges.

The NSW Ministry of Health spokesperson said the department was working with Hunter New England Health to ensure that patients had their prescriptions and that their dispensing was effectively managed.

– Sophie McNamara

1. MJA 2012; 196: 391-394

Posted 2 April 2012

12 thoughts on “Serious shortage of methadone programs

  1. Joanne says:

    Can any one tell me if qld doctors can write suboxone for up to 5 patients for addiction without doing the specialist addiction course. ?

  2. Greg Morrison says:

    If that is the issue about opiate, then, why do some medical providers still continue to use it. Instead of improving the condition of patients, it just worsen their case by being more reliant on the said drug. will give you more glance about opiate detox and its adverse effects.

    So together let’s help each other to give what our brothers deserve. I mean they are human, too and they deserve to be treated as one. My friend told me that there are medical specialists in Arizona who provide far better alternative to OST which is called sauna detox. I think it should be given a try.

  3. William says:

    I’m a GP and a FAChAM. In the GP context, a great deal of the work is complex and time consuming. A “straight foward” referral from a clinic can have at least depression, or a community services or medico legal issue. In the NSW the script and PSU mechanics are time consuming. Many are benzodiazepine dependant as well. Guidelines to assist with this seem to be just emerging. Currently as a FAChAM I bring no/nada/zero – useful rebates to my GP group. Practising as a Level 2 mental health GP, these sessions were recently severely rationed. If my patient needs psychology, I just work for less. Clearly specific and improved rebates and renumeration, to both GPs and FAChAMs are needed. As well as timely pain service, psychiatry and addiction med back up. A less smug attitude from hospitalists/area health appointees who see 8 patients a week when times are tough would help too. That’s all.

  4. Realistic Doctor says:

    It’s time everyone stopped saying that GPs should have every kind of problem dumped on them. Google the case of Dr Stuart Reece, a Brisbane opioid substitution therapy prescriber, who was pushed down stairs in a violent attack by a patient last year, who suffered several fractured vertebrae and could have been paralysed. Is the Government going to pay for security guards as well as the extra time taken to see patients in these OST clinics? No, thought not!

  5. G R says:

    I agree with Colin S, but not rhys. Does rhys know that Suboxone is sold on the street?
    Choosing not to see opiate dependent patients may be a reflection of Medicare’s failing to recognise opiate (and other) addiction as a complex chronic illness, requiring a multidisciplinary team approach. I do not see it listed in Medicare’s examples of chronic illnesses. Is treating the symptom rather than the chronic illness the answer?
    NSW and HNE Health are concerned that “patients ..prescriptions and… dispensing are effectively managed”. Too bad about about their hep C, including that contracted in prison, mental illness, other addictions, chronic pain, malnutition, dental abscesses etc.
    No doubt we GP hacks will manage them in a level B consultation for a few dollars while being audited for long consults, dental referrals, and concession cards.

  6. rhys says:

    Adding Methadone and Suboxone onto the PBS, rather than leaving them as s100 drugs, will ensure that patients can get the treatment from a local pharmacy. Treatment would be ‘main stream’, covered by the Safety net and hightlight that medical practitioners deciding NOT see an opiate dependent patient would be discriminating against someone on the basis of a disability.
    If all doctors accepted as few as 5 patients on Suboxone [most states will allow this] there would be enough treatment places for all users wishing to access treatment.
    Complicated patients [or on Methadone] could be referred to Methadone prescribers or Addiction Specialists.

  7. Colin S says:

    Before semi-retirement from GP practice (NSW) in 2000, after 20 years of prescribing Methadone, I finally achieved 120 cases {including assessments). My suggestions for interested GPs are : (1) The patient must have spend 3 months in a well-run clinic previously (2) Must be “stable” (3) Must attend for assessments frequently and have urine testing (4) Prolonged counselling is essential (5) Take-away doses need great care. If GPs accept these Guide Lines, they should be well-able to handle Methadone patients. Successful outcomes are a great stimulus to both patient and doctor.
    To me, it seems that Donna is “on the ball”. Best wishes to her!

  8. LEE T L says:

    We must not forget that drug addiction is an organic brain disorder, not only personality problem. So there is a need to go on a long term treatment, only some, a small percentage can stop medication and stay drug free. Why the need to stop treating them?

  9. Aniello Iannuzzi says:

    Like many things in Medicine, it is the paperwork and dealing with multiple layers of well-intentioned “clinicians” that turns off so many prescribers. What should be a fairly simple prescribing process is subject to too much obstruction.

  10. Donna says:

    I certainly think there are some people who can be reduced off ORT but given the factors that contribute to drug use in the first place this will not apply to everyone. The contributing factors to drug use are – poverty, abuse, family history/genetics and availability. We would not stop diabetics getting insulin and there are many people on ORT who are the same. There is no problem for the community if some one is on ORT for longer but the rebound effect is great if they are undertreated. I have patients who are are too scared to go off ORT because they are concerned they will relapse – so for them removal of ORT is the problem not taking ORT.

  11. RayT says:

    I’ve long been of the view that there is too much focus on to drug substitution, and not enough on gradually weaning people off those substitutes so they can be drug free. I also think most detoxification centres run too short a programme, encouraging a revolving door effect.

  12. Donna says:

    It is vital that anyone who wants to give up drugs is given the opportunity. No one loses when some one is in drug treatment. There is less crime, less emergency admissions to hospital, less trauma for families, lower costs for taxpayers and obviously a far better outcome for the person themselves. We need to remember these people are a part of our communities and they are part of someone’s family.

Leave a Reply

Your email address will not be published. Required fields are marked *