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Renewed calls to fully subsidise methadone treatment
GPs and addiction experts fear hidden costs are preventing more people from accessing treatment.
People with dependency are shifting to strong prescription opioids like fentanyl and morphine, which are much cheaper than methadone because they have no dispensing fees.
For more than a decade, experts have called for methadone to be fully subsidised by the Federal Government, ending a situation in which patients are forced to pay pharmacist dispensing fees that can be up to $75 a week, or almost $4000 a year.
The renewed calls come after warnings that Australia may only be a few years behind the US in terms of deaths from opioid misuse. Australia’s opioid-related deaths – licit and illicit – have almost doubled in a decade, with prescription rates of highly addictive opioids such as oxycodone and fentanyl up 40% between 2009 and 2018.
But frustrated GPs say no action has been taken, despite the fact methadone treats all types of opioid use, from heroin to fentanyl, and is regarded as the best treatment for heroin addiction. More than 50,000 patients use methadone regularly in Australia.
Speaking at the RACGP’s GP17 conference, Dr Simon Holliday, a GP who runs a methadone service in rural NSW, asked Federal Health Minister Greg Hunt a question regarding the hidden costs of methadone.
After Minister Hunt asked for the question in writing, Dr Holliday sent him a letter, but received no response.
‘Private treatment costs to the patients around my region are about $40 per week, but elsewhere may be two or three times this cost,’ the letter states.
‘Many clients I see tend to be welfare recipients and have multiple major physical or psychosocial conditions …. [Patients] ask me, ‘Now that I am finally turning my life around, why do I have to choose between stopping treatment or doing crime to pay for it?’
Dr Holliday told newsGP the fact methadone is not fully subsidised is a ‘gross omission based on fear, stigma and moralising’.
‘We know that opioid-substitution therapy is very evidence-based and highly cost effective,’ he said. ‘For every $1 spent on opioid-substitution therapy, there is $7 in benefit for the community.
‘This very simple change could make an impact on everything from mental health outcomes, indigenous health outcomes, parenting, returning to work, unemployment and crime rates.
‘Fear and shame are not the way to make evidence-based policies.’
Dr Holliday’s call has been backed by John Ryan, the CEO of drug and alcohol advocacy group Pennington Institute. Mr Ryan has previously called for methadone to be fully subsidised, which would cost an estimated $90 million a year.
‘Nothing has changed. The fact of the matter is, there’s been no real action to fix it,’ he told newsGP. ‘People are generally without resources after a serious dependency, so they drop out because they can’t afford it.
‘[The fact methadone is not subsidised] is a disincentive that keeps people out.’
Mr Ryan said that since the early expansion of opioid-substitution therapy in the 1980s, very little had changed other than the passing of the buck between federal and state authorities.
‘These patients don’t elicit the same level of sympathy as other people accessing healthcare,’ he said. ‘They’re a silent and suffering population who don’t have their own advocacy voice.’
GP Dr Simon Holliday described the fact methadone is not fully subsidised as a ‘gross omission based on fear, stigma and moralising’.
According to Mr Ryan, people with a dependency are increasingly shifting to strong prescription opioids like fentanyl and morphine, which are much cheaper as a result of no dispensing fees.
‘They are self-medicating, in a sense, but they’re not receiving treatment for their dependency,’ he said. ‘They are just prolonging their dependency in a cost-effective manner, rather than getting their lives back on track.’
Methadone is listed on the Pharmaceutical Benefits Scheme (PBS) when used for opioid dependence, but dispensing fees are not covered.
In a submission to a 2016 Government review of pharmacy funding, the Victorian Area Based Pharmacotherapy Networks note that the situation for methadone and its fellow opioid-substitution therapy medications, bupenenorphine and buprenorphine/naloxone, is unique.
‘[T]he PBS listings for S100 opiate dependence treatments [are] unique in that they do not include any remuneration for the supply of the medicines,’ the submission states.
‘Unlike all other PBS medicines supplied through the community pharmacy channel, all remuneration for dispensing, supervision, assessment is recovered via a private agreement between the patient and the pharmacy providing the service.
‘This ad-hoc fee has remained essentially the same for 30 years. At a minimum of $120 per month, many patients find the payments a significant barrier to initiating treatment for opioid dependence.’
Dr Hester Wilson, Chair of the RACGP Addiction Medicine Specific Interests network, backs Dr Holliday’s calls for the Government to cover dispensing costs.
‘Given this is a group of people who quite often struggle to make financial ends meet, it would make sense for the Government to support the cost of pharmacy dosing,’ she told newsGP. ‘The money saved through treatment is substantial.
‘We know treatment stops death, stops blood-borne viruses, stops crime, stops incarceration, improves people’s health and wellbeing. In short, it really works and putting financial barriers in place is short sighted.’
Pharmacists charge the fee to cover the time and expertise of dispensing, maintaining the dosing register and making up take-home doses as patients stabilise.
Dr Wilson said costs to the patient vary between states, with some providing large public clinics and free dosing, while others have limited free dosing that requires patients to dose at a community pharmacy.
‘Most public dosing clinics do not provide take-away [methadone],’ she said.
‘Indeed, we encourage patients to stop dosing at public clinics once they have stabilised and to move to their local pharmacy, as this allows the public clinic to take on new people starting treatment and allows the stable patient to be “mainstreamed” by getting their medication from the pharmacy, just as other patients do.’
Dr Wilson believes methadone has to be controlled due to its associated risks as a strong opioid agonist.
‘It is a well evidenced-based treatment that allows people to recover and get on with their lives,’ she said. ‘At the same time they do need to attend regularly for dosing to maintain themselves in treatment.’
Questions for Minister Hunt were referred to the Department of Health (DoH).
A DoH spokesperson told newsGP that states and territories are responsible for administering the Opiate Dependence Treatment Program, and that the Federal Government pays the full cost of opioid-substitution therapy medicines.
‘Where pharmacies are involved in distribution they may choose to impose charges relating to the administration, dispensing and supervision of doses associated with these medicines,’ the spokesperson said. ‘Some states and territories offer financial incentives to pharmacies participating in the [Opiate Dependence Treatment Program], to reduce their administration costs.’
The spokesperson said that this year’s Federal Budget included $268 million of funding for Australians with drug and alcohol issues, including $7.2 million to develop a Take Home Naloxone pilot program aimed at improving access to naloxone for people at risk of or likely to witness an opioid overdose.
‘[I]ndividuals will be able to access naloxone through a variety of settings including community and hospital-based pharmacies and facilities, such as alcohol and drug treatment centres, and needle and syringe programs, without a prescription and at no cost,’ the spokesperson said.
Shadow Federal Health Minister Catherine King did not respond to questions over her party’s policy.
methadone opioid substation therapy PBS pharmacotherapy
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