Suboxone: freedom on a big stick

1
Suboxone freedom on a big stick

• Some consumer concerns and perspectives
• By Damon Brogan
• VIVAIDS Inc.

2
User involvement in Suboxone implementation

• Reckitt Benckiser recognised importance of
  consumer participation in the introduction of
  Suboxone in Australia
• AIVL and its members (state user orgs) invited to
  participate via consumer forums from 2003.
• Role of forums
• Information to user groups on pharmacology,
  pharmacokinetics of Suboxone, companys plans and
  progress, progress of trials etc.
• Opportunity to voice consumer concerns
• If not to encourage demand, at least to minimise
  resistance

3

• Early user group debate and concerns
• Being used to market a drug unethically
• How could we trust a drug company why should
  they care what we think?
• Bupe / naloxone cited as the big stick smacks
  of control
• States might replace Subutex, reducing consumer
  choice, and freedom
• Buys into moral panic over injecting, instead of
  rational debate over injectable maintenance
  therapies
• Do we lose more by staying out or by critical
  participation?

4

• AIVL Suboxone Forums
• UK User orgs experience of working with Reckitt
  Benckiser OK
• Same company markets Subutex and Suboxone
• However cynically, user opinion was being
  sought
• Some opportunity to influence implementation
  and State policy
• High quality briefings on both the pharmacology
  and the trial (Dr James Bell)
• Possibility, if not guarantee, of real gains
  for consumers unsupervised dosing, affordable
  therapy
• Grave misgivings remain around states using the
  Big Stick approach
• Sets back injectables debate

5
Aims of OST Pharmacotherapy

• User aims
• Control, choice over own psychoactivity
• Freedom from black market prices, poverty, risks
  of CJS
• Freedom from withdrawal desperation
• Safety from OD, BBV
• Time and money to devote to other interests
• Some genuinely desire abstinence for its own
  sake, more just want an end to poverty, stress,
  alienation and risk
• To be seen as a health consumer, not a public
  menace self respect

• Govt aims
• Control over users psychoactivity
• stop drug dealing and acquisitive crime from
  dependence on black market
• Stop / Reduced injecting and desperation, less
  ODs and BBV risk
• Imposed abstinence (despite the talk of HR)
• Health treatment cheaper than CJS
• ? Consumer freedom, autonomy
• ? Consumer social participation, wealth, status
• ? Consumer health (not public health)
• Minimal political risk / adverse headlines.

6
Maximising community benefit from pharmacotherapy

• What is an optimum program?
• Facilitates consumers participation as
  self-determining individuals in the economic,
  social and cultural life of the community
• Is cost effective (does not mean cost neutral to
  govt)
• Is supported by consumers
• Significantly reduces risks, costs and harms of
  dependence on illicit drug use / black market
  does no harm

• How?
• Freedom of movement so that employment, family,
  travel, leisure and creative pursuits are
  feasible.
• Same cost-benefit formula and PBS criteria as
  other drugs
• Recognises differing needs, offers choices,
  respects right to self-determination
• Safe, effective treatment and does not add to
  quantum of harm (eg the treatment / poverty trap)

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Suboxone can deliver if

• Unsupervised dosing gt Freedom of movement gt
  social participation
• Dispensing fee based on same formula as other NHS
  / PBS drugs (same monthly fee to consumer)
• Offers an additional choice to consumers
  doesnt replace existing options
• Does not further disempower users not used as
  social control device (Big Stick)

8
The Big Stick

• Replaces Subutex and perhaps methadone
• Is about coercion and loss of individual control
• Puts reaction to injecting / diversion before
  higher aims of the program
• Is a one-size fits all, pharmacological solution
  that wont work to a problem that hardly exists
• Doesnt investigate, quantify or detail the harms
  (or benefits) from diversion / injection of bupe
• Puts social control before social integration

9
What we are seeing interstate

• Govts forcing people from Subutex to Suboxone
• Restrictive takeaway regimes maintained
• No fee relief for consumers
• Consumer loss of confidence in pharmacotherapy
• Increased potential for individual and societal
  harms
• More profits for crime cartels

10
What were seeing in Victoria

• Best pharmacotherapy policy
• Cautious pathway to unsupervised dosing
• More discretion to prescribers, more methadone
  T/As, more choice
• Pharmacists still want daily dispensing fee
• Many pharmacists forcing consumers onto Suboxone
  some GPs ?
• Consumer support poised in the balance !

11
PAMS Pharmacotherapy Advocacy Mediation and
Support

• Telephone service for pharmacotherapy consumers,
  providers and support workers
• Information, referral, mediation, support and
  training
• Seeks win-win situations where disputes threaten
  service outcomes or continuity
• Provides training to agency staff on consumer
  issues
• New series of SUBOXONE workshops for agencies
  supporting pharmacotherapy consumers
• Call Sarah Lord 9329 1500

12
Thank you

• VIVAIDS Inc
• Recognising Rights, Reducing Harms