Drug Alc Review 2007 26;4:411-416
The impact of community pharmacy dispensing fees on the introduction of buprenorphine - naloxone in Australia. Winstock AR, Lea T, Ritter A.
These authors have survey responses from over 400 NSW pharmacists about current and proposed prices for methadone and buprenorphine under various regimens including daily, weekly, fortnightly and monthly attendance. A figure of $31 weekly recurs with little variation according to the number of attendances until this reached one per fortnight when the lowest response was $19 per week.
These authors do not examine these fees in relation to other commercial aspects of community pharmacy, nor are we given an international comparison. Ideally, as with other medical treatments, those who are unemployed or indigent should be looked after in the public system. In many areas there is simply no alternative to pharmacy treatment since most hospital pharmacies steadfastly refuse to become involved. In the 1980s, the published recommended price in NSW was $5 daily �including counselling� ($35 per week). Pharmacists still charge approximately the same price which is a philanthropy without parallel in health care in my experience.
The authors state that the introduction of the bup-naloxone combination product: �permitted the revision of takeaway policies � and � the possibility of unsupervised treatment.� Only one of the 24 references refers to the combination product which hardly supports the contention that this constitutes a �new treatment paradigm�. They suggest a need for: �early dissemination of unambiguous information regarding the introduction of a new medication, especially where supervised dispensing through community pharmacies is essential to the provision of treatment. The potential impact upon the successful rollout of a new treatment paradigm that was developed to benefit stable patients in the community may be jeopardised when such processes are not followed.�
I would suggest that the only thing jeopardising this new treatment paradigm being rolled-out (hate those terms!) is a lack of evidence that it actually works in practice. There is a dearth of research on both the combination product itself and on (completely) non-supervised treatment such as is commonly used in France and England. This all makes the tone of the paper somewhat confusing since the benefits proposed for buprenorphine-naloxone are still theoretical.
These authors appear to believe that long term dispensing or administration of buprenorphine should be cheaper than traditional short term maintenance treatments and they seem disappointed with outcomes showing otherwise, at least for less than fortnightly attendance.
It is hard to be �unambiguous� about a new and untried treatment, and pharmacists of all people, know that dealing with addictions can be tough and unpredictable. Also, the new proposal assumes that doctors are able to distinguish which patient is going to be stable long term, yet there is no simple way I know of doing that. The best protection for patients may be the innate conservatism of Australian health care workers, sceptical of claims made for new drugs until proven in practice. It is indeed a �brave new world�, giving addicted patients medication without the continuing supervision of a pharmacist, nurse, psychologist or even a self-help or group therapy session. In fact, this �paradigm� flies in the face of the DSM definition of addiction, involving some degree of loss of control over drug use at certain times.
Another concern was borne out in a paper from Melbourne recently (Neilsen 2007) where administering buprenorphine as a sub-lingual tablet was associated with numerous reported practical problems compared with the use of liquid methadone. I wonder how many Australian doctors are prescribing unsupervised buprenorphine.
Comments by Andrew Byrne ..
References: 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. Drug Alc Review 2007 26;2:143-152