Renewed calls to fully subsidise methadone treatment

Doug Hendrie

10/04/2019 3:19:33 PM

GPs and addiction experts fear hidden costs are preventing more people from accessing treatment.

Person with dependency
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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Dr Peter j Strickland   11/04/2019 11:35:44 AM

Having been a methadone prescriber I do NOT agree with a subsidy for what is largely a self inflicted condition, and especially those who are heroin addicts. These same people now requesting their addiction to be subsidised have caused thousands of dollars damage to surgeries, robbed people (including their close families), and committed crimes causing deaths and damage to innocent people. A cost of $40/week is nothing to pay for their treatment at all, and the fact that they have access to this treatment (methadone) means they can rehabilitate themselves and get a job. I would much rather see a subsidy for hard-working and socially responsible people for their dental treatment of $2000/year, or adding worthwhile medications to the PBS such as some antihistamines (for example). The greatest problem with the PBS costings is that subsidies should be more on a percentage basis for expensive medications, rather than a dollar value, as that would satisfy the budget better.

James Rowe   15/04/2019 6:16:44 PM

As a recipient of opioid pharmacotherapy since 2007, I find the above comment offensive, partic. the generalised and assumptive nature of the claims. I have no criminal record nor do I deserve one. Problems began with criminalisation as drug control - the impetus for the negative costs Strickland attributes to the heroin user? Indeed, much economic-compulsive crime IS committed to meet the needs of drug dependency - but this is due to grossly inflated prices demanded when political authority ignores laws of supply and demand (and leaves the supply of demand to the criminal market). Would Strickland like to see subsidised treatment removed for ALL injury and illness caused by activity entered into voluntarily? Of only activity deemed 'criminal' (or immoral?) because of arbitrary legal status that rests on historical racism and acquiescence of a small nation to the demands of the superpower on which it depends for security? Pray tell, what's the difference between heroin & morphine?

Karen   27/04/2019 10:15:01 PM

Methadone already subsidised. It's Pharmacy Guild powerful lobby making money out of it. Can charge whatever they like. Not regulated at all. Treat us with so much contempt. I've been on and off maintenance programmes for 40 years. It's used as a form of social control nothing to do with helping addiction. Never really designed to come protocols from drug companies. Doctors do best they can to help but are in the dark. Money for jam for pharmacy.

Karen   27/04/2019 10:27:22 PM

Some prescribers should not have been given prescribing rights when they have not the slightest interest in addiction medicine...have no understanding apart from propping up surgeries and pharmacies that other wise would be struggling. Totally punitve regime for the poor. If you can afford your addiction you're not considered an addict ...don't get me started on the legal addictions like alcohol that cause more damage intergenerationally ,medically etc

Dr Paul Grinzi   1/05/2019 9:55:28 PM

Sadly, some of the comments to this article place our profession in very poor light. Stigmatising language and attitudes such as these create enormous barriers to care, and to caring. Sometimes we reflect the attitudes of the broader community and media, but we should attempt to rise above this filth and act like the health PROFESSIONALS that we are.
No one, in the history of humanity, has EVER chosen to develop an addiction. The very nature of addiction is 'loss of control'. In this setting, esp with prescription medications, it is a severe (but treatable) complication of pain management. Treatment = better outcomes for the patient, the community and the taxpayer.
To create barriers of stigma is immoral in my opinion.

To any registrar (or other GPs) reading these comments - would you treat an asthma relapse (another chronic relapsing remitting medical condition) in such a stigmatised way? If not, don't follow suit of our 'esteemed' colleague.

Tim Griffiths   2/05/2019 9:58:56 AM

Dr.Strickland's comment is appalling and it seems he is ignorant of the nature of addiction and the many barriers those seeking treatment for opioid dependence encounter. He also apparently lacks the compassion that, thankfully, is standard equipment for most of our GPs. I have to wonder about the quality of care this doctor is providing to his pharmacotherapy patients.

It's really simple - methadone and buprenorphine are both considered essential medicines - medicines that should be accessible, of a high quality, and affordable to those who need them. These medicines are listed on the PBS but are the ONLY medicines in the entire PBS schedule, where the supply component is not funded. Literally every other medicine is funded for supply, either through community pharmacies, or through supply streams embedded in our public hospitals. This anomalous disparity must be corrected

Sam   8/05/2019 9:44:45 PM

The UK it's free , we are supposed to be like them NHS often is a matter of power bill or medication . Fix this itsa health issue, it's the dispensing fee that's hard to maintain . Follow the UK program , it's free for closing the gap recipient so why pick chose people? Pensioners etc shouldn't pay . Hi James Rowe he has a great article from years ago proving this barrier

Sam   8/05/2019 9:47:41 PM

Dr Peter j Strickland Lucky you sent in the Uk then, and it's a disease . Sad your opinion doesn't keep up with times and may cost Lives . Do you feel the same about diabities type 2 inflicted ?

Free clinics   2/06/2019 3:33:16 PM

Ridiculous esp if on concession, Mr Hunt needs to fix this.

Graeme Allen   13/08/2019 8:46:11 AM

I have been on methadone for chronic pain and I was on Kapanol for seven years before being addicted to methadone why is it that I have to pay a dispensing fee just the same as a heroin addict. I are tarred by the same brush as a heroin addict, I think it is appalling that a doctor addicts me to morphine only to addict me to methadone?

jenny   13/08/2019 3:16:28 PM

I can't afford it after my methadone went from $25pw which is cheap compared to the majority of chemists(& I still could barely afford it)to now $40pw,that is 2 1/2 times my internet bill monthly more than my elec & gas bill, it is disgusting they are making money from the most vulnerable people, the chemist get it free they also get $1000 to take the"undesirables "so there is something in it for them,the government get some money back through the taxes the chemist pays. I am only living on $160pw after my bills & food are paid & I have a car to run too. It was once free then they slowly charged people, would they rather people using&stealing costing them more?it would not cost 90million for 50,000 patients at $1160 p/a some charge $25,$30,$35pw, it cost 58million (if $40pw) not 90million they want to pocket the other 30(some pay 60pw but that isn't a lot of people&usually they work&the ones who work get in back in tax,they should allow us to get it back in tax too

anonymous   13/08/2019 3:21:28 PM

build more free clinics and allow us some freedom to get the same take aways so we aren't tied to the place daily or run into people you really do not want to run into,its hard when you're trying to get your life on track the last people you want to see is people who are still using or just starting out & still using ,its temptation you do not need,

Sam   29/09/2019 11:18:44 AM

Hi Grahman i didn't know pain patients pay dispense fee also?, I used to only pay $1 in a country town, now its $3-4 . Greg Hunt should fix it... If the UK can do it so can we, pharmacies just get sent a cheque , its free anyhow from the Government the actual medication, its to dispense the darn stuff we are charged?? other people dont get charged that for their scrips

Sam   29/09/2019 11:20:10 AM

The whole point of the program is to change your lifestyle?, well if you have to revert to old ways to afford to pay it isn't that pointless???