Chasing the illusive sweet spot.
Recently my eyebrows made an impromptu twitch when I read the AMA Queensland consultation paper Options to Improve the Queensland Opioid Dependence Treatment (ODT) system.
It contained a recommendation to make emergency departments a setting for ODT initiation. However, this appears to be an opioid agonist therapy (OAT), not registration on an opioid treatment program.
Medically Assisted Treatment of Opioid Dependence Services (MATODS) include the provision of drug substitution combined with the appropriate psychotherapy and non-judgemental human contact, whereas ED-initiated ODT replaces MATODS with OAT alone.
For me, it’s not what you do, but the way that you do it. In a sense, my conundrum is the grey zone between enabling “crisis” patient behaviours or holistically treating these, often vulnerable, patients. The discourse is limited to those who inject heroin or prescription opioids.
The critical issues I would like to discuss are:
- How patients are initiated on to the program;
- How EDs transfer ongoing care to a long-term service is not discussed;
- Is wait time detrimental or beneficial to the patient?
To provide context, a typical case scenario sets the scene for when harm minimisation can lead to unhelpful enabling behaviour. For clarity the following three concepts are explained: harm reduction, ODT and low value medical care.
Harm minimisation
Harm minimisation was adopted in Australia during the 1980s and is still recognised internationally as best practice.
The federal government formulated the National Drug Strategic Framework 1998-2002, from which the policy of harm minimisation evolved comprising three pillars: supply reduction, demand reduction and harm reduction.
Opioid dependence treatment
ODT began in Australia in 1969 when psychiatrist Dr Stella Dalton started prescribing methadone to patients with heroin addiction (now referred to as opioid use disorder).
Initially a patient was registered for six months treatment, which included talking therapy, then discharged off the program. Due to unacceptably high relapse rates the six months was extended to 12 months, and then for an indefinite period.
ODT has now expanded to include sublingual buprenorphine with naloxone or long-acting buprenorphine subcutaneous injection. All patients are offered complimentary psychotherapies if they are ready and willing.
Research suggests some people will be on ODT for life. This is possibly because OUD is a misnomer. There are multiple causes of OUD including: genetics, adverse childhood events in the first 2000 days (sometimes extending to the first 18 years of life), family modelling and social network factors.
The present majority report favours the opinion that OUD is merely a symptom of complex conditions sometimes including co-existing psychiatric morbidity. Often the relationships between the conditions are bidirectional.
Low value medical care
The RACP’s Australasian Chapter of Addiction Medicine cites the following recommendations to prevent low value interventions:
- Do not undertake elective withdrawal management in the absence of a post-withdrawal treatment plan, agreed with the patient, that addresses their substance use and related health issues.
- Do not prescribe pharmacotherapies as stand-alone treatment for substance use disorders but rather as part of a broader treatment plan that identifies goals of treatment, incorporates psychosocial interventions, and identifies how outcomes will be monitored.
In the case of ODT, care should comprise of a combination of OAT and psychotherapies. The OAT is merely the carrot that sets the stage for where the real magic happens.
Case scenario
Imagine this mock scenario.
Jim, aged 37, is a mostly “content” person who injects drugs from a Melbourne suburb where heroin is bountiful. On a whim, Jim decides to visit his mother in a rural Queensland community. After four days his heroin stash runs out, and Jim hits up his mother for her diazepam and oxycodone and now that has run out. He now has an “emergency”.
Or is it? Is Jim’s emergency a failure to forward plan? In Melbourne, whenever there’s a temporary heroin supply problem, Jim has access to a small number of GPs who provide interim ODT. This is not the case in every jurisdiction, but how was Jim to know that? To my knowledge, there are limited private OAT medical prescribers outside of Brisbane, Gold and Sunshine Coast areas.
Jim’s mother takes him to see her local GP who rings the public hospital’s alcohol and other drug service to make an “urgent” appointment. The earliest appointment to start someone on ODT varies according to demand and is generally two to four weeks because we only do new registrations on a Monday or Tuesday to have the rest of the week to safely titrate the OAT. We are not staffed to accept walk-ins.
For Jim, it’s an emergency and he is two hours away by car. As you can imagine there are now three unhappy people. Jim, his mother and the GP. Their question is if Jim must wait to access treatment, what does he do in the interim.
Jim is offered three options. The “safest” thing for Jim to do is to keep on using illicit opioids which are readily available where he currently is. Alternatively, Jim can stop using cold turkey. That choice is mentally and physically painful but is not life-threatening as many believe. Or Jim could attend Narcotics Anonymous (in person or online), a proven effective support service.
Medical treatments are always subject to the politics and social contracts that the community will accept. Should we provide “emergency” OAT to everyone?
There is irrefutable evidence that length of treatment for people with OUD is a good prognostic marker for recovery. Individual recovery correlates to functional performance as measured by reintegration into their “normal” cultural and social context.
My anecdotal experience over 26 years is that the attrition rates for those offered same-day access to OAT is greater than the attrition rate of those who must wait two to four weeks for treatment.
Is this due to immediate access being merely a supply program for a patient’s “emergency”? There appears to be no literature on length of waiting times to engagementand long-term outcomes.
In this instance, primary engagement refers to the patient attending their first appointment. Secondary engagement is the duration of consistently receiving MATODS treatment. When I sought evidence-based medicine literature on this topic there was none. What follows are the results of my own limited “research” on waiting times to engagement and whether a purely supply OAT service is harmful and enabling.
Related
First, I spoke to two lived-experience peer support workers. To set the scene I used the case scenario above. They referred to two types of patients. Those who are happy PWID and those who are not.
Happy PWID reject ODT because they feel they will lose the choice to self-soothe or have “a party for one”. Their fear is the fear of missing out.
Unhappy PWID are generally sick and tired of being sick and tired. Their fear is the fear of having to suffer the horrors of withdrawal.
These patient experiences are not static, and people oscillate between both over time. In the beginning drugs are the solution to their problems, rather than being the problem.
Should ODT be a supply program or a treatment program?
The peer support workers suggested that on balance a supply program was enabling and possibly brought the MATODS program into disrepute by covertly undermining the benefits and integrity of comprehensive treatment. They suggested the emphasis should be on the “how” and not the “what” of treatment services. Supply alone is not a treatment modality.
When I put the case scenario to an addiction psychiatrist and chief of staff of a prominent Canadian research collaborative of international renown, he concurred that there wasn’t any research data demonstrating outcomes on waiting times to engagement in MATODSmodels of care.
His view from a harm minimisation perspective was that even one day of medically supplied “clean drugs” were better than a possible risky illicitly acquired opioid alternative.
There was a time when some services in Queensland offered on-demand OAT supply, but patients offered the opportunity would not drive for hours to receive it and so primary engagement was poor. Those who did come would collect their daily titration before dropping out of treatment at around day three, because they preferred returning home to easier illicit supply chains.
It became obvious that ATODS was being used as an alternative short-term supply program, not a treatment program.
Should EDs be the substitute supplier of OAT or should all patients wait to be accepted onto a comprehensive treatment program?
There are two logistical reasons why we have a two to four week wait.
First, a 50-70% “failed to attend” rate for patients with appointments causes delays for others who want to access the program.
No problem, you might say, just double book. Well, we do. The problem with overbooking is it generally takes the medical specialist half an hour to determine if MATODS and OAT is the best treatment option. Many complex polysubstance PWID are chiefly amphetamines-type substance users who are better directed to other treatment pathways.
Another reason Jim couldn’t have an urgent appointment at AODS is because public sector MATODS are highly regulated and documentary requirements represent a time barrier, needing three hours per patient to input all the data “deemed” essential.
Our intake days are Mondays and Tuesdays which are double-booked, but if all patients turn up, it becomes mayhem for the nurses. This administrative burden and “data bloat” which occupies valuable clinical time has been recognised at the top level, but has not yet been addressed.
We assume that individuals seeking our “help” want and are ready for talking therapies. However, the reality is for many of the “unhappy users” their lives have become meaningless, and they don’t want talking therapy, despite the evidence that CBD or iCBD has a beneficial effect size in contemporary research.
Anecdotally 50% of patients either do not want to engage in talking therapies or recover without it. So, there is no one size that fits all. Could it be that what people really need is stigma-free positive regard?
OUD is a complex chronic relapsing condition and Eds are purpose-designed for acute presentations.
Let’s not confuse access with appropriate clinical care. Deputising the ED as a public AODS agent, rather than addressing the current AODS inefficiencies to cater for more patients, is a masquerade.
Access and caring relationships are paramount in medical care and not something the ED was designed for.
Alternatively, should we simply fully democratise healthcare and put OAT into free public vending machines along with the syringes? What will be the unforeseen consequences of medical care without follow up? Let’s not make the mistake of being so understanding and forgiving that you think enabling easy access to OAT is an appropriate form of treatment.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.
