Methadone maintenance is provided in a wide variety of settings in different jurisdictions throughout Australia. Prescribers may be found in large specialist clinics (both public and private), public hospitals and in primary health care settings either as general practitioners or psychiatrists. Dispensers of methadone may be found in a variety of settings parallel to these categories, with community pharmacies being the industry equivalent of the primary care setting.
While research into the effectiveness of methadone services has largely been limited to the larger public and specialist clinics in NSW, one of the major factors found to affect outcomes has been the experience and approach of those providing services. Common to all practice settings is the need for service providers to be suitably qualified in the first instance, and to maintain those skills over time. These needs extend to all aspects of service delivery, and in particular to those prescribing and dispensing methadone.
8.1 Prescriber training
8.2 Dispenser training
8.1 Prescriber trainingIn the public sector in all States, prescribers are usually formally qualified in the area of drug and alcohol treatment services.
In the private sector, considerable variation exists between States in regard to the mix of GPs and psychiatrists providing methadone services. In Queensland, the majority of private practitioners providing methadone services are psychiatrists (17 of 24 approved practitioners are psychiatrists, treating 93% of private clients). In NSW, only 35% of authorised methadone prescribers are psychiatrists, but they treat 62% of private clients in NSW. In Victoria the overwhelming majority of private practitioners are GPs. In the remaining States, the preference is for GPs to be involved in methadone services.
In most States, there has been difficulty in attracting GPs to participate in the provision of methadone services which has been a limiting factor to expanding services, particularly in more remote areas. There is a dilemma between the need to ensure that medical practitioners are appropriately qualified to provide methadone services, while at the same time not creating a barrier to participation by an onerous training requirement. The training programs offered in each State seek to maintain this balance.
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In regard to training for methadone services, all jurisdictions either have training programs in place or are in the process of establishing them for private practitioners. Participation in these training programs is compulsory in some States as a condition of approval to prescribe methadone, but not in all States. While these programs have similar themes and are based on the national guidelines, they vary in their content and duration. Manuals for the accreditation of methadone prescribers exist (or are being finalised) in all States, and have generally been derived from the Victorian manual. However, there is scope for a greater degree of standardisation to ensure comparability between States. Further, the large majority of persons consulted were in favour of training being a prerequisite for approval of medical practitioners to prescribe methadone.
As previously stated, no research has been undertaken to evaluate the effectiveness of methadone services in the smaller primary health sector units, nor are there consistent data collected to examine outcomes of treatment in this sector. Anecdotal evidence given during the course of this review has indicated that there are considerable differences between the quality of services provided, which, if true, may be attributable at least in part to variations in the training provided. This adds greater weight to the argument supporting a uniform approach to prescriber training across all jurisdictions.
While initial training is a requirement of the approval process in most States, there is currently no requirement for medical practitioners to maintain their skill level through ongoing training or participation in training renewal or ongoing education programs. There is concerted opinion among many of those consulted during this review that such training is an essential part of maintaining and improving the standard of services provided. Again, such training should be provided on a consistent basis across jurisdictions. Training is more likely to be supported by GPs if it forms part of the activities approved for continuing education under the vocational registration requirements for GPs.
A further concern in regard to the level of training relates to the qualifications and experience of medical practitioners required to adequately cater for clients whose condition is unstable or who have complex needs or need more intense services during times of crisis. The need for a basic level of training for all practitioners providing methadone services is seen as essential. This training should be such that all participating practitioners have the necessary qualifications to meet the service needs of more stable clients, whose care fits a well defined treatment regimen. Of equal importance, however, is the need to ensure that practitioners treating more complex cases are appropriately qualified and experienced to meet the specific needs of this group of clients.
In this regard, consideration should be given to differentiating the level of training to discriminate practitioners considered suitably qualified to treat more complex cases. Such an approach would enable GPs who wish to be involved in the treatment of stable clients to undertake a basic training course, which is less likely to act as a barrier to their participation in methadone programs. For practitioners who wish to treat more complex cases, a higher level of training would be required. Such an approach is consistent with the service delivery models being developed in South Australia and Victoria. It would also be consistent with the service delivery model proposed in Section 10.
This approach will clearly require the further development of specific training courses and documentation to meet the needs of the different groups of practitioners and their clients. The relevant professional bodies should be approached to assess the merit of such an approach, and to assist in the development of appropriate training courses. Once again, we recommend that this approach be developed on a consistent basis across jurisdictions.
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8.2 Dispenser trainingTraining of pharmacists in the dispensing of methadone, like that for medical practitioners, also varies between States. The increasing reliance on community pharmacists for dispensing methadone in nearly all States has given greater impetus for standardised training programs. Most States have developed manuals for pharmacists which, like those for prescribers, are similar in content, but do contain variations. These manuals have often been prepared in conjunction with State branches of the Pharmaceutical Society of Australia (PSA), or the Pharmacy Guild of Australia (the Guild).
At the national level, the PSA and the Guild have established a joint working party to develop a proposal for a separately funded national scheme for the distribution of methadone and other substances for drug abuse clients. Two of the agreed fundamentals of the working party is the need for attendance at an approved training course as a pre-requisite to approval for dispensing methadone, and the use of a standard training manual. These aspects are considered to be particularly important to ensuring cross-border consistency in treatment services, and to enhancing the quality of services on a national basis.
- That a national approach to prescriber training be established, participation in which is a requirement for approval of a medical practitioner to prescribe methadone.
- That consideration be given to differentiating the training required of medical practitioners treating more complex cases, and that, if agreed to, suitable training courses be developed on a consistent basis nationally.
- That ongoing education and training be a requirement for continued approval of medical practitioners to prescribe methadone, with such training to qualify for inclusion in the vocational registration requirements for GPs.
- That, in conjunction with the Pharmaceutical Society of Australia and the Pharmacy Guild of Australia, a national training program be developed for dispensers of methadone, participation in which is a prerequisite for approval to dispense and administer methadone.
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