OPIOID agonist therapy – the use of methadone or buprenorphine to help people dependent on opioids including heroin and prescription opioids – is a life-saving treatment and needs to be normalised as a routine part of comprehensive patient care, according to the authors of a Perspective published today by the Medical Journal of Australia.
Dr Pallavi Prathivadi, a GP and PhD candidate, and Dr Elizabeth Sturgiss, a GP and Senior Research Fellow at Monash University’s Department of General Practice, wrote that “56% of unintentional opioid deaths now involve pharmaceutical opioids (as either sole drug or polydrug overdose), compared with 45% of deaths involving heroin and 23% involving methadone”.
“Despite this, methadone carries considerable stigma and misconceptions among clinicians and community members.
“The cost of private prescriptions, provider unfamiliarity with the medication and clinician reluctance to manage patients with illicit and prescription opioid use disorder are common barriers to opioid agonist therapy (OAT).”
Prathivadi and Sturgiss wrote that the profile of people dependent on opioids had changed.
“Historically, OAT was prescribed for people who illicitly use opioids, mostly heroin.
“Now, there is another at-risk population — an estimated 26% of patients in general practice taking long term pharmaceutical opioids are dependent.
“OAT could reduce opioid-related morbidity and mortality, and improve quality of life in this group.
“Furthermore, with increasing opioid prescribing restrictions and sanctions in Australia, opioid-dependent patients who are denied their prescriptions may instead seek illicit opioids, as seen in Canada, resulting in higher deaths.
“Restricting opioids for public health concerns means we must also ensure patients with opioid use disorder have safe and easy access to OAT.”
Currently, OAT medications prescribed by specialists or GPs require prescriber permits and are not covered by the Pharmaceutical Benefits Scheme in Australia. OAT medications are initially limited to daily dispensing, and people must attend the pharmacy each day to access their medication. Often prescribers and pharmacists require patients to agree to a set of rules and may require them to sign a contract for treatment. Patients are typically reviewed by providers at minimum 3-month intervals for comprehensive pain assessments and/or addiction review, and suitability for ongoing treatment.
“The processes involved in OAT prescribing and dispensing commonly occur entirely within a primary care setting,” Prathivadi and Sturgiss wrote.
“GPs could therefore play a leading role in recognising and treating opioid use disorder.
“About 50% of pharmaceutical opioids are prescribed by GPs, and one in five GP presentations relates to chronic pain.
“GPs already perform comprehensive pain and psychosocial assessments, which include type of opioids used, their quantity and frequency, episodes of overdose, concurrent drug and alcohol use, current and past treatments, availability of social supports, and patient beliefs.
"GPs could prescribe OAT as part of their comprehensive patient-centred health services, especially given difficulties accessing addiction specialists.”
Barriers to physicians becoming OAT prescribers include lengthy approval processes, additional provider training, and burden of regular updates.
“These restrictions signal to potential prescribers that OAT is difficult, dangerous and to be avoided,” Prathivadi and Sturgiss wrote.
“This system perpetuates a professional fear that OAT is too risky to prescribe; for example, there are concerns about medico-legal consequences or patient harms, including mortality. Yet there are similar numbers of deaths involving non-OAT analgesic opioids as there are involving methadone.
“International evidence has shown OAT prescribing is well within the capability of GPs, improves patient outcomes, and strengthens long term patient care.
“Therefore, major efforts including overhaul of the current administrative burden, development of diverse approaches to upskilling and changes in attitudes towards OAT need to be taken by professional and representative organisations and the GP community,” the authors concluded.
“We must accept OAT as the life-saving treatment that it is.”
- Cate Swannell