Vol 16 Edition 2

‘Done’, ‘bupe’ and next ‘depot’ – what?!?
The today and tomorrow of pharmacotherapy

Called pharmacotherapy by frontline workers and ‘The Done’ and ‘subbies’ by people who inject drugs – knowing about Medication Assisted Treatment for Opioid Dependence (MATOD) is an important skill in the NSP worker’s toolkit.

Pharmacist Lachlan Rose

Lachlan Rose, a community pharmacist and Pharmaceutical Society of Australia (PSA) NSW branch committee member, says that pharmacotherapy is important but not the only piece of the treatment puzzle.

“All addictions require intervention – they won’t just go away. It’s fortunate in the case of opioid dependence that there are effective medications that can assist,” says Lachlan.

“Of course, these medications are just one component and need to be paired with appropriate medical advice and support.”

Current options for pharmacotherapy

The National Opioid Pharmacotherapy Statistics Annual Data collection (NOPSAD) 2018 reports that, on a snapshot day in 2018, just over 50,000 clients received pharmacotherapy treatment for their opioid dependence at 2,852 dosing points across the country.

A small variety of medication assisted treatments are currently available in Australia, Lachlan explains.

“Methadone comes in two oral liquid forms – methadone syrup and a sugar-free version called Biodone,” he says.

“The ‘pros’ of methadone are that it’s easy to adjust or tailor the dose and it’s quick and easy to administer. The main ‘con’ is that it can be diverted, often restricting the number of unsupervised doses (‘takeaways’). It also has a shorter duration of action so requires daily dosing.”

Buprenorphine is available in two forms: sub-lingual (under the tongue) or buccal (between the cheek and gums). These are Subutex® sub-lingual tablets (buprenorphine) and Suboxone® films (buprenorphine/naloxone).

“Suboxone includes naloxone to act as a deterrent to people diverting the product and injecting it. This means it’s more appropriate for unsupervised ‘takeaway’ doses,” Lachlan says.

With buprenorphine the ‘pros’ include a longer duration of action meaning some patients can dose every second day rather that every day.

“The ‘cons’ of buprenorphine include that because the films and sublingual tablets come in fixed strengths there’s less flexibility with small dose adjustments. Also, supervised administration in the pharmacy can be a longer process as sublingual tablets and films can take longer to dissolve or disperse,” he says.

The view from pharmacies

Lachlan finds dispensing MATOD a positive experience, as he can build a relationship with the patients.

“The patients you serve on a MATOD program are sometimes the patients you get to know the best, as you are often seeing them every day. It is very satisfying to provide a MATOD service.” Lachlan says.

The cost to patients is usually $5-7 per day and the cost isn’t regulated by government. This cost can be a major barrier to patients staying on treatment

“Imagine if the daily supply of pharmacotherapy was covered by a prescription on the PBS [Pharmaceutical Benefits Scheme], in a consistent format across every state and territory!? I’d vote for that!” Lachlan says.

You can read more about the cost of pharmacotherapy in the Penington Institute report ‘Chronic unfairness: equal treatment for addiction medicines?’.

The benefits for clients

The most obvious benefit of pharmacotherapy is that patients/clients gain more stability in their lives. This can improve their mental, physical and social health.

Tony has been receiving treatment for opioid dependence since the 1970s. He praises Suboxone® for its effect on his day-to-day life.

“Subbies helps me function,” he says. “They help me get up in the morning.”

Suboxone® alleviates Tony’s back pain while also minimising his urge to inject opioids.

“It eases the pain in my back and takes away the desire to score.”

Tony recommends Suboxone® to others because of the positive impact of the treatment on his quality of life.

He much prefers Suboxone® compared to methadone, both of which he has used. He cites methadone as the reason for losing all his teeth. (For more on this topic see the article ‘Teeth and oral health’ in this edition of the Anex Bulletin).

The future of pharmacotherapy

With methadone and buprenorphine well-established forms of pharmacotherapy, what’s on the immediate horizon?

At its March 2019 meeting the Pharmaceutical Benefits Advisory Committee (PBAC) was considering whether to recommend two new formats of buprenorphine for listing on the Pharmaceutical Benefits Scheme (PBS). Sublocade® is made by Indivior and Buvidal® is made by Camurus.

Dr Mark Daglish*, director of Addiction Psychiatry at the Royal Brisbane and Women’s Hospital, explains the new formats:

“Buvidal and Sublocade are both slow release forms of buprenorphine,” says Mark. “They are injected subcutaneously into the fatty layer of the skin such as in a patient’s belly fat. The game-changer is that the slow release [of the pharmacotherapy] lasts from a week up to a month or more.

“We haven’t had a change of this magnitude since buprenorphine was introduced in the 90s.

“You’re going from supervised consumption in a pharmacy or clinic with a variable number of takeaways, measured in days. You’ll soon be able to go to a health professional for the injection, but you’re doing that once a week or once a month. And I think most people will end up on the monthly dose,” Mark says.

As the medication is still an opioid, the overdose risk remains – particularly if a person on the new pharmacotherapy consumes alcohol and other drugs such as benzodiazepines and/or pregabalin.

The other danger is diversion, which is why the injections have to be given by a health professional and will not be given to clients. NSP workers need to be aware that injecting the new formats into a vein or muscle will have very serious health consequences for clients.

“Both Sublocade and Buvidal and would be extremely dangerous products to put into a vein,” Mark says.

“If people have managed to acquire it somehow and come into the NSP looking for injecting advice workers need to make it very clear that the products are only safe when injected subcutaneously.

“Don’t put it into a muscle, don’t put it into a vein. It has got nothing to do with dose.”

Sublocade also requires a cold chain.

“Sublocade has to remain stored below 4 degrees [centigrade] for transit. It can be out of the fridge for up to seven days prior to administration,” Mark says. “This should be invisible to clients, but has implications for clinics, pharmacies and particularly private prescribers with small numbers of clients.”

On the plus side, Mark believes that the long time between doses offers major benefits and opportunities.

“There are many advantages of the new formats. If you think about people who are working or whose work hours don’t match pharmacy hours or clinic hours – it will be very convenient to have a monthly dose.

“Imagine not having to go and ask your clinic for takeaway doses because you spontaneously want to do something fun and go away with your partner for a weekend. Or you get a call at 6pm with a job opportunity. You’re on the bus at 6am and you don’t want to tell the boss ‘actually I’ve got to get some takeaways’ and it’s too late to phone your clinic. These everyday things,” he says.

“What’s more, for many people there is a lot of stigma [of receiving pharmacotherapy], being in line, being identified as someone on opioid replacement.”

“There are ways that this is going to change treatment that we’re not even aware.”

* Disclosure: Dr Mark Daglish has consulted for Indivior, the makers of Sublocade®.

– Rob Pfeiffer and Sophie Marcard

Related article: Pharmacotherapy key to effective hepatitis C treatment

Key acronyms for pharmacotherapy: 

MATOD: Medication Assisted Treatment for Opioid Dependence

MATOD and pharmacotherapy are also known as:

OMT: Opioid Maintenance Therapy

ORT: Opioid Replacement Therapy

OST: Opioid Substitution Therapy

MATOD comes in the form of:

  • Methadone and Biodone®
  • Buprenorphine in Subutex ® and Suboxone®
  • Naltrexone
  • Sublocade®
  • Buvidal®

Slang:

Sub/Subby/Subbies = Suboxone®

Done/The Done = methadone

Bupe = buprenorphine

Further reading:

WA Health: Opioid pharmacotherapy in the community

Department of Health and Human Service Victoria: pharmacotherapy guidelines

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