Impacts to methadone patients from 60-day dispensing and associated changes

In my ongoing series which could be titled “How bad could things get” I want to talk to you about Opioid Management Therapy (OMT). In particular I want to talk to you about methadone.

TLDR version: the proposed funding model is actually a cut in funding. It is administratively impossible to get it off the ground on July 1. The proposed new process will add a level of complexity to each dose making it even more burdensome. Patients will miss out and pharmacies will reduce or cease providing the service.

In more detail:

OMT patients use a dose of medicine, administered on a regular basis, to treat their opioid addiction. This is most commonly methadone liquid (given daily), Suboxone (given daily or second daily) and less commonly a long acting injection.

Funding OMT through the PBS is absolutely brilliant. It is listed as one of the offsets or reinvestments of the monies stolen from pharmacy however it is currently funded by state/territory funding and a patient contribution. Moving it to the PBS just rearranges the funding.

Let’s talk about methadone. Methadone comes in a 200ml bottle. But it is NEVER issued in the original bottle. It is issued in a cup in the pharmacy for a “daily dose” which may be 2 ml or may be 30ml depending upon the patient. When the patient is stable, it is given as a daily dose for today, with a small bottle for at home tomorrow and sometimes for the subsequent day. These are called takeaways. Typically a patient visits the pharmacy on a Monday for a dose with a takeaway for Tuesday; Wednesday for a dose with a takeaway for Thursday; and then on Friday with two takeaways on the weekend. Any combination of daily doses and takeaways is possible; this is controlled by the prescriber in consultation with the pharmacist (who sees the patient behaviour) and the patient.

OMT is administratively complex. We are talking about the strongest drugs we dispense. Even the smallest dose could kill an opioid naïve patient (especially a child). Every dose and patient visit is recorded. At any point in time the pharmacy knows how much product is under their care; they can also identify who has dosed and who has not (essential for patients who end up in hospital; a double dose could kill them). OMT also presents some challenges – sometimes – with patient behaviour however most pharmacists acknowledge that their OMT patients are well behaved and the whole process is professionally and personally very rewarding.

State and territory funding models differ; we support hundreds of patients in the ACT whereby the funding is as follows:

• Product is supplied free of charge via a PBS funding mechanism (known as Section 100).
• Patient pays a daily fee, usually a week or two at a time and preferably in advance.
• Territory government pays a fee per dose monthly in arrears.

Technically the supply currently is outside the PBS (even if the product is supplied at wholesale via a PBS funding mechanism). I don’t really know the historical background to this; it has just always been this way.

Under the so-called reinvestment the pharmacy will buy the product – currently it is free. The pharmacy will receive a dispensing fee (as per a normal PBS script). The pharmacy will receive a per diem payment through an external mechanism. The total reimbursement is less than currently AND the pharmacy has to pay for the stock. Pharmacy will be $50 per patient per month DOWN. Reinvestment? Not likely. I know pharmacies are already reviewing their programs and seek to actively cut back the numbers of patients when the new system is introduced.

But there are other problems:

It is impossible to issue a PBS script to every OMT patient to be valid on July 1. Prescribers are already under duress; they CANNOT make this happen.

The current arrangements suggest that each patient will need their own 200ml bottle. Not practical. These products live in a safe which is of finite size. We decant into a larger stock bottle and dose out the smaller dose as needed using an accurate dosage device. It is physically impossible to carry a separate bottle for each patient (some stores have over 50 patients).

The administrative burden and new arrangements will require significant changes to software and reporting. There is little chance this can be achieved in 6 weeks.

The administrative requirements are large and require pharmacist time. The loss of staff from the massive hole in our dispensary income means there are no staff to run the program.

Bottles for take home doses are provided in the ACT. There is no provision for bottles in the federal program; again the pharmacy will be more out of pocket based on the need to buy the consumables.

Furthermore doses change. It is common to have a dose of 5ml with permission to vary up our down by 0.5ml per week (based on patient’s response). It is impossible to predict what a monthly dose total will be.

And the last point: pharmacies are already cutting their trading hours. Access for OMT patients is needed throughout the day including early mornings and late evenings so OPMT patients can have jobs and lead a relatively normal life. When their access is cut will they go without? Revert to heroin? Go to the hospital who will only see them between 12 and 1, but now have a waiting list of hundreds of patients?

The Office of Impacts Assessment summary states: the IA would have benefited from more recent public consultations on potential stakeholder impacts, particularly for small businesses and pharmacies in rural and remote areas. Moreover, where stakeholder impacts are difficult to ascertain at this point in time (e.g., individual pharmacy-level financial impacts), the IA would have benefited from a more detailed evaluation plan that outlines metrics and data required to monitor the impacts on stakeholders following implementation.

Herewith yet more evidence of a completely incompetent assessment process along with a pathway to chaos and carnage upon implementation.