Buprenorphine Down Under

Much thanks to a doc in Australia for recent comments:

From one Doc to another (I’m in Australia). You may be interested (or possibly know) how we do things here. Basically, addicts can register at any Dr who’s completed a programme and is then authorised to prescribe what we call Schedule 100 drugs: mainly buprenorphine and methadone. Almost all these Dr’s ‘bulk bill’ ie. are free for the patient. Once prescribed, the patient turns up at a chemist (who’s set up to dispense S100 drugs) daily and receives their dose. After 2-3 months of stability ‘takeaways’ may be authorised by the Dr: up to 3-4 a week. In general terms there is almost NO prescribing of 30 day bottles here – Px need too see the pharmacist daily and their Dr at least once a month. This is free for the patient, however most pharmacies will charge a couple of dollars a day to dispense, and keep patient’s skin in the game. The provision of the drugs themselves is free. ie. done by the Dept. of Health. So..all in all our systems is quite different in that it’s a) pretty much cost-free to the patient and b) requires regular attendance at a pharmacy ie. daily or almost daily.
In terms of prescribing: Dr’s over here are far less ‘go my own way’ than the US (I have found anyway). There is established practice, and you leave yourself wide open to criticism from your peers if you vary from that. In the case of suboxone, the established standard is to keep patients on suboxone for as long as possible, if not permanently. We are under no pressure to ween addicts off suboxone/methadone, and in general I actively discourage it, except for a very few motivated individuals with stable lives eg. other healthcare workers. A Dr that promoted leaving a programme would face a barrage of criticism, and possibly be reported by his/her peers. This is great in one way, but bad in others: the individual’s healthcare can’t be overly tailored.
So…that’s buprenorphine et al in Australia…hope you and your readers find it interesting, and keep up the outstanding work of this blog!
Thanks Doc— for the info, and for the kind words. I’m sure that people will find things to prefer in either the US or Australian approach to buprenorphine. I’ll offer my own comparison, for what it is worth… starting with things I prefer about the US approach. In the US, all doctors with the ability to prescribe controlled substances can prescribe buprenorphine, although most are not aware of that ability. Buprenorphine is really just another pain medication when used to treat pain, whether given as a sublingual tablet, transdermal skin patch, or (eventually, hopefully) a depot injectable product. The regulation comes into play only when buprenorphine (or ANY narcotic) is used for addiction. No opioid can be prescribed or administered to prevent withdrawal or to treat addiction, except in the case of methadone (by formal methadone programs) or by buprenorphine-certified physicians prescribing buprenorphine. In the US there are no formal limits on the number of days of buprenorphine prescribed at one time, and no formal regulation of the frequency of doctor visits.  Like in most areas of medicine, the only guide is the ‘standard of care,’ something that varies from region to region and that hopefully evolves in the correct manner as science adds to our knowledge.  I’ll mention this evolution in a moment in regard to the length of treatment.  I would not be happy with the requirement that patients present on a daily basis;  at some point I believe that even addicts deserve to be treated like regular people!  You’ve probably read my comparisons of addiction to other diseases;  I realize that addicts have a reduction in their insight at times of active use, but I have many patients who are doing very well, who do fine with quarterly visits. Those patients receive a month supply of medication at one time, and can pick up refills each month for up to 90 days before another appointment.  I reserve such situations for people who have done well– i.e. no relapse, erratic use of buprenorphine, or other irregularities for at least a year– and I strongly encourage patients to come in sooner if they have any problems.
Doctors certified to prescribe buprenorphine for addiction must have the ability to refer for counseling, but patients are not all required to attend counseling. On one hand this allows for flexibility, but on the other hand it creates a situation where the doc has the power to force patients to attend counseling (even in the doc’s own clinic) in order to get buprenorphine, a potential conflict of interest.
The cost issue issue has arguments on both sides.  On one hand, there are many people in our country struggling to get by, especially right now.  But on the other hand, people tend to pay for what they value– and value what they pay for.  I am not real sympathetic toward people who spend $1000 per week on oxycodone, and then refuse to pay a fraction of that amount for treatment.  In a free system I’m sure there are people who abuse the benefit, going in and out of treatment without getting to a point of desperation that might produce a firmer commitment.  On the other hand, making buprenorphine more available to addicts is going to reduce mortality– and it is hard to argue with something that results in more lives saved.
I am particularly interested in your comments about long-term maintenance.  The Australian approach appears to be much more ‘intelligent’ in that respect.  There has been SOME evolution in the US, as study after study shows virtually 100% relapse after discontinuation of buprenorphine.  But there is a buck to be made by the detox centers, whether ‘rapid detox’ for 10-20 grand, inpatient detox for days to weeks, or several months of residential treatment that claim to make people ‘completely clean.’   The attitude among most people, physicians and lay people, is that buprenorphine should eventually be discontinued.  I disagree with that attitude and believe it to be the result of ignorance and a disregard for reality– as I have shared a number of times.  By my thinking it seems so clear;  opioid dependence is a chronic disease that finally has a long-term treatment. 
Thank you very much for sharing your experiences, and for describing how another country manages this difficult issue.    G’day. Mate!