5 June 2007

The pros and cons of pharmacy only opioid treatment from Melbourne researchers - coal face views

Drug Alc Review 2007; 26;2:143-152

Nielsen S, Dietze P, Dunlop A, Muhleisen P, Lee N, Taylor D. Buprenorphine supply by community pharmacists in Victoria, Australia: perceptions, experiences and key issues identified.

Dear Colleagues,

This large study examined pharmacists� impressions of prescribed maintenance opiates for addiction treatment in a large postal survey covering 75% of the treatment field in Victoria, Australia, relating to the treatment of about 7500 patients. It is probably the largest such survey in the world literature and had an enviable response rate with the diligence of the researchers using preliminary phone contacts and careful follow up. It may have been beneficial to have had further demographics, average dose levels, numbers of take-home doses (if any), swaps between methadone and buprenorphine, etcetera.

Both methadone and buprenorphine were available in 90% of the pharmacies involved in dependency treatment. The average had been involved for 7 years, treating a median of 16 patients each (range 1-150). Two thirds were metropolitan, one third rural or regional.

Regrettably, but consistent with other Victorian reports (eg. IDRS), the rates of reported diversion of supervised buprenorphine tablets were very high. Overall there were 33 episodes of suspected or confirmed diversion per month for every 100 patients treated. This occurred despite 82% of pharmacies crushing all doses before administration.

Sixty percent of all detected and conceded diversion episodes were stated to be for later consumption by the patient. Twenty percent said that it was to inject.

There were over 100 negative comments by pharmacists, more than half concerning diversion and administration problems. There were less than 20 positive comments from the 287 pharmacies surveyed. Most disappointingly, twelve pharmacists said that they would no longer accept buprenorphine patients due to the difficulties.

The authors speculate about reasons for the high rates of non-compliance. However, they do not question the nature and quality of the treatment being given, nor why the rates would be so different from other Australian states.

Dose levels may have been inadequate for some patients. Access to methadone, the only alternative medication, may have been limited or even discouraged. Take-away doses were very limited at the time of the study for both medications.

It is possible that some of the frustration reported by pharmacists was due to the practice of second daily (double) dosing which was strongly promoted in Victoria. Equally, universal crushing of tablets is time consuming and implies a lack of trust with patients.

Another problem with treatment in Victoria is that few if any dispensaries open early enough for labouring work hours. Hence, holding over some medication for the following day may be a temptation to diversion for those who need their dose before work.

The authors� defense of pharmacy-only treatment runs contrary to their own negative findings in this study. The authors do not make a case against a choice of alternatives such as public and private clinics, hospital, doctor�s surgery, mobile van dispensaries and jail-based treatment services. No single avenue of treatment is likely to suit all patient needs.

Hence the substantial black market reported from Victoria (and elsewhere) may well be due to a community need making a ready and willing market, possibly related to a lack of provision of accessible and appropriate services. The latter is not unique to Victoria, of course, and few jurisdictions to date have fully satisfied the need for opiate treatment services.

These authors are to be congratulated for exposing many major problems with the delivery of buprenorphine in Victoria (diversion, injecting, costs, expulsions, frustrations of health workers, etc). Further work must be done to determine why buprenorphine has apparently been so successful elsewhere as an alternative for those opiate dependent subjects who find methadone unsatisfactory.

In the meantime, it is essential that we all try to bring our own practices closer to the evidence base or �best practice�. There should be good access to a range of service delivery methods, including dedicated clinics; primary care community services for stable patients; no prejudice against methadone; no undue emphasis on 2nd daily dosing and importantly, flexible take-away dose availability (since diversion of a take-away dose is unquestionably safer that diversion of buprenorphine spat out of a patient�s mouth). Also, we should not forget adequate psychosocial supports and choice of treatment.

Comments by Andrew Byrne ..