The ‘Pharmacotherapy Advocacy, Mediation and Support (PAMS) Service

A Program of HRV

Presented By: Sarah LordADF 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• 2nd 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 responsibilitiesAttitudes 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 2nd 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!