Depot buprenorphine
Jovi:
Okay. So good evening everybody and welcome to tonight's webinar, GPs and Pharmacists Working Collaboratively to Assist People in Opioid Dependence Treatment: Pharmacist Administration of Depo Buprenorphine. I am Jovi, your host for this evening.
And before we continue, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Island colleagues that have joined us online tonight. I myself am joined from Cammeraygal land on Sydney's North Shore.
I would like to introduce you to our speakers for this evening. Firstly we have Dr Hester Wilson. Hester is a GP and Chair of the RACGP Specific Interest Addiction Medicine Network. Hester has many years’ experience working with people with addiction issues in both general practice and specialist settings. She is also the Lead Clinician and the GP Liaison in Alcohol and Other Drugs Project in South East Sydney Local Health District, and she is also a Joint Lecturer and PhD Candidate in the School of Public Health and Community Medicine at the University of New South Wales.
Our second speaker for this evening is Joel Hillman. Joel is a Drug and Alcohol Clinical Pharmacist Educator at the University of Sydney. Joel has a passion for substance related care, accessibility and education, Joel also manages the New South Wales Pharmacist Administered Depot Buprenorphine Pilot. Welcome to both our speakers for this evening.
Now before I pass you on to our first speaker, I would like to go over the learning objectives. So by the end of this online CPD activity, you should be able to compare and contrast depot buprenorphine as a treatment option for opioid dependence and outline steps to commence a transfer a patient to depot buprenorphine. Secondly, identify patients prescribed depot buprenorphine who are suitable for community pharmacist administration. Number three, implement referral and communication models where appropriate between GPs, drug and alcohol specialist services and pharmacists to support quality patient outcomes. And lastly use a structured approach to review and assess patients who may have developed OD and the role of LAIB as OD treatment for the follow up activity. I would like to hand you over to Hester.
Hester:
Thank you so much. Good evening everybody. I am down here on Wiradjuri Country. It is very, very cold. I have got a nice little back drop here, but that is not really where I am. But I have got my puffy jacket on and welcoming you all here tonight. And thanks so much Jovi for the introduction, and we are so fortunate to have Joel with us tonight, as well as all of you.
So first of all we just wanted to find out a little bit about you. So just a poll to you know, what best describes your profession? Just so we can get a bit of a sense of who we have got in the room today. At the moment there are 86 of you attending, we will probably get a few more, and we have got GPs, pharmacists around about 50:50, it looks like, a few others. Intrigued by what the others are. If you are an other, if you want to put in the Q and A what your profession is, that would be totally brilliant. So what we have got is, we have got 45% GP, no, 47% GP, 45% pharmacist and a small percentage of people as other. So as I say, if you are an other, I would love to hear what your profession is. So it is really brilliant that we have got GPs and pharmacists here because the focus of this is absolutely for you guys, it is around how we can work effectively together to ensure, you know, really good care for our patients experiencing opioid use disorder or opioid dependence.
So, we have got these things there. So, just getting out of here. Just first because I am a clinician, I always think clinically, I am going to use a couple of examples that are kind of composites of people that I have seen. So a 51-year-old man who lives with his wife and two teenage kids, and some years ago he had a workplace injury, quite severe with multiple pelvic and sacral fractures, and he has not worked since. This has really had a huge impact on his life. He has chronic pain, daily pain, anxiety and depression as a result of the pain condition, and it is really affecting his relationships. He has moved to your surgery four years ago, and after he was seen in the emergency department after being found unconscious by his wife. At the moment he is on oxycodone slow release 160 milligrams, diazepam 10 milligrams a day and pregabalin 150 milligrams a day and duloxetine 60 milligrams. He was seen by a pain specialist who very helpfully suggested he needed to stop his medications and he attends your service, your practice, requesting help. So he wants help with his medications. And when you are doing your assessment, one of the things that you find out is that over time, his oxycodone dose has increased. So he had started off on, you know, a quarter of what he is on now. So 40 milligrams, or 20 milligrams twice a day, and has ended up on 160, which is an oral morphine equivalent of roundabout 210 milligrams, something like that, 220. And he is still in pain, it is still waking him at night. It is still troubling him during the day. He tries really hard to take his medicines as prescribed. He has been prescribed the 80 milligrams twice a day. He tries hard to take them as prescribed, but some days takes extra and then runs out and experiences nausea, cramps and diarrhoea. So the first question, another poll for you guys. Is Sam opioid dependent? Does he have an opioid use disorder?
So we have got almost 70% of people. Okay. So it is 75%. We will share those results. So the majority of you, 84%, are saying yes, a small proportion saying no, and 12% saying unsure. Fantastic. So let us have a look at what opioid dependence actually is. Moving on to the next slide.
And one of the things that is confusing about this and really it is the reason that I will always say opioid dependence and opioid use disorder, is that there are two nomenclatures that you can use, either the DSM, the Diagnostic and Statistical Manual from the Australian Psychiatric Association or the ICD-11, which is the International Classification of Disease. So IDC-11 uses opioid dependence, whereas the DSM uses substance use disorder, or in this case it is an opioid use disorder. And they are very similar. They are just set up slightly differently. And what you will see with the IDC-11, which is on the on my right, I think it is your right as well, a black triangle that looks at substance dependent, harmful, episodic and hazardous, is that it actually breaks it down into more categories. Whereas the substance use disorder has put the two substance use diagnoses of DSM-4 and DSM-5 into substance use disorder. The really nice thing about substance use disorder is you do not have to have tolerance and withdrawal. And in fact, if you are looking at the way that people can present, having tolerance withdrawal does not always mean that you have a de novo substance dependence or a substance use disorder. But when we are looking at it, it is that impaired control. He is trying to keep it under control, but he is taking extra because the pain is really troubling him and then he runs out. He is craving the medications. It has kind of taken over his life, the salience, has become very, very important. He is very focused on it, he needs to get his medications. Failing to carry out other tasks, we do not know much about Sam, but he has certainly not worked. So this injury has had a really significant impact. The physiological features, tolerance, withdrawal. So tolerance needing more for the same effect which he is experiencing, and withdrawal which he is also experiencing potentially with the nausea and the vomiting and the diarrhoea. But not essential for diagnosis and we will come back to this.
With the DSM-5, we have got 11 criteria that fit into those five that I have mentioned, and it is also mild, moderate and severe. And the really important thing for us with someone like Sam is that he has chronic pain. This is really significant. This has had a really significant impact in all parts of his life, his mental health, his physical health, his work health, his work life, and his family life and his, you know, social life. And people that have chronic pain who are prescribed opioids, we are questioning the role of prescribed opioids, but not everybody that has prescribed opioids is going to develop a de novo opioid dependence or an opioid use disorder. They may have some tolerance, they may have some withdrawal, but that does not necessarily mean that they have developed a disorder. Moving on to the next slide.
So one of the things that is clear with Sam is that this pain is not responding to opioids. And this is a really good conversation to be having with people. You are on this big dose of opioids and you are still in pain. These opioids are not working. There is this kind of idea that if you just keep increasing, increasing, increasing. It is not opioid responsive. And yes, he has physiological dependence. But what evidence do we have that he has developed a de novo diagnosis of opioid dependence or opioid use disorder? And not everyone who develops an opioid dependence or an opioid use disorder will need opioid dependence treatment. But not diagnosing it is an issue, and opioid dependence treatment is a highly effective treatment, really important, and really important for us to know what this treatment is, to acknowledge it, and to look at whether in our chronic pain patients it may be an option. Certainly for someone like Sam, we will come back to him about his story to give you some more information around what that story held for him. Moving on.
Okay, so here we go. We have got another Sam. We are moving on to this straight away. So he is our 51-year-old, oxycodone is increased, still in pain, trying hard to take as directed, getting withdrawals, so tolerance and withdrawal very clear. You suggested Sam has a physiological dependence, and that is where I would be with this man, with this information, and work with him to cease the diazepam, the pregabalin and cut down the opioids, working towards ceasing. He is able to stop the diazepam and pregabalin. Tick really, really terrific. He is able to get his opioids down to 60 milligrams twice a day. But he is kind of stuck at that level. Lots of cravings, running out early, lots of withdrawal. He is just not coping. And he tells you that he is getting extras from a friend and is still in pain. So we probably agree, and there were some people that were unsure as to whether he was opioid dependent. I think he is, and I think he does have an opioid use disorder and opioid dependence. Does he need opioid dependency treatment? Let us have a look at what you think with a poll.
So we have tried to de- prescribe, we have tried to cut down. Waiting until about 75% of you. A few more. Okay. Almost there, 73%, a couple more. Beautiful. So if we end that one and just share it.
Look I think, he would be a candidate for opioid dependency treatment, and I understand there are some of you that are unsure and a few that say no, look he does not need treatment. What I would say to that is that this is certainly a treatment option that I would be discussing with him. And really talking to him about the potential benefits of this treatment and really helping him to understand the role that it could play. I think it is really important to acknowledge that treatment for opioid dependency does not treat his pain. He still needs pain treatment. And what we know is that his pain is not really responding to opioids, but what he has very likely developed is an opioid use disorder or opioid dependence. And the treatment that we have for that is really effective and can really help people get their lives back on track, but he does need treatment for his pain. Moving on to the next slide.
So what are the treatment options for opioid dependence or opioid use disorder in New South Wales? So we have methadone and buprenorphine. Now methadone has been used for the treatment of opioid dependence or opioid use disorder since the 1970s. In Australia, buprenorphine became available in the early 2000s. It came out first of all as buprenorphine mono, a sublingual tablet, just buprenorphine. And then in about, and if I have got this right, about 2006, I think, it came out with the buprenorphine naloxone combination as a sublingual tablet or a film. Now, methadone is a terrific medication for opioid use disorder or opioid dependence. It is a pure agonist. So it acts like other opioids. It is somewhat idiosyncratic as a medication and so it is a higher risk medication than buprenorphine. So in New South Wales, and we may well have some attendees from outside New South Wales, so you need to check what your state guidelines are, but in New South Wales, methadone generally, when you are put on a program with methadone to manage your opioid dependence or opioid use disorder, you generally need to attend a dosing point, a pharmacy or a clinic at least three times a week. It depends on how well you are and how much support you need. But it is a medication that has some risk, and certainly if you become accredited, you can prescribe it. Also as a non-accredited prescriber you can also prescribe it, but it would tend to be people that are very, very stable and working in conjunction with your specialist setting to some extent.
Buprenorphine mono was the first buprenorphine that came out as sublingual tablet, and then the naloxone combination with buprenorphine has really taken over. The film is much easier for people to take and it also, you know, has some benefits in terms of risk of injection and making that a little safer in terms of people not injecting. Buprenorphine is a partial agonist and it has a really excellent safety profile. It is a really safe medication. So if you compare it to things like fentanyl or oxycodone or hydromorphone, it is so much safer. It is a really safe medication. And in 2018 we saw the long acting injectables which is what we are looking at really tonight more than anything else, a buprenorphine long acting. And there are two brands and it can either come as a weekly dose or a monthly dose. Prescribing, you do need to get an authority from New South Wales and that is going to slightly change in the future, but you still are going to need to fill in forms so that New South Wales Health knows that you are doing this. As I said you can become accredited, and there is the www.otac.org.au which has run through Sydney Uni that have courses. There is one which is just for looking at buprenorphine and another which is looking for buprenorphine and methadone.
Unaccredited prescribing, any GP with S8 rights or any doctor with S8 rights, currently can prescribe for 10 stable people on methadone and commence and continue the care for 20 people on buprenorphine. So those numbers might change. We will see how that ends up with the review of the Poisons Act. But at the moment you as a non-accredited prescriber if you wish in your practice setting can prescribe for 30 people, 10 on methadone and 20 on buprenorphine. Moving on.
Let us look at Julie. She is a 51-year-old woman who lives with her husband and two teenage children in stable housing. She is working part time now. You have known her for a long time. Workplace injury 15 years ago, also had some chronic pain, anxiety, depression and relationship issues, but also has a previous history of heroin use in her early twenties. She was commenced on methadone before her first pregnancy and ceased this after the pregnancy completed. Having a bit of a stressful time, relapsed back to heroin two years ago, and went and got help in a local drug and alcohol team, and they started her on buprenorphine and transferred her through to one of the long acting buprenorphines, Buvidal 64 milligrams monthly. And the injections are being given by the local pharmacy. So she is being managed in the specialist setting. Her injections are being given at the local pharmacy and she is now stable on this treatment. Still smoking, no other drug use, no other medications and her pain, actually she is managing it very well. So she comes in to your practice. As a GP, you know her, you know her family, and she says can you take over the care? I do not really want to keep going to the specialist drug and alcohol clinic to get my prescriptions. They do not need to see me. They are really happy. They have suggested that my GP could do this and are really happy for you to take over. Can you, you know, would you like to take over my care?
So the question that we have and I hope we have a poll associated with this Jovi is, would you feel equipped as a GP to take over her care? And for our pharmacists in the room, she is already being dosed by pharmacist. But if you want to put in there, do you feel equipped to actually undertake that administration in the pharmacy setting?
So once again, getting up to 75% if we can. We are up to 62% for both the pharmacists, GPs and the other. Think about do you feel equipped to take over her care as a prescriber or as a pharmacist or in administering and dispensing? Okay. We are almost there. We are almost at the magic 75%. Just a few more to put in if we can.
Okay. I think we have stopped at 72%. How about we end it there and share the results. So I am totally impressed. Half of the people in this audience are saying, yes, I would feel equipped. Fantastic, that is brilliant. There is another just under 50% that do not feel they are equipped or on unsure. Hopefully by the end of this conversation with Joel and myself, you guys will feel a lot more confident around your role and how you can undertake this. Moving on to the next slide.
I am going to hand over to Joel.
Joel:
Hi there. I am absolutely delighted to be here talking about my favourite thing which is depo buprenorphine. So as Hester was saying, buprenorphine is really, really a very safe drug. It has that sort of mixed agonist antagonist or partial agonist activity, but also this really, really high mu receptor affinity. So what that means is that the drug binds really tightly to the mu opioid receptor and it actually then kind of blocks that receptor from other opioids, and I will come back to that in a minute. So there are two formulations as Hester mentioned. They are both subcutaneous, and I really want to emphasise that because there have not been any reports of any accidental intramuscular administration, but it is something I live in constant fear of. But they are subcutaneous as either weekly or monthly formulations there. They are really, really, really well tolerated and really, very efficacious.
So some benefits I guess from both prescribing and administering is that there is not really a diversion risk. So not only do clients get a lot of flexibility, but also frankly I find them quite easy to supervise, this patient population. So the clients get a lot of freedom and flexibility. It allows them to, you know, engage in things like work and travel. You do not have to see me every day. And from the 1st of July with our PBS changes which are still a little bit complicated, but clients will end up paying less than they were before, is effectively the summary there. And next slide please Jovi.
Hester:
I think, sorry Joel, it is important to acknowledge that from our point of view, that these changes July 1 of this year are historic and amazing for this group of patients who have been paying a lot of money for their treatment to date. And it is a historical inequity that our federal government is shifting. Also to acknowledge that there may well be people in the room who have been providing this care, doing these injections, you know, and charging for it either in the GP or the pharmacy setting and certainly these shifts on July 1 will change that. We do acknowledge that for some people that is a real challenge, you know, but it but certainly if we look at it from a consumer point of view, it means that people are not paying 160 or 200 dollars a month. They are paying 7.30 if they have got a healthcare card or 30 dollars if they have not, you know, so I do acknowledge, want to acknowledge the shift that this is making, and the way that it may well be affecting some of our colleagues that might be on this webinar tonight, but really to acknowledge that it actually is in the long run, it is going to be a really good thing.
Joel:
Yes, I absolutely agree that I think in about a year’s time this will be absolutely amazing. And I do really, really want to underscore that in my opinion, the fact that OTP clients pay so much money for a chronic health condition, sometimes 15 plus times more than any other chronic health condition in the country, it really is quite gruesome really that, you know, clients on OTP have paid so much money for so long. And I really, really do also want to echo what you are saying about the benefits to clients that this will have. Obviously some teething stuff to be sorted out. But you are absolutely right that in the long term this is a really huge win for clients I think.
And so this is a table that I really enjoy showing people, but it is just to have a bit of a look at the differences between the plasma levels that can be obtained with different formulations. Now this actually does not show every formulation and dose strength. But if we look there on the left there, we have got some sublingual formulations and we can see that 24 milligrams is not the highest dose. But if we just consider that 24 milligram dose there, that that sort of average concentration of buprenorphine there, you can compare that to on the far right there Buvidal, which is one of our brands of buprenorphine, and then that one there that is Sublocade. And Sublocade and buprenorphine, I would say their main difference is really in the plasma concentration that can be achieved.
So with the monthly formulations of Buvidal and Sublocade, they are administered in a substantially similar way. They are both subcutaneous once monthly. But they can result in really quite different and quite distinct responses in the client in terms of how much buprenorphine they have. And on the right there is a really beautiful guide. I really, really like this guide that New South Wales has put together, and I really commend it to anyone who is interested. It is quite a good guide in my opinion. Next slide please, Jovi.
Hester:
Sorry. Sorry, Joel, I just want to acknowledge that Mehdi has put a question or a statement in, and he has said no in the poll to taking over Julie's care and I totally understand. There are multiple bureaucratic issues and paperwork that he faces and also this issue that perhaps GPs are blamed for when things go wrong. Medicare rebates are an issue and lack of time. Totally acknowledge those experiences on the part of my GP colleagues and look, you know, we are all busy and pharmacists are all busy. I guess the thing that I want to point out with this is that if we can use the shift that is happening on July 1, and there are some changes that will happen to the Poisons Act, we are not sure quite what they will look like, but they may actually hopefully decrease some of the bureaucratic stuff for GPs. But it is working collaboratively together that we can ensure that we can do a really good quality care that does not take too much time, that is within our financial resources, you know. So really, really do want to acknowledge what Mehdi is saying and there are some complexities there, but hopefully by the time you finish this, you will have a sense of how you can do this more collaboratively in a way that works.
Joel:
Yes. I absolutely agree that there is quite a lot of pressure on GPs and on all primary care. And I guess there is some really interesting research being done in America at the moment on what they are calling low threshold access to buprenorphine. And so the Americans are looking at changing who they allow to prescribe buprenorphine. And another example might be say France, which I am sure many people know has a relatively liberal approach to prescribing OTP. So there are some other approaches internationally and potentially, hopefully, we can take what is useful from some of those.
So I wanted to just talk about two interesting reports here. The one on the left there is actually from Instagram that a mate of mine actually sent to me that she just found and said, oh, isn’t this the drug that you work with? And I was like, oh, actually it is. So I thought what was interesting about this is that, you know, this was on a social media platform that has nothing to do with drug and alcohol. It is sort of like a public meme sort of Instagram account, but Buvidal is enough of a good thing and well, you know, viewed so positively that it is making its way into mainstream media. The report there on the right is a client with lived experiences talking about his experience receiving depot buprenorphine, and I really think what is quite interesting here is that both of these clients, both of these people here, are talking about the idea that the buprenorphine is giving them a kind of opioid blockade effect. And I think that is really interesting because it is something that a lot of clients will describe and I think also from my perspective and maybe from Hester yours as well, but I actually think this is a real benefit of buprenorphine, but specifically of the depot. And one thing that I find is that this tends to help make clients quite easy to manage, but also that it maybe is not necessarily right for everybody of course, there are some clients who for example are not interested in not being able to use. There are some people who really like the ability to skip a couple of doses so that they are able to use, and maybe buprenorphine is not appropriate for that person. But I think it is quite interesting here that people describe very commonly this experience of the opioid blockade effect. But also though that clients have very positive views, and I will come back to that with some research later on. Next slide please. Jovi.
So what I want to have a quick chat about was our pilot that we have been running here in New South Wales. So this has been running now for about a year and a bit, where we have been looking to train pharmacists to administer depo buprenorphine. The pilot also paid for the treatment during that time. And kind of the overall goal here is to not only, you know, facilitate movement of these clients into a community setting, but also to really reduce some of the pressure on some clinics. So you know, my clinic that I used to work at, Royal Prince Alfred, all my nurses do from dawn till dusk give the depot over and over and over again. So back to the pilot here, it was a Ministry of Health partnership with PSA, the Guild, and the University of Sydney and we have gotten a really good number of depots given recently. It is about 460 depots given to about 110 clients. And we have got some really, really great research coming out of it. And also what we are trying to sort of put together is a bit of an idea of what pharmacists will need to know to do this process and also to get a bit of a model of care going, which I will also be very interested in everybody's opinions on later. Next slide please, Jovi.
So in terms of what that training involved, we sort of developed it here at the University with the input of some wonderful specialist physicians, including my esteemed colleague Hester here, some pharmacists and drug and alcohol nurses as well. The entire course is about two and a bit hours online with a written assessment and then also involved some dummy injecting kits, plus minus some clinical observations. So it involved a number of different domains there, some things around the drugs and their use and also the management of problems associated with them, for example, things like overdose, the use in special patient populations and also some really, really important stuff there around the social interactions with these clients around things like appropriate and safe language for people with lived experience using substances, but also things around flexibility and opportunistic care and also some things around screening and referral. So this is hopefully going to put together a bit more of a formal process for how pharmacists will develop these competencies moving forward. Next slide please, Jovi.
So some really cool stuff in my opinion. Here is some stuff that is been said by some of our clients. So this is some of the research that is come out of our evaluation here. I do want to flag though that this is quite preliminary and in fact the pilot is still running, but this is some initial stuff from some clients, some clients who have been really very happy there. I quite like this one. “I cannot fault them in any way. I am really, really happy with the way they treat me. They are really respectful”. There has also been some really interesting stuff around the clients’ experience moving away from the public clinic setting. So there is quite a lot of research done on clients’ experiences in a clinic setting versus in a community setting. And I do want to emphasise that this is talking about a public LHD type clinic rather than a GP clinic. But there is a lot of benefits that clients get from being away from that public clinic setting, mostly around contacts with people that client would like to avoid, and also with that maybe a bit more personable interaction with somebody who maybe you have a bit of a closer relationship with, you know, a general provider that you have in the community as opposed to a rotating group through the clinic. Next slide please, Jovi.
So I do not think anybody in drug and alcohol would be surprised to hear that there is quite a lot of stigma involved in every element of care for drug and alcohol. And I do want to point out that of course there is a little bit of development that we could be improving on, in stigma in all of our settings. But also that some clients have found that the community setting has been quite positive in their reduction of their stigma, which is great as well. And some other kind of themes came out around the cost concerns, and this was before the PBS changes were announced and formalised, but obviously I really wanted to draw your attention to that second one about the cost concerns, that the clients recognise that the clinic setting has problems associated with it and that even if a client can get the medication and treatment for free, some clients would in fact rather pay privately to avoid the clinic setting. And some really good themes there coming out around convenience as well that clients really enjoy the connection to, you know, their local, getting their treatment in a local setting. And I think that is useful there because there is a good bit of research around barriers to treatment in drug and alcohol and that convenience and you know, accessibility, are absolutely central to supporting drug alcohol care going forward. Next slide please, Jovi.
So these are some quotes from our prescribers who are all physicians here. I have not had a chance to speak to any nurse practitioners. But in terms of what prescribers think about the depot and I am sure Hester will have something to say as well, is really that clients have, sorry prescribers, sorry, have really very positive views of depot buprenorphine and I do as well. I think in particular that comes around the safety and practicality for clients in that first quote there, but in particular that safety element, that from a prescribing perspective if your client has quite a large quantity of buprenorphine in their system because of that opioid blockade effect, clients are relatively shielded from the effects of other opioids. And it is certainly not a complete effect and it does depend a bit on the saturation of buprenorphine, how much buprenorphine that person is on. But I really think that is a real central part of these depots is the safety, and kind of the peace of mind for the prescriber effectively, that if you have a client on a depot that while it is certainly not a fail-safe, it really is quite safe and this last point down here as well about that it facilitates a bit of a cleaner or neater interaction with the client because you do not have arguments about things like takeaways or intoxication. So and then of course that point around avoiding undesirable contact with people that that person might be trying to avoid. Next slide please, Jovi.
This is a bit about the prescribers’ experience of the actual pilot. So these are physicians prescribing into community pharmacy. So mostly prescribers find this pretty easy, did not really have any problems. I do really want to emphasise, and I will come back to communication, that these prescribers were pointing out how important it was to keep very close communication in particular at the beginning when things are still sort of being worked out, keeping in really close contact with both the client and the pharmacist, so that everyone sort of is able to get in touch with each other if there are any problems. Next slide please, Jovi.
So in terms of where we are going from here, we are sort of wanting to put together a bit of a model of care and I might even call it may be like a best practice guide for how this arrangement should work, or could work, between a prescriber and a community pharmacist administering it. So the kind of things that we have got in that at the moment are around the requirements for the pharmacy and the pharmacist, who does what, kind of the scenarios in which referrals might occur. So there might be a client who is already very stable on a depot that is just being transferred, changing their dosing point. It might be, you know, a person converting from Suboxone onto the depot or there could be other scenarios as well, and some things a bit around treatment planning and collaboration. So what I guess I would be really interested in doing a bit of a call out for, is if there is anyone on the call who would be interested in talking to me about this model of care document, about how this model of care should look moving forward, we would be really very interested in talking to you, because obviously we want this document to be useful to clinicians and to really provide what people need to have in these kind of collaborations moving forward. Next slide please, Jovi.
Some things around how this can be facilitated, some things around collaboration. I have got some research down the bottom here a bit around pharmacist and physician collaboration. But really what we all want is the same thing. We all want good patient outcomes and we all really, really want good communication. I think it is really important that communication goes both ways and that people are accessible to each other. It is not necessarily any particular designation of being available. People want to be able to access each other and know who is doing what, and be respected for that. And that collaboration really is built on knowing who is doing what in advance, and that kind of agreement in advance, and then also that really, really being fundamentally about communication. And so I have mentioned communication a number of times, and I will probably say it a few more times. But I think that that is so important really there, that not only that the client knows that they are able to get help from both providers, but also that providers can get in touch with each other to confirm that things are going well, and also a pharmacist can get in touch to make sure the prescriber is you know, keeping an eye on what is happening, and can give advice on management of issues. Next slide please, Jovi.
So I will invite Hester back as well if she has anything to add on to this. But opioid use disorders are chronic and relapsing, that these are sort of long term situations, but we will be looking after clients for a large portion of their life, if not the majority of their life. And so we have got a really good opportunity to facilitate that care collaboratively, and some things about how that might look is a bit of a dedicated and reliable way of communicating. So Hester, I think we were talking about it in our planning that, you know, the frustration that can come about from trying to get in touch with somebody and not being able to, or you know, for a physician not being able to check that a dose has been given, or a pharmacist not being able to confirm that a clinical situation is acceptable, all of those kinds of things. So having a pathway that is reliable, but also maybe considering something that is dedicated, so having a way that you know that you can get in touch with another person.
Some things that I think are really supported by the literature are around written plans, so deciding in advance who is doing what and under what circumstances things are to be done. And also there are potentially, if you have maybe a large group of clients or particularly complicated clients, case conferencing I think is a really good way of handling those. Another thing as well is what information do you as a prescriber for example, want? What do you want us to tell you? And if you tell me in advance what information it is that you want to know, that will ensure that I can provide it in a way that is useful to you. I think another issue as well that I think is important is this escalation pathway, being able to access a prescriber when an issue is occurring or having a pathway to seek additional care, because of course, a pharmacist can contact, you know, DASAS or send a patient to a hospital. But obviously involving the prescriber is a much preferred way of doing that. So as well, this last point here a bit around clinical context, the idea that I want to be able to support you as the prescriber and the more information and context that I have for our mutual plans, the better I will be able to support that. So just making sure I guess that if there is anything relevant that, you know, that you want me to be looking out for, or you want me to be assisting you with, that we discuss that in advance so that I can keep an eye on that for you as well. Did you have any thoughts on any of those, Hester?
Hester:
Yes. So totally, totally agree with everything you are saying, Joel, and certainly as a GP prescribing opioid dependency treatment, methadone, buprenorphine, you pharmacists are absolutely core to this, to support the people that I am seeing, you know, working part time, it is really great to know that that person has a therapeutic alliance with the pharmacy and the pharmacist. And it is not just the pharmacist, sometimes it is the pharmacy assistants and the other staff in the pharmacy as well, that is incredibly important. Pharmacists see my patients more than I do, and so they can alert me if there are issues or if they have got concerns. And so I work with a number of different pharmacies and pharmacists. And you know what I am really keen on and what I set up with them is, what is going to work for you and what is going to work for me. And it will be different for different prescribers, different situations, different pharmacies of course. But you know for example, the pharmacies that dose my patients do have my mobile number so that they can call me out of hours if needed, and I will take that call. And they rarely do it and I know it is for good reason. And so we set that up beforehand so that I know that my patients are getting a good service and that we as the pharmacy and pharmacist and GP can support each other. I could not do it without you guys, you know, and I would not want to, it is such an important part of the team with complementary skills that support each other and really important.
In terms of case conferences, absolutely agree. You know, so once again, GPs are very fortunate that unlike pharmacists, we can charge a Medicare item number for case conferencing as long as we have got the number of people that we need in that case conference. The same thing for your GP management plan and your team care arrangement. You know, this is a group of people that have a chronic illness that is quite complex. Sometimes they do need ongoing care and they absolutely are appropriate for a chronic disease management care plan, team care arrangement, case conferencing and for those that have mental health issues, a mental health plan. So certainly both the patients that I alluded to before would be appropriate for mental health plan, you know, but I cannot agree more, you know, have those conversations with your GP, with your pharmacist, and sort out what is going to work for you. And make sure that you do have that pre-existing relationship so that, you know, what will happen in my practice is, if a pharmacist rings up and says oh, look I just need to talk to Hester about one of her, you know, her buprenorphine clients, the receptionist will put it through to me, you know, and I will take that call. I will interrupt a consult to take that call because that works for me. Other people may say, look it has got to wait until the end of the consult, I will call them back, you know, but just really you need to work out what is going to work out for you guys and written communication is great because once again it goes into your clinical file, whether that is in the pharmacy setting or the GP setting. So I cannot emphasise anymore how important that is.
I guess the other thing I was thinking Joel, just as you were talking about that, is that you know, the long acting injectables are fantastic for many people, totally, totally support that. But I would hate to see patient choice taken away and there may well be people who do not want to have an injection for whatever reason and want to continue on their methadone or want to continue on their Suboxone because it is working for them. Yes, so really want this to be very client centred, very patient centred, in a way that supports them to have good outcomes, and we are very fortunate to have some treatment options. You know, the long acting injectables are fantastic. I want it to be a choice rather than the only option. But I do acknowledge that in some settings and particularly in rural regional settings, sometimes it is the only option because there are not other options available, and it is a great thing, you know, people want to go overseas, they want to go on holidays. They want to not come into a clinic very often. This can be absolutely fantastic for them.
We do have a few questions coming up. Mehdi is saying, being removed from November and also mental health plan usually charge out of pocket. Yes, okay. So there is some issues around the Medicare and also the Medicare freeze and the amount of money, look that is an ongoing issue for us. Not all psychologists will charge or maybe your patient can afford that. It depends on the situation. I do acknowledge that.
Anonymous attendee has asked, should pharmacists refer a patient to their GP or the specialist for opioid dependency if the pharmacist believes the patient will benefit from long term opioid treatment? Okay. I think that that is an individual case. Joel, I would love to get your sense on that as a pharmacist.
Joel:
Yes, it also is individual. I mean obviously I am of the view that the GP is at the centre of the web of care kind of model and so I would, if a patient has a regular GP, I think going through that GP would be my optimal approach to that. But obviously also, you know, a service like a drug health service where I used to work over at RPA, that is sort of a service is really, really well suited to care for people who are in extraordinary need. So you know, if a person is, I do not want to suggest that, you know, that there is, you know, a safe level of opioid misuse, but a person who is having some trouble with opioids, that is maybe a different situation to somebody who is injecting, say, four or five grams of heroin a day. And so, you know, maybe there might be a situation where GP might refer a client on directly to a service. But I do really think that going through a GP would be my preferred approach. What do you think?
Hester:
Yes, look, I think I would offer those options, so that if I know that the person has a good relationship with their GP, you know, as a pharmacist I would probably be saying go and see your GP, do you want me to give them a call? We really want to make sure that you are doing well. I am worried about you. There are drug and alcohol options, you know, and you can go to either. How can I support you? So it really needs to be person-centred, and look Joel, I agree that, you know, it does depend on the level of risk ,and there are different levels of risk, you know, but ideally working collaboratively with the person and with the services that they are engaged with and have a level of trust with, is really important.
I wanted to come to anonymous attendee here says, what is the benefit of having the weekly dose over the monthly dose of buprenorphine? What do you think are the advantages? What have you seen?
Joel:
Well, one approach that I see a fair bit is that the benefit of the weekly formulation is that you can compress the number of doses very quickly. So there is a sort of a general rule of thumb that about four to five doses of a formulation of the depots will get to steady state. So something that I see quite a lot is prescribers will give a weekly formulation compressed, so at the minimum interval which is every five days, and give a number of doses very quickly, and that allows us to kind of like shunt into the steady state quite quickly, and then convert over from there into the monthly. Another thing is that it allows quite a fine titration of doses.
Another thing I guess is that similar to what we were saying before about being patient-centred, I had a client at RPA who would turn up pretty much every day, even if he did not have a depot due because it was a social engagement for him as well. So he would turn up once a week for his injection and then he turned up pretty much every other day as well to say hello. And so we offered him the monthlies all the time and he was saying, oh, I do not want them, I want to stay on the weeklies. So I guess some people have those preferences and that is fine. But I guess if it was up to me, I reckon I probably would go the monthlies. But it is up to the individual, absolutely.
Hester:
And certainly if you are worried about someone's mental health or other stuff that is going on or they need additional support, the weekly can be quite a good way to continue seeing people for a period of time, you know, but yes, patient preference is important there. And I agree with you Joel, if I was on it, I would want the monthly so that I could get on with my life. But you know, as I say, for some people they do not want to have the injection and that is okay, we have some treatment options.
I wanted to come to anonymous attendee again. Is it beneficial for Panadeine Forte dependent patients and also how would you dose methadone with buprenorphine? Huge questions there. Look, Panadeine Forte, you are talking about codeine, it is a prodrug, it gets converted to morphine. So certainly people who have become dependent on codeine can absolutely benefit from treatment through opioid dependence treatment. It really depends on what dose they need. And quite often people with codeine will have a dependency, but it will be a lower dose of morphine. And so it may be that they do not need the dose that you get through the long acting injectables, and generally with that group I would start them on a lower dose sublingual buprenorphine. But I have had some people who have settled really well on an injectable in the longer term. Joel, have you had any experience with that group?
Joel:
So sorry, I was actually just reading the Q and A there. Can you repeat that one for me?
Hester:
I am sorry, I am just looking at the Q and A as well. It was just about the role of the injectables, the long acting injectables, in codeine dependency.
Joel:
There is actually really good research on the areas that the depots can be used in. There is a really good Cochrane review on the use of buprenorphine in prescription opioid dependency and also in non-pharmaceutical opioids. So things like, poppy seed tea, all kinds of things that buprenorphine really has evidence across a whole spectrum of opioid dependence. And I really favour buprenorphine. And I think I would say, my view would be that in about five years, I would see a very significant percentage of OTP clients being on the depot. And I mean, as you say, of course, the reason that we keep the other ones is that there are people who will want and need different approaches. So methadone, I do not think is in any danger of going away yet. But I really reckon that buprenorphine is appropriate for a really large group of people irrespective of the opioid on which they are dependent. But in the specificity of prescribed opioids, I really do think that involving that prescriber or communicating your concerns with that prescriber are really key.
Hester:
Absolutely. And certainly we have got the support of a tool like Safe Script to really help us with our patients work out what is happening and what is the best option for them. Coming to the second part of that question is, how do you dose methadone and buprenorphine? There is a lot in that question. So I would really encourage that anonymous attendee to go and have a look at the guidelines which are on the New South Wales Health, the New South Wales Opioid Treatment Guidelines. But just very briefly, methadone you need to make an assessment. You start them on a quite low dose and you gently over time, you start low and go slow, and build it up slowly over time. People initially will dose daily, whether that is in a public or private clinic setting or a pharmacy setting, and then when they are stable, they can start having some takeaways. The majority of people will end up on three visits to the pharmacy a week. So that is four takeaways a week. With buprenorphine, the sublingual, a little bit different. You do not do the start low, go slow. You build up that dose quite quickly. And in New South Wales, people will start off dosing daily, but may as they become more stable, move to more liberal takeaways weekly, second weekly or even monthly. So certainly there are a group of people who are quite happy on their monthly sublingual Suboxone and do not want to do the shift to the injection. They will probably continue on that. But that is a huge question. I am not sure, Joel, if I have given it in that really sort of tiny summary. Is there anything else that you would add for that question?
Joel:
Yes. The thing I guess I would say is that we do tend to have a bit more of, I guess, a liberal approach to buprenorphine, again because of that safety and also particularly around Suboxone in particular, that that formulation has a lot of benefits. I would say that converting between methadone and buprenorphine, so going from methadone to buprenorphine, is not an easy process necessarily. And you know, there is you know, guidance from specialist clinics through DASAS for example, is a good way that prescribers can get access to guidance on that. But I would say that converting between buprenorphine formulations is very, very easy. So going between sublingual formulations and the depot formulations is really quite simple. We basically just switch the formulation when the next dose would be due. And also I can see a couple of questions there around going between the different formulations. There is no real restriction on shifting between the weekly and the monthly. Whatever the prescriber prescribes is able to be done. The next dose just is given when the dose of the previous formulation would be given. And just quickly there as well, the GP does require prescribing authority for buprenorphine for opioid dependence, but that once that permission is obtained from the New South Wales government, it is confusingly called an authority, it is not a PBS authority, it is a drug authority. But once that prescriber has the authority to prescribe buprenorphine to an individual, then converting between those formulations is not so much of an issue.
Hester:
There is one here from Amanda. Joel, new PBS co-payments, increased cost for weekly injections, loading doses, weekly maintenance, financial deterrent. Yes.
Joel:
this is a little tricky and I would not say that it is 100% worked out, but the plan is that clients will still only be paying for about one injection, sorry, will be only paying one co-pay per month, and that the prescriber can with the number of depots on that prescription authorise care within that period. So it is not per depot, the patient is not paying per depot, they are actually paying for a period of time, although there may be some differences around converting between those doses. So going from say a weekly formulation to a monthly formulation would, as far as I understand at this point, attract another co-pay. I would say that that is something that I have not quite worked out about the new system, is that clients who are on methadone, it appears to me, will only pay one co-pay. Whereas a client who changes formulation on buprenorphine may attract a second co-pay. I will defer to our Commonwealth colleagues on that though, and direct people to the VPA web page and the PBS ODT web page which have some recent information published.
Hester:
I think you are right Joel, but I would also defer for that. I am just writing a little reply to Mehdi. So I think maybe let us move on with the presentation. Okay sorry, I am just trying to do this just quickly do that. and send that.
So really just wanted to come back and look at what was happening for our two patients. So, Sam who is the guy with the chronic pain and he commenced on Suboxone sublingual and then transferred to an LIB and he has been attending pharmacy monthly. His withdrawal symptoms have resolved, he has no cravings. He still has pain, but the pain is actually improved and he is seeing a physio and a psychologist and that is really making a difference to his pain. Nothing in his urine drug screen. So they are NAD. His wife says he is a different man, much less anxious and fearful. And this is a really common thing that people will say to me is, Oh my God, why didn’t I start this treatment sooner? You know, it can be tricky with people that are suffering chronic pain to get to that point where they think, well will I give this treatment a go? But really, really common that they say once they start it, this has made a huge difference. I still have pain, the pain is better and I have got my life back on track. Moving on to the next one.
And Julie, you do decide to take over her care. You are seeing her three monthly and writing three monthly scripts for her Buvidal. She tends a pharmacy for injection. You and the pharmacist check in daily and both are happy. On review, she is stable and doing well. Her pain is manageable. She is enjoying work and is happy with her treatment. She is going on holiday to Tassie and has been able to plan this around her treatment. So this is the very common story that I see, Joel, and I am sure you are the same as I, that it really does help people to get on with their lives. And it can take a bit of time for people to kind of get into treatment because of their fears or what they think it might mean. But more than anything else it is a really successful treatment that makes a huge difference, it is really an effective treatment that helps people get on with their lives. Would you would you like to comment on either of those cases at all Joel?
Joel:
Yes, I guess just that what the depot buprenorphine really does offer clients is that freedom. And I really, I have heard just rave reviews effectively from clients about how much of a difference it makes in their life to not have to see me every day, you know, to be able to not have to think about going away for a weekend or you know, going to travel to see a friend. You know, even just the daily dynamic effects that clients are not having this sort of up and down effect from regular dosing. I just, I really want to emphasise how positive a lot of clients find this change and how exactly is as Hester has pointed out, that a lot of clients have that kind of wow, I really wish we had done some stuff like this sooner. I am really very happy with how clients get so much freedom from it.
Hester:
Just a couple of questions. There is one from Amanda, and this is talking about when is methadone preferred? Buprenorphine is safe in pregnancy. It really is, and we are using the injections in pregnancy as well. I would suggest in pregnancy with the injections at the moment, I would probably get a drug and alcohol specialist involved. I would want your specialist team in terms of the pregnancy management to be involved and in terms of the delivery and care for the baby, would be important.
Methadone. Look, there are some people where the buprenorphine just does not fill the spot, you know, and so it is an option and, you know, I do agree with Joel that what we will find with time is that there are people have been on methadone for a long time and they will stay on it and it is totally fine. But more people are actually starting on the buprenorphine options and there will be a small group of people where methadone works better for them than the buprenorphine. And I would also flag that there are a group of people and we see this in the literature, where heroin treatment actually works very well for them as well. We do not have that as an option in Australia. We may in the future for people that, you know, for a select group, but that would be my statement for that. Joel, do you would you like to make any addition?
Joel:
I would add is that people might know, there is a really, really interesting study going on right now at Saint Vincent’s about hydromorphone self-administration. The Canadians and Americans and British have done quite a lot of this heroin assisted and injectable OAT formulations. I think there is some interesting research to be done there, but some future research. In the interim, the depots.
Hester:
Terrific. And we have got one from Quinn. Agree Joel, our patients love the monthly depot. And one from Jenny, what problems do patients have transitioning from methadone to buprenorphine? Do you want to quickly answer that in the time we have available?
Joel:
Very quickly. The primary issue is that buprenorphine affinity is so high that it will displace other opioids. So a person who has currently got other opioids in their system and we give them some buprenorphine, the buprenorphine will win. So it will push everything else off those receptors. If that client has currently, you know, got a high level of opioid dynamic response, kicking out all of those opioids will kick that client into precipitated withdrawal. And it does not occur every single time, but it is a high risk situation that is worth having a good close supervision on to avoid.
Hester:
Absolutely. So I would encourage you to get your local specialist drug and alcohol team involved. For more information, go to the New South Wales Health website. Jovi can send you the link in your email afterwards. And also have a look at the OTAC training for more information.
We have got to finish up, we are a minute late. But look, I just wanted to say Jovi has popped up there. She is reminding us that we are on time. I just wanted to thank everybody so much for being here tonight and for taking part and for your fabulous questions. It is really important, you know, it is a great time to be thinking about engaging and taking part in this treatment as a prescriber and as a pharmacist. You know just really, really, really want to encourage you to think about how this could be part of your practice moving forward. And I wanted to take this opportunity to thank Joel. It is so fabulous to have you. Pharmacists, if you are looking for some support around how you start doing this injection, Joel is your man. He is really, really fantastic with this. Consider getting in contact with him about that model of care, you know, so you can really have some input around what that looks like for you in your setting, you know. So just really want to say thank you to everybody. Thank you to Joel, thank you for New South Wales Health for supporting this webinar and Jovi and the RACGP Faculty in New South Wales, ACT, you are all legends. Thank you to everybody.
Jovi:
Perfect. Thank you so much, Hester and Joel. So that is the end of our presentation for this evening. We hope you enjoyed tonight's presentation. So just a reminder that this is a CPD accredited activity and to be accredited for your CPD hour, you must complete the survey following this webinar. I will also be sending out the resources tomorrow morning to all your emails. Good night everyone.
Joel:
Thank you.