Introduction
3. What is the name of your organisation?
Organisation
Network of Alcohol and Other Drug Agencies (NADA)
Terms of Reference
1. Describe and compare essential elements of models of service delivery for opioid dependence treatment (ODT) in Australia (and internationally) including best practice guidelines and current models (including models developed in response to the COVID-19 pandemic) that support timely access to ODT medicines through both pharmacy and non-pharmacy settings*.
Terms of Reference One
NADA supports the examination of models of service delivery for ODTP, particularly to develop a more consistent approach across jurisdictions, regions, pharmacy and non-pharmacy settings.
In NSW, the Non Government Organisation (NGO) Alcohol and other Drugs (AOD) sector currently provides access to ODT in some residential rehabilitation settings as an adjunct to therapeutic program delivery. This enables people wishing to withdraw from, maintain current levels, or transfer to longer acting ODP medicines to do so, in a supportive environment capable of addressing the considerable and complex physical, social, emotional, financial, and relational challenges often faced by people who are dependent on illicit or pharmaceutical opioids. This is particularly significant for pregnant women and women with children.
Person centred care
In examining essential elements of models of service delivery, the principles of human rights and person-centred care are paramount. This translates in practice to ensuring that:
• the full range of ODT medicines (methadone, films and injectables) and appropriate staffing are available, regardless of geographical location.
• services providing ODT medicines, in particular the NGO AOD sector, are adequately funded to do so, given the requirement to provide an adequate setting, space and storage and to employ registered nurses at increased cost to an already underfunded sector.
• consumers are provided with the full range of wrap around support services required to ensure the best possible outcomes. These include supports to access employment, housing, education, financial support, childcare, and cultural connection.
• opioid dependence is recognised as a health condition that is managed in the same way as other chronic health conditions, such as asthma and diabetes, where PBS supported pricing of medicines is consistent and equitable across pharmacy and non pharmacy settings and, in particular, between private clinic, public clinic and pharmacy settings. It would be unacceptable for essential asthma and diabetes medicines to require a dispensing fee. This is currently the case for ODT medicines.
Covid 19
• To ensure continuity of access to ODT medicines in response to COVID-19 restrictions, different models have been adopted such as the use of telehealth, additional take-home doses, transfer of consumers to community pharmacies, and an increase in the use of depot injections. These more flexible options could be extended in the future to remove some of the barriers to access to ODP medicines and to support ongoing retention in the program, lending to improved outcomes for consumers. These options need to be examined in the context of consistent pricing, dispensing fees and equitable access.
In NSW, the Non Government Organisation (NGO) Alcohol and other Drugs (AOD) sector currently provides access to ODT in some residential rehabilitation settings as an adjunct to therapeutic program delivery. This enables people wishing to withdraw from, maintain current levels, or transfer to longer acting ODP medicines to do so, in a supportive environment capable of addressing the considerable and complex physical, social, emotional, financial, and relational challenges often faced by people who are dependent on illicit or pharmaceutical opioids. This is particularly significant for pregnant women and women with children.
Person centred care
In examining essential elements of models of service delivery, the principles of human rights and person-centred care are paramount. This translates in practice to ensuring that:
• the full range of ODT medicines (methadone, films and injectables) and appropriate staffing are available, regardless of geographical location.
• services providing ODT medicines, in particular the NGO AOD sector, are adequately funded to do so, given the requirement to provide an adequate setting, space and storage and to employ registered nurses at increased cost to an already underfunded sector.
• consumers are provided with the full range of wrap around support services required to ensure the best possible outcomes. These include supports to access employment, housing, education, financial support, childcare, and cultural connection.
• opioid dependence is recognised as a health condition that is managed in the same way as other chronic health conditions, such as asthma and diabetes, where PBS supported pricing of medicines is consistent and equitable across pharmacy and non pharmacy settings and, in particular, between private clinic, public clinic and pharmacy settings. It would be unacceptable for essential asthma and diabetes medicines to require a dispensing fee. This is currently the case for ODT medicines.
Covid 19
• To ensure continuity of access to ODT medicines in response to COVID-19 restrictions, different models have been adopted such as the use of telehealth, additional take-home doses, transfer of consumers to community pharmacies, and an increase in the use of depot injections. These more flexible options could be extended in the future to remove some of the barriers to access to ODP medicines and to support ongoing retention in the program, lending to improved outcomes for consumers. These options need to be examined in the context of consistent pricing, dispensing fees and equitable access.
2. Examine the consumer experience, focussing on equity of access, geographical barriers to access, cultural safety, and affordability of ODT medicines across the different models of service delivery. This will include consideration of access to ODT for at risk population groups including people living in rural and remote areas, Aboriginal and Torres Strait Islander peoples and other populations who may have limited access to health care services, including ODT.
Terms of Reference Two
Equity of access and geographical barriers
• NADA members have expressed concern regarding the barriers to ODT access in rural, regional and remote areas. Some report travelling times of up to 3 hours return, per day in areas where the only available public transport is the local school bus run, which requires people on ODT to be away from their homes from 7am – 5pm. This excludes people on ODT from employment opportunities and is a significant barrier to people, usually women, with young children.
• Many rural/regional areas do not have access to Addiction Medicine Specialists. Where a specialist is available, they report that Medicare item numbers for addiction medicine are inadequate. In addition, the high number of “no shows” means Specialists are not remunerated for their time. These concerns act as deterrents for Addiction Medicine Specialists to provide services in rural/regional areas and further increase the inequity for consumers in these areas.
Equity for women
• Women overwhelmingly have responsibility for child care which significantly affects their capacity to attend daily dosing. Free ODT clinics are unsuitable for children, thus incurring fees associated with pharmacies and private clinics adding an additional financial burden.
• There are concerns regarding Department of Communities and Justice accessing information about an ODT consumers and the potential for negative consequences for mothers on ODT and their children.
Stigma and discrimination
• Stigma and discrimination can deter people from accessing ODT in smaller communities due to the lack of anonymity. It is also a major concern for pregnant women.
Affordability
• Dispensing fees for ODT medicines are inequitable and create a major barrier to treatment access, retention and optimal outcomes.
• Dispensing fees vary markedly across NSW. This differs from arrangements for other PBS prescription medications. The average cost for 12 months of ODT is between $1,800 - $2,600. For consumers on a Government benefit, this represents at least 12% of their weekly income. The consequences of this financial burden on consumers and their families include going without necessities, engaging in illegal activities, jeopardising treatment success due to missed doses and exiting treatment prematurely.
Safety
• Many consumers who seek ODT recognise the benefits of moving away from their past culture of drug use. Public clinics, particularly in smaller regional/rural communities, reportedly increase the risk of exposure to their past social/cultural cohorts and increase the risk of drug use. Alternative collection/dosing methods, through community pharmacies, increased takeaway doses, depot injections and home delivery, can create a safe distance from past connections and triggers and contribute to improved retention in the ODTP.
• In the presence of domestic and family violence where an AVO is in place, some women in regional areas report difficulty accessing ODT in public clinics, as exposure to perpetrators who are also on ODT is likely, due to the limited clinic hours. This places some women at serious risk of harm and psychological distress.
• Members have expressed concerns regarding privacy and security for consumers due to outdated communication technology. Many clinics, prescribers and pharmacies use fax machines which pose a potential and significant privacy risk, particularly in smaller communities. It is recommended that a more secure and private system of communication be developed for ODT prescribing and transfers.
• NADA members have expressed concern regarding the barriers to ODT access in rural, regional and remote areas. Some report travelling times of up to 3 hours return, per day in areas where the only available public transport is the local school bus run, which requires people on ODT to be away from their homes from 7am – 5pm. This excludes people on ODT from employment opportunities and is a significant barrier to people, usually women, with young children.
• Many rural/regional areas do not have access to Addiction Medicine Specialists. Where a specialist is available, they report that Medicare item numbers for addiction medicine are inadequate. In addition, the high number of “no shows” means Specialists are not remunerated for their time. These concerns act as deterrents for Addiction Medicine Specialists to provide services in rural/regional areas and further increase the inequity for consumers in these areas.
Equity for women
• Women overwhelmingly have responsibility for child care which significantly affects their capacity to attend daily dosing. Free ODT clinics are unsuitable for children, thus incurring fees associated with pharmacies and private clinics adding an additional financial burden.
• There are concerns regarding Department of Communities and Justice accessing information about an ODT consumers and the potential for negative consequences for mothers on ODT and their children.
Stigma and discrimination
• Stigma and discrimination can deter people from accessing ODT in smaller communities due to the lack of anonymity. It is also a major concern for pregnant women.
Affordability
• Dispensing fees for ODT medicines are inequitable and create a major barrier to treatment access, retention and optimal outcomes.
• Dispensing fees vary markedly across NSW. This differs from arrangements for other PBS prescription medications. The average cost for 12 months of ODT is between $1,800 - $2,600. For consumers on a Government benefit, this represents at least 12% of their weekly income. The consequences of this financial burden on consumers and their families include going without necessities, engaging in illegal activities, jeopardising treatment success due to missed doses and exiting treatment prematurely.
Safety
• Many consumers who seek ODT recognise the benefits of moving away from their past culture of drug use. Public clinics, particularly in smaller regional/rural communities, reportedly increase the risk of exposure to their past social/cultural cohorts and increase the risk of drug use. Alternative collection/dosing methods, through community pharmacies, increased takeaway doses, depot injections and home delivery, can create a safe distance from past connections and triggers and contribute to improved retention in the ODTP.
• In the presence of domestic and family violence where an AVO is in place, some women in regional areas report difficulty accessing ODT in public clinics, as exposure to perpetrators who are also on ODT is likely, due to the limited clinic hours. This places some women at serious risk of harm and psychological distress.
• Members have expressed concerns regarding privacy and security for consumers due to outdated communication technology. Many clinics, prescribers and pharmacies use fax machines which pose a potential and significant privacy risk, particularly in smaller communities. It is recommended that a more secure and private system of communication be developed for ODT prescribing and transfers.
3. Explore the utilisation of PBS ODT medicines in Australia, including funding, benefits (health system and societal) and costs incurred in the supply and dispensing of Opiate Dependence Treatment Program (ODTP) medicines in pharmacy and non-pharmacy settings. This will include examination of current PBS restriction criteria and the impact of listing of modified release buprenorphine injections on the PBS ODTP.
Terms of Reference Three
Economic analysis
Any economic analysis of funding and costs of the ODTP should include analysis of the cost-savings of the program.
In 2015-16:
• 645,260 Australians use ‘extra-medical opioids’
• 104,000 Australians are dependent on extra-medical opioids
• 2,203 Australian deaths are attributable to extra-medical opioid use
• The total cost of extra medical opioid use in Australia in 2015-16 was $10.13 Billion. This includes tangible costs of $5.63 Billion including: premature death, healthcare, drug related crime, workplace costs and road crashes. Intangible costs include over 70,000 years of life lost. This study also examined the lost quality of life for partners and children living with a person dependent on opioids. There were more than 41,000 adults and 70,000 children living in these households.
Health and societal benefits and therefore cost savings of the ODTP include:
• Reduced drug use
• Reduced overdose
• Reduced mortality and morbidity
• Reduced risk of blood borne virus transmission
• Improved physical health
• Improved psychological health
• Reduced acquisitive crime
• Improved social adjustment and functioning – improved quality of life, employment, housing, education, parenting, relationships, and financial independence.
Any economic analysis of funding and costs of the ODTP should include analysis of the cost-savings of the program.
In 2015-16:
• 645,260 Australians use ‘extra-medical opioids’
• 104,000 Australians are dependent on extra-medical opioids
• 2,203 Australian deaths are attributable to extra-medical opioid use
• The total cost of extra medical opioid use in Australia in 2015-16 was $10.13 Billion. This includes tangible costs of $5.63 Billion including: premature death, healthcare, drug related crime, workplace costs and road crashes. Intangible costs include over 70,000 years of life lost. This study also examined the lost quality of life for partners and children living with a person dependent on opioids. There were more than 41,000 adults and 70,000 children living in these households.
Health and societal benefits and therefore cost savings of the ODTP include:
• Reduced drug use
• Reduced overdose
• Reduced mortality and morbidity
• Reduced risk of blood borne virus transmission
• Improved physical health
• Improved psychological health
• Reduced acquisitive crime
• Improved social adjustment and functioning – improved quality of life, employment, housing, education, parenting, relationships, and financial independence.
4. Propose improved service delivery arrangements for access to ODT medicines, with an aim of identifying an ODTP that is equitable, timely, reliable and affordable for consumers and stakeholders involved in the supply and delivery of ODT medicines and cost-effective for the Australia Government.
Terms of Reference Four
ODT Prescribers
• Members report a significant lack of prescribers. This hampers access to ODTP. Increased incentives for prescribers may increase interest and succession planning support would be welcomed by existing prescribers.
• The ODTP would also benefit from establishing structures or programs with a focus on recruiting new prescribers and pharmacists.
Innovative models
Innovative models for ODT service provision are needed, particularly in regional and rural contexts. Such models might include:
• NGO AOD Sector
Some NGO AOD services in NSW currently provide ODT stabilisation and reduction programs as part of their integrated therapeutic approach. These programs also offer ongoing wrap around support for consumers. NADA recommends expansion of these models delivered by the NGO AOD sector, with adequate funding to deliver required outcomes.
• Expand capacity to meet current and future demand
NADA recommends expansion of ODTP nurse practitioner models to improve access and increase the capacity of ODTP to meet current and future demand
• Improved flexibility of ODTP
Options for improving the flexibility of the ODTP include:
o provide sessional ODT clinics in existing AOD and harm reduction services
o outreach models – home deliveries, remote dosing clinics
o more flexible hours of public clinics to enable people to work
o shared care arrangements – between NGOs and LHD/pharmacies/GP prescribers
• Improved outcomes
Members and consumers have identified the need to provide wrap around supports for people in the ODTP that include:
o Transport
o Housing
o Mental health
o Health
o Child care/support
o AOD specialist services
o Employment
o Meaningful (to the client) activities
• Naloxone
An important adjunct to any ODTP is the provision of harm reduction strategies. With this in mind, consideration should be given to providing Naloxone to all ODTP consumers and their family and friends as part of the ODTP
• Reduction in administrative burden of ODTP
Bureaucracy is a major barrier. Members report spending 5-6 hours some days following up consumers, prescribers, exit forms, scripting, and transfers.
Decreasing the administrative burden when transferring care from residential rehab or custody to community based ODT is recommended.
Improved communication (including technological solutions) across all stakeholders is required to ensure timely delivery of ODTP, particularly when transferring care. Systems need to be compliant with privacy legislation and provide timely access between prescribers, clinics, pharmacies, mental health services, residential rehabs and LHD AOD specialist services.
• Workforce development
The workforce development needs of GPs, pharmacists, nurse practitioners, pain management specialists and other health professionals to support the delivery of a more accessible, affordable and efficient ODTP is required.
Support to other sector workforces including Needle and Syringe Programs, homelessness services, DCJ and others who regularly engage with individuals experiencing opioid dependence who may require additional support to access ODT.
• Members report a significant lack of prescribers. This hampers access to ODTP. Increased incentives for prescribers may increase interest and succession planning support would be welcomed by existing prescribers.
• The ODTP would also benefit from establishing structures or programs with a focus on recruiting new prescribers and pharmacists.
Innovative models
Innovative models for ODT service provision are needed, particularly in regional and rural contexts. Such models might include:
• NGO AOD Sector
Some NGO AOD services in NSW currently provide ODT stabilisation and reduction programs as part of their integrated therapeutic approach. These programs also offer ongoing wrap around support for consumers. NADA recommends expansion of these models delivered by the NGO AOD sector, with adequate funding to deliver required outcomes.
• Expand capacity to meet current and future demand
NADA recommends expansion of ODTP nurse practitioner models to improve access and increase the capacity of ODTP to meet current and future demand
• Improved flexibility of ODTP
Options for improving the flexibility of the ODTP include:
o provide sessional ODT clinics in existing AOD and harm reduction services
o outreach models – home deliveries, remote dosing clinics
o more flexible hours of public clinics to enable people to work
o shared care arrangements – between NGOs and LHD/pharmacies/GP prescribers
• Improved outcomes
Members and consumers have identified the need to provide wrap around supports for people in the ODTP that include:
o Transport
o Housing
o Mental health
o Health
o Child care/support
o AOD specialist services
o Employment
o Meaningful (to the client) activities
• Naloxone
An important adjunct to any ODTP is the provision of harm reduction strategies. With this in mind, consideration should be given to providing Naloxone to all ODTP consumers and their family and friends as part of the ODTP
• Reduction in administrative burden of ODTP
Bureaucracy is a major barrier. Members report spending 5-6 hours some days following up consumers, prescribers, exit forms, scripting, and transfers.
Decreasing the administrative burden when transferring care from residential rehab or custody to community based ODT is recommended.
Improved communication (including technological solutions) across all stakeholders is required to ensure timely delivery of ODTP, particularly when transferring care. Systems need to be compliant with privacy legislation and provide timely access between prescribers, clinics, pharmacies, mental health services, residential rehabs and LHD AOD specialist services.
• Workforce development
The workforce development needs of GPs, pharmacists, nurse practitioners, pain management specialists and other health professionals to support the delivery of a more accessible, affordable and efficient ODTP is required.
Support to other sector workforces including Needle and Syringe Programs, homelessness services, DCJ and others who regularly engage with individuals experiencing opioid dependence who may require additional support to access ODT.