6.2.1 HistoryThe Victorian Methadone Program (VMP) has been operational in Victoria since 1985. Its "Statistical Review 1993" states that it is distinctive for its generalist and community-based approach. In most cases, Methadone treatment is seen as most appropriately occurring as part of a generalist health service, with particular emphasis on general practitioners, who are provided with support through education and back-up facilities.
6.2.2 Current situationThe use of large, specialist clinics is reserved for more complicated cases and most treatment (80%-90%) is routinely provided through approved general practitioners and local community pharmacies. Some individuals have treatment needs that generally cannot be met through the services of a general practitioner and Government services offering approximately 40 places have traditionally managed this group. Plans exist to expand this service across four metropolitan regions giving access to a total of 240 places for this special needs groups. In September 1994, tenders were invited from suitably experienced service providers in the private sector to provide these services under contract to the Victorian Department of Health and Community Services (H&CS).
There is an approval process for doctors to become methadone prescribers and upon approval, each provider needs to apply for a permit to prescribe to each client. Permits are issued for six months and renewal required for continuing treatment beyond that time. If the client withdraws from the Program, for whatever reason, the prescriber must submit a termination form.
Clients may enter the service via general health and welfare services or be referred into the specialist system from the general health provider or enter at the specialist level independently.
H&CS has published a comprehensive manual of procedures and rules for prescribing practitioners entitled "Methadone Prescribers' Manual for General Practitioners" and it is part of an on-going program of general practitioner support called the Methadone Information Network. It includes information on the objectives of the Methadone Program and clinical information related to the potency, dose, long-term effects, side-effects and withdrawal symptoms of this synthetic opioid.
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6.2.3 AdministrationClients wishing to commence on the Program must undergo a thorough assessment by the practitioner. At this time a Client Management Record is established for the client to provide a useful clinical tool and to act as a prompt to the key points to be considered when assessing and managing the client. The Record requires personal information and drug related history of the client, also general medical and social/personal history. Sexual and risk practices, mental state examination and general physical examination must be documented. There is a recommended set of laboratory tests which the practitioner is advised to carry out.
At this stage, an assessment of the client's suitability to be enrolled in the Program is made, and guidance to assist with reaching that decision is given. The Manual assists in determining the most appropriate regimen for managing each individual client and gives treatment options.
H&CS requires that before clients commence on the Program they are subjected to the provision of certain information regarding the aims of treatment, side-effects, and warnings, for example, regarding overdose. Non-compliance may result in removal of some or all of the services under the Program.
Clients must consent in writing to treatment before it begins. Progress of the client is to be reviewed continuously, but comprehensively at six months, at two years a report must be sent to the Drugs of Dependence Unit. It should contain an outline of the client's progress and reasons for continued methadone treatment.
Take-away doses are allowed in specified circumstances and under strict conditions.
Counselling plays an important part in the treatment, as does HIV and pregnancy awareness.
6.2.4 FundingA revised method of funding public services was developed for regions for 1994/95. The formula is based on population of the region, a socio-economic disadvantage index, and a non-metropolitan weighting.
Most pharmacies charge a dispensing fee, although most charge less than the Pharmacy Guild recommended fee. The average dispensing fee for non-concession clients was $28.01 per week. The average fee for concession clients was $20.21 per week. The average overall was $24.20 per week.
Funding for the four specialist clinics to be operated under contract with H&CS will be based in the first years on a lump sum payment from H&CS of $190,000 per clinic for all methadone maintenance services for 60 placements at each clinic. This payment level provides for a mix of clients, ranging from long term placements, down to treatment lasting less than 6 months.
The primary health care needs of these clients will continue to be funded under Medicare.
6.2.5 StatisticsThe number of clients in the public and private sectors in Victoria since 1986 are contained in the Table 4 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 following statistics:
The data illustrate the relative static nature of public sector participation in Victoria at approximately 0.1 persons per thousand, while the private sector has grown significantly from 0.04 persons per thousand in 1986 to 1.26 persons per thousand in 1994. Overall participation has grown nearly tenfold from 0.14 persons per thousand in the target population group in 1986 to 1.35 persons in 1994.
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Table 4: Numbers of private and public clients in Victoria, 1986 to 1994