Commentary on ‘Opioid agonist treatment and patient outcomes during the COVID‐19 pandemic in south east Sydney, Australia’

Lintzeris et al. [1] provide the first analysis of changes to opioid agonist treatment (OAT) programs and patient outcomes in response to COVID-19 in New South Wales (NSW). We commend the authors for undertaking the analysis, especially considering the additional challenges involved in offering complex care to people with opioid use disorder during the COVID-19 pandemic. The findings were generally positive [1]. The number of people receiving six or more takeaway doses (TAD) a week increased from 6% in March 2020 to 31% following COVID-19-related service delivery changes, with no major adverse outcomes for recipients. In fact, increased rates of alcohol or other drug use over the study period may have been related to more frequent supervised dispensing. The lack of adverse outcomes associated with increased TADs will likely resonate with the experience of many people enrolled in OAT. However, we feel that there is one major implication that is not sufficiently addressed in this paper, that is, the cost to consumers associated with community pharmacy dosing may be prohibitive and limit a person’s ability to access treatment and these costs remain despite the changes to service delivery. The OAT service delivery model in NSW consists of a mixture of limited, no-cost programs available through public clinics, and fees-based programs via either private clinics or general practitioners and community pharmacy dispensing [2]. The current model requires consumers at public clinics to attend for daily dispensing of methadone or buprenorphine, while consumers at pharmacies and private services generally receive at least one TAD each week after a period of stabilisation. Current NSW guidelines recommend to limit consumers to four methadone TADs per week or 28 buprenorphine TADs per month [2]. Weekly and monthly depot injections of buprenorphine have recently become available in Australia, although most patients remain on oral OAT. Lintzeris et al. [1] found that the number of patients transferred from (free public) clinic dispensary to private community pharmacy for dispensing during the COVID-19 pandemic increased from 25% to 49%, almost doubling the number of people attending pharmacies. This shift to the private system could have profound impacts on the finances of clients. The study period ran until September 2020, a period in which unemployment benefits were exceptionally and temporarily raised (approximately doubled) in response to the pandemic. This temporary change lifted many out of poverty as the pre-COVID unemployment benefit rate in Australia was below the poverty line, at about $560 per fortnight [3]. Other income support such as the Disability Support Pension, which some OAT clients receive, is not significantly higher with 41% of Disability Support Pension recipients in 2017–2018 reported as experiencing poverty [3]. Although ultimately unemployment benefits have been raised by $40 per week from pre-COVID levels, it is generally agreed that this amount is insufficient, particularly for those who are required to pay fees for pharmacy-based OAT dispensing. We agree with Lintzeris et al. that ongoing evaluation of the COVID-related impacts on clients is needed in this shifting financial environment [4,5]. Retention rates in OAT depend on a number of factors but affordability is a central reason for low-income people leaving OAT [6,7]. The cost has always proved a major barrier to OAT treatment for consumers in Australia [8]. As indicated, the program in NSW includes a limited number of free places provided through public clinics but average fees associated with private dispensing range from $134.82 to $354.70 per month in NSW (or up to $4256.40 per year) [9]. These fees are a significant financial burden for clients, particularly as the best outcomes for OAT consumers appear after long-term treatment, over months to years [10]. One Australian study indicated high levels of personal debt among people attending OAT programs [9]. The resulting poverty makes it hard for consumers to make the changes they would like to make in their lives, as well as meet the requirements of the OAT program [11–13]. A range of adverse events may ensue if a