6.1.1 HistoryMethadone treatment in NSW dates back to 1969, when a small number of clinicians began prescribing methadone to assist opioid dependent persons improve their health and social functioning and alleviate the social consequences of their drug use.
6.1.2 Current situationThe methadone program in NSW is provided in both the public and private health sectors. In the public sector it operates through specialist programs in most Area Health Services and Regions of the Department of Health. Methadone treatment is also available in the private health sector from medical practitioners in private medical practice who are approved by the NSW Department of Health and NSW Department of Corrective Services (the latter for the Prison Methadone Program). In the private sector, services are provided by general practitioners and psychiatrists with relatively small numbers of clients as part of their wider practice, as well as by larger clinics which specialise in methadone treatment with larger numbers of clients. There is also a mix of public and private services, where private practitioners prescribe methadone but operate from public clinics. This has been brought about by a shortage of funds in the public sector (for visiting medical officers) and difficulty in attracting medical practitioners to career drug and alcohol positions in public clinics. Private practitioners have been loathe to treat clients in their own rooms, and so have done so from rooms in public hospitals.
There is a document entitled "Policies and Procedures for the Methadone Treatment of Opioid Dependence in NSW" by the Drug and Alcohol Directorate of the NSW Health Department which describes the policies and procedures of the program. The procedures are consistent with the National Methadone Policy.
Under the guidelines no medical practitioner may prescribe methadone without a current authority to do so from the NSW Department of Health. Such authority is subject to conditions in accordance with section 29 of the NSW Poisons Act 1966. Approval of a client to enter the program is generally given only when the client is physically dependent on opioids with a history of chronic relapse. If the client is not physically dependent on opioids, then the client must demonstrate that the potential benefits of the program outweigh the disadvantages. Other criteria relating to age and history of drug use are also taken into account.
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Prospective clients are assessed and their written consent to join the program is required. The assessment involves an evaluation of their HIV risk and testing for HIV is performed, as well as relevant medical, social and personal details, psychological status and drug use history. It is necessary to demonstrate physical opioid dependence through noting observable signs of withdrawal produced by acute opioid abstinence. New clients will almost always be required to attend a public or private methadone dispensary daily for the first three months.
Treatment is to be reviewed regularly by the prescribing medical officer and at six months a "Progress Review Form" is completed. Renewal of the prescription must be accompanied by assessment on every occasion. Comprehensive reports of the treatment for each client are required after two years on the program. However, it is problematic as to how well these requirements are followed in practice, and the extent to which clinical practices are monitored and disciplined.
Take-away doses are allowed under certain circumstances, and divided methadone doses are available with specific authority from the NSW Department Health. In recent times, there has been considerable controversy over the increasing availability of take-away doses, and their abuse by some clients. This recently led to a review of the take-away policy in New South Wales, and changes to the regulations concerning their availability.
Under the guidelines, urinalysis is mandatory every week in the first three months and thereafter the frequency is according to the clinical discretion of the prescribing medical practitioner, but not less than once a month. Actual practice varies, depending on the individual practitioner's attitude towards urinalysis.
6.1.3 StatisticsThe number of clients in the public and private sectors in NSW since 1986 are contained in Table 3 below.
Expressing these levels of participation as rates per thousand of population aged between 15 and 44 years (the primary age group of opioid dependent persons) results in the rates illustrated in the following statistics:
The data illustrate the increasing role of the private sector in the provision of services in NSW, particularly since the early 1990's. While public sector participation per thousand in the target population has grown from 0.50 persons in 1986 to 1.07 persons in 1994, private sector participation per thousand has increased from 0.54 persons to 1.94 persons over the same period. Overall participation in the methadone program in NSW nearly tripled from 1.04 persons per thousand in the target age group in 1986 to 3.01 persons in 1994.
Table 3: Numbers of private and public clients in NSW, 1986 to 1994