Fortunately, with the current coronavirus pandemic the Victorian Department of Health and Human Services has authorised prescribers to prescribe increased take away doses and longer duration scripts in suitably screened and stable patients. This is certainly a welcome intervention but leads me to wonder about the overall treatment and management of our patients on opioid substitution therapy (OST).
Methadone and Suboxone are prescribed medications given to patients with heroin or opioid use disorder. They are intended as a substitute for heroin and other prescribed opioids under the philosophy of harm reduction, understanding that there are some patients who for whatever reason will not remain abstinent of using drugs and trying to decrease the risks of harm both to the patient and to society as a whole. Some of the harms reduced include reducing the risks of blood borne viruses from sharing needles or drugs, decreasing the risks of overdose by prescribing an appropriate dosage of medication or prescribing take home naloxone, decreasing societal harms such as stealing and other criminal activity to fund an illicit drug habit.
This is an extensively researched and evidence-based form of harm reduction and personally I have seen many people turn their lives around on OST yet unfortunately there is still a dearth of OST prescribers. The reasons are seemingly obvious in that it is not well remunerated work with 'difficult patients' whom you wouldn't want clogging up your waiting room. You also don't want 'that' reputation as 'the drug doctor'.
But to me this attitude is misplaced. OST provides a treatment to people who are addicted. In no other area of medicine do we ignore or try to avoid prescribing evidence-based treatment for a disorder and substance abuse disorder is a medical condition.
Furthermore, there are structural and bureaucratic issues and hurdles associated with OST. For instance, one can easily prescribe opioid medication in one's consultation room initially. There is no need to obtain a permit immediately, no further training is required for the doctor and no real onerous conditions placed on the patient.
For Methadone the prescriber must undergo Medication Assisted Treatment of Opioid Dependence (MATOD) training and be assessed. Then when prescribing the medication the patient must find a pharmacy willing to prescribe OST to them, take an authorised photograph to the pharmacy, may be asked to prove that they can store the medication safely when they are allowed take away doses and for the first few weeks and then months have to present to the pharmacy daily where they are dosed in front of other pharmacy patients. To top it off OST is not PBS funded and the patient usually has to pay an additional dispensing fee. The system appears geared to penalise people who have acknowledged that they have a problem and are taking some of the necessary steps to rectify their situation.
These issues with OST appear emblematic of a larger issue of appropriate prescribing of drugs of dependence. The problems of harms and deaths related to prescription medication are well known particularly with the mass of information related to opioid medication deaths in America. More locally in Victoria in 2017, there were 414 pharmaceutical medicine-related deaths compared to 271 deaths associated with illicit drugs and a road toll of 258 in the same time period. Most pharmaceutical medicine-related deaths involved some form of polypharmacy-multiple different medications such as opioids and benzodiazepines contributing to the adverse outcome. In 2016-2017 in Victoria, there were 10,517 pharmaceutical medicine-related ambulance callouts compared with 11,097 illicit drug-related ambulance call-outs. This is a problem that has been growing for some time and is beginning to be tackled.