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DrugInfo seminar: The Pharmacotherapy, Advocacy, Mediation and Support (PAMS) Service

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Presentation by Sarah Lord to the DrugInfo seminar: Heroin and other opioids, 27 September 2011 in Melbourne, Australia.

Presentation by Sarah Lord to the DrugInfo seminar: Heroin and other opioids, 27 September 2011 in Melbourne, Australia.

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  • Issue: accused of bupe diversion by pharmacist (says he “didn’t divert” and tells pharmacist to “shove it”), he is then told program is in jeopardy due to suspected diversion and rude behaviour. No other pharmacy with vacancy in his area. Rings PAMS to find out what he can do to ‘clear his name’ and record his complaint. PAMS negotiates a ‘treatment agreement’ between pharmacist and consumer to allow Jason to stay on the program under strict conditions – Jason agrees. 2 months later Jason rings PAMS and says his pharmacist is awful to him makes him wait and, he believes gave him ‘crushed Panadol’ in a TAD. PAMS speaks to the pharmacist about not crushing bupe TADs, locates another pharmacy (much further away) and supports Jason through formal complaints process to AHPRA, who investigate and are unable to find evidence to prove consumer allegation.
  • Issue: Renee is told she is 8.5 weeks pregnant by prescriber who encourages her to consider swapping to methadone or at least BPN. Renee wants to keep the baby and doesn’t want to swap to methadone, but agrees to take BPN. Prescriber explains there are some risks with BPN and pregnancy and says it is her choice to remain on buprenorphine during the pregnancy. Pharmacist then informs Renee she shouldn’t be on bupe at her next dose. Renee explains she has spoken to her doctor, but feels she is now ‘treated differently’ by the pharmacist, shop assistant and other customers since becoming pregnant. With increased appointments for her pregnancy (and increased travel costs, etc), Renee falls behind in her dispensing fee payments. Her pharmacist has told her no $, no dose! Renee is terrified of potential miscarriage from withdrawal and she is very stressed. She normally lives on $40.00 per fortnight for food after paying other expenses. She has been buying second hand goods for her baby and now can’t pay her dispensing fees. She rings PAMS to find out what she should do. PAMS manages to refer Renee to a welfare agency who agree to pay for two weeks of her dispensing fees and discusses with the pharmacist the research around pregnancy and buprenorphine, along with the value of pharmacotherapy programs for pregnant women. Issue: Renee is told she is 8.5 weeks pregnant by prescriber who encourages her to consider swapping to methadone or at least BPN. Renee wants to keep the baby and doesn’t want to swap to methadone, but agrees to take BPN. Prescriber explains there are some risks with BPN and pregnancy and says it is her choice to remain on buprenorphine during the pregnancy. Pharmacist then informs Renee she shouldn’t be on bupe at her next dose. Renee explains she has spoken to her doctor, but feels she is now ‘treated differently’ by the pharmacist, shop assistant and other customers since becoming pregnant. With increased appointments for her pregnancy (and increased travel costs, etc), Renee falls behind in her dispensing fee payments. Her pharmacist has told her no $, no dose! Renee is terrified of potential miscarriage from withdrawal and she is very stressed. She normally lives on $40.00 per fortnight for food after paying other expenses. She has been buying second hand goods for her baby and now can’t pay her dispensing fees. She rings PAMS to find out what she should do. PAMS manages to refer Renee to a welfare agency who agree to pay for two weeks of her dispensing fees and discusses with the pharmacist the research around pregnancy and buprenorphine, along with the value of pharmacotherapy programs for pregnant women.
  • Michael needs to take his dose before he goes to work each morning. He starts work at 7.30AM when the pharmacy isn’t open. He asks his prescriber for additional T/As who says “no” after a +UDS and 5 ‘missed doses’ in the last month. Michael is afraid of losing his job and rings PAMS to find out what he can do. PAMS offer to speak to Michael’s prescriber on is behalf. Prescriber agrees to provide Michael with a ‘split dose’ (1/2 dose before work, ½ after work at the pharmacy), the prescriber agrees to do this on a trial basis with “no TADs” and to review the situation after one month, Michael is pleased with this as an ‘interim’ outcome and agrees to call PAMS back in one month to discuss how things are going.
  • GP prescribes Oxycontin (80mg 2Xs p/d) for 6 weeks, applies for a permit – permit application denied on the basis of IDU history, GP refers J to a PMS but waiting list is at least 6 months. GP can’t do anything until he has a recommendation from the PMS! Jamie tries 5 other GPs and is ‘knocked back’ – original GP is informed J has been to 6 GPs in 3 months (‘doctor shopper’ notification by HIC), J is in excruciating pain constantly with no quality of life until his shoulder can be operated on. Jamie contacts PAMS and asks what we can do to assist him!

DrugInfo seminar: The Pharmacotherapy, Advocacy, Mediation and Support (PAMS) Service DrugInfo seminar: The Pharmacotherapy, Advocacy, Mediation and Support (PAMS) Service Presentation Transcript

  • The ‘Pharmacotherapy Advocacy, Mediation and Support (PAMS) Service A Program of HRV Presented By: Sarah Lord ADF Seminar – ‘Heroin and Other Opioids’
  • Presentation Overview
    • Role of Pharmacotherapy
    • Introduction to the Victorian Pharmacotherapy System
    • History of ‘The PAMS Service’
    • Brief overview of ‘The PAMS Service’
    • How the Service Operates
    • PAMS Data: 2010-2011 Financial Year
    • Unique Service
    • Key Issues
    • Major Challenges
    • Case Studies
  • Role of Pharmacotherapy – Heroin and Other Opioids
    • Reduction of Drug Related Harm
        • Overdose
        • Rate of Injecting
          • BBV transmission
          • Other IRID
        • Illicit Drug Use
        • Crime
        • Imprisonment
    • Stable Life – employment, family & social relationships
    • Successful Response – highly researched
    • Cost Effective
  • However ….
    • Consumer
        • 2 nd Class ‘Substitute’
        • Loss of Control
            • Route of administration
            • Place of Use
            • Social Setting
            • Time
            • Amount
        • Cost
        • Access
    • SPs
        • Complex Clients
            • Support & Advice
            • Referral Options
        • Cost
  • Victorian Pharmacotherapy System
    • State Guidelines – ‘Pharmacotherapy Policy’
    • A ‘community model’ of service delivery
        • GP prescribers
        • Community pharmacies
        • 5 ‘SPS’
        • No ‘clinic’ system
    • Approximately 13,700 consumers in treatment (DoH, 2011)
        • About 450-500 dispensing pharmacies
        • About 80 practicing GP prescribers (20-25 GPs see 80% clients)
    • Pharmacotherapies – Methadone Syrup, Biodone Forte, BPN/NAL (tablets & film), BPN
        • Approximately 60% of consumers on methadone
        • Approximately 28% on BPN/NAL and 12% on BPN
  • Victorian Pharmacotherapy System
    • TADs – up to 5 p/w (max) of Methadone/BPN/NAL, ‘stable clients’
        • Suitability for TADs assessed by prescriber
        • Guidelines inform prescriber re ‘client stability in treatment’
        • 3 Levels of dose supervision (low, medium, high)
        • Then what?
    • Minimal Supervision Regime (MSR)
        • Only for very stable clients
        • Prescriber must be chapter fellows (or arrange consultant)
        • Up to 28 day supply
    • Cost to Client – average $5 per day
        • ‘ Program Fees’
        • Charge clients for ‘missed doses’ (most often)
        • Charge clients ‘double’ for one ‘2 day dose’
        • Some charge extra for TADs
        • ? Cost of dispensing MSR
  • History of ‘The PAMS Service’
    • VIVAIDS - Group (methadone consumers)
        • Consumer complaints & grievances
        • Addressing these concerns – a consumer (peer based) focus
    • VIVAIDS Research in 1999
        • Investigation into methadone consumer concerns
    • First Funded in 2000 (TP AOD Centre)
        • Peer based support and complaints (BIT/LIT/SROM Trials)
        • Based at and project of VIVAIDS
    • DoH (Mental Health and Drugs) Funded 2001- present
    • Originally MACS, PACS, PAMS
        • ‘ Methadone Advocacy and Complaints-resolution Service’
          • Introduction of buprenorphine
        • ‘ Pharmacotherapy Advocacy and Complaints-resolution service’
          • Problems associated with ‘complaint’
        • ‘ Pharmacotherapy Advocacy, Mediation and Support-service’
          • ‘ The PAMS Service’
  • ‘ The PAMS Service’
    • A state-wide telephone service (1800, free call)
        • Peer based advocacy service
        • Consumer focussed
        • Staffed by peers (pharmacotherapy)
    • Provision of:
        • Information; support; debriefing; advocacy; mediation; negotiation; complaints resolution, referral and support
        • Policy advice (dispensing fees, TADs etc)
        • Input into research (steering groups)
        • Peer education and training – an ideal, no longer practical
        • Pharmacotherapy Networks/Committees
    • Service Users:
        • Pharmacotherapy consumers: potential, current and past
        • Pharmacotherapy Service Providers (SPs): prescribers and pharmacists
        • Other Agencies (welfare, AOD, prisons, Centrelink etc)
        • Significant others (family members, partners, friends, carers etc)
    • Goals:
        • Keeping clients ‘on programs’ or enabling access to pharmacotherapy programs
        • Assisting SPs with ‘client related issues’
        • Keeping ‘everybody happy’
    • Data Collection
        • Confidential service
        • Data base (Microsoft ‘Access’)
    • Reporting:
        • Key performance indicator (KPI) = 25 cases per month
        • Annual report to DoH
  • How the ‘PAMS Service Operates’
    • Callers access service via state-wide ‘free call’ (PH: 1800 443 844)
    • Staffed by 1.6 EFT
    • Referrals to the ‘PAMS Service’:
      • Self
      • Via SPs or
      • Word of mouth,
      • Other agencies
      • Promotional materials (posters, business cards, flyers)
    • How we work
        • Listen to caller issue/concern
        • Provision of information, debriefing and support
        • Provision of advocacy to and mediation/negotiation with ‘other party’
        • Provision of referral/s and/or resources for caller & ‘other party’
    • Case Resolution:
        • Completely resolved
        • Partly resolved
        • Not resolved
    • Caller ‘satisfaction rate’ monitored
        • Very satisfied
        • Satisfied
        • Not satisfied
        • Not asked
  • PAMS Data: 2010 - 2011
    • Total Cases = 843,average 70.25 (p/m), max=100, min=22
        • Consumers = 86%
        • SPs = 5.3%
        • Other = 4.5%
        • Significant Other = 3.8%
    • Caller Location – all cases
        • Major cities 78%
        • Inner regional 10%
        • Outer regional 4%
        • Unknown 9%
        • Inter-state 1%
    • Income – consumer cases
      • Benefit/Pension = 90%
      • Employment (F/T) 6%
      • Employment (P/T) 3%
      • N/A 1%
    • Age Groups – consumer callers (Min=16YO, Max=69YO, Average=35YO)
      • 15-24YO – 8%
      • 25-34YO – 40%
      • 35-49YO – 44%
      • 55YO plus – 6%
      • Age Unknown – 2%
    • Gender – consumer cases
        • Female 36%
        • Male 63%
        • Transgender 1%
  • PAMS Data: 2010 - 2011
    • Program Type – consumers only
      • Community Program 97%
      • Pain Management 2%
      • Prison 0.5%
      • Other 0.5%
    • Treatment Type – consumers only
      • Methadone 70%
      • BPN/NAL 22%
      • BPN 4%
      • Pain Management 2%
      • Other 2% (Eg Naltrexone, benzos, no treatment)
    • Treatment Time – consumers only
      • Waiting to Start 7%
      • 1-7 Days 4%
      • 1-4 Weeks 6%
      • 1-3 Months 7%
      • 4-12 Months 9%
      • 1-6 Years 44%
      • 7-10 Years 15%
      • No Current Program 7%
      • Unknown 1%
  • PAMS Data 2010 - 2011
    • ‘ On Program’
        • Yes 85%
        • No 5%
        • Waiting to Start 7%
        • Previously on Program 1%
        • Unknown or N/A 2%
    • New versus Previous Client
        • New Client 67%
        • Previous Client 30%
        • Don’t Know 3%
    • Referral Source
        • Direct Line 24%
        • Service Providers 15%
        • Word of Mouth 17%
        • Promotional Materials 9%
        • Other Agencies 33%
        • Unknown 2%
  • Caller Issues and Concerns 2010-2011
    • Majority of consumer cases relate to pharmacies (dispensing related problems)
        • Pharmacies 68%
        • Prescribers 28%
    • Request for problem-solving over ‘complaints’
    • Main Issues:
        • Requests for information and debriefing 11%
        • Pharmacotherapy dispensing fees 41%
        • Access (to SPs) 7%
        • Program Termination 7%
        • Non-Collaborative Treatment Plan 2%
        • Access to Pain Relief 2%
        • TADs 6%
        • Dosing issues 3%
        • Transfers 3%
        • Behaviour/Non-compliance 1%
        • Problems with prescriptions 4%
        • Rights and responsibilities
        • Attitudes of SPs towards consumers
  • Outcomes of Pams Service Intervention
    • PAMS HAS NO BROKERAGE FUND OF OUR OWN!!!
    • Supported referrals to welfare agencies for financial assistance and/or negotiation of payment agreements
        • Verbal advocacy
        • Written referrals
        • Liaison with all parties concerned
        • Payment Agreements – Follow-Ups
    • Mediation and negotiation with SP re: consumer concerns – agreement reached or alternative SP located
        • Eg ‘treatment agreement’ (formal/informal)
        • Eg supported referrals to alternative SPs (advocacy)
    • Provision of information and support – both parties
    • Referrals to ancillary services (detox, counselling etc)
    • Provision of resources (printed material) – both parties
    • Support Client
        • Formal Complaints Process (AHPRA, PBV,MPB, HSC)
        • Check ‘agreements kept’
        • Informal complaints process – informing DoH, PBV etc
  • PAMS Findings 2010-2011 (cont.)
    • Follow-Ups: average 7.5 per case, minimum 0, maximum 103
    • 728 Consumers = 5568 FUs
    • Degree Case Resolved:
        • 83% Completely Resolved
        • 8% Partly Resolved
        • 1% Not Resolved
        • 7% Ongoing
    • Time Taken to Resolve Case:
        • Less than 1Hr 16%
        • 1-4 Hrs 7%
        • 5Hrs-1 Day 5%
        • 1-5 Days 51%
        • More than 1Week 19%
    • Caller Satisfaction:
        • Very satisfied – 82%
        • Satisfied 7%
        • Not Asked 5%
        • Not Satisfied/N/A 6%
  • What Makes PAMS Unique?
    • Peer-based Service
        • A program of HRVic
    • Go the Extra 1000 miles!
        • Keep Going Until Win-Win Solution Achieved
    • Keeping all Parties Happy
        • Consumers
        • Service Providers
        • Others (case workers, welfare services etc)
    • A Small, Under-Resourced Service with a BIG, Important, Job!
  • Key Issues
    • Pharmacotherapy dispensing fees – cost to consumers (low income consumers)
        • HCC holders can’t afford the cost of dispensing
        • Lack of referral options for financial assistance
        • Pharmacist ‘stuck in the middle’
    • Cost of and Access to MSR
    • Access to SPs in rural areas
    • Access to Services and Support for ‘Complex Clients’
    • Lack of GP prescribers and pharmacy dispensers
    • Lack of access to appropriate services for ‘complex clients’
    • ‘ One size fits all’ system
    • Limited understanding of HR (SPs)
    • Limited access to BPN (pregnant women)
    • New BPN/NAL Film (?)
    • Lack of exit strategies for pharmacotherapy consumers
    • Stigma and Discrimination
    • Methadone, BPN/NAL, BPN and ………… ?
    • Long-term stable clients – 5 TADs p/w – any better?
    • Travel difficult
    • Pharmacotherapy Consumers = Aging Cohort
  • Major Challenges for PAMS
    • Addressing the issue of dispensing costs (for consumers)
        • Lobbying
            • Welfare sector and other agencies (Eg job network providers), some agency policies exclude assistance for dispensing fees
            • Government departments – state/commonwealth resp?
        • Access to funds is limited
            • HRV no additional funding for disp fees
            • Funding via welfare agencies is ‘regionalised’, some regions have ‘no services’
            • Difficult and time consuming to locate $ for consumers
    • Inadequate funding for the ‘PAMS Service’
        • 1.6EFT is not enough (current case-load)
    • Worker stress and ‘burn-out’
        • Availability of debriefing and support, external supervision
    • Cases becoming ‘more complex’
        • Callers require intensive support, extensive ‘follow-up’, difficult behavioural issues
        • Lack of appropriate SPs for ‘complex clients’
        • SPS at capacity and none in outer metro or regional areas
    • Service Promotion – no funding!
        • Limited capacity to attend forums, give presentations, steering committees etc
    • ‘ The PAMS Service’ – no powers of enforcement
  • PAMS Key Recommendations
    • Dispensing fees
        • Free or low cost for those with HCC
        • Interim solutions:
            • PAMS manage a state-wide ‘dispensing fee fund’ for clients in legitimate financial crisis
            • Government funded ‘priority groups’ (pregnant women, mental health)
            • Increase number of PAMS ‘partner agencies’
    • SPS per regional city – complex clients
        • Capacity to dispense (at no cost) and prescribe
    • More funding for ‘The PAMS Service’
        • State-wide ‘brokerage fund’ for dispensing fees
  • Case Study 1
    • “Jason”: 28YO male, BPN/NAL - 32mg every 2 nd day, on program for 2 months, stable dose
  • Case Study 2
    • “ Renee”, 32 YO single female, on 16mg of BPN/NAL per day, on program for 2.5yrs, doing well (reduced illicit drug use), unemployed.
  • Case Study 3
    • “Michael”, 30 YO male, recently employed as landscape gardener. On 80mg of methadone per day.
  • Case Study 4
    • ‘ Jamie’ 48 YO male, on methadone 10Yrs ago, work-place accident damages his shoulder, (currently in-operable).
  • And Last of All …….
    • Referrals to PAMS
        • ‘Client Cards’ Available Today
        • PH: 1800 443 844, M-F, 10AM-6PM
    • Thanks for Listening!