Drugs, Poisons And Controlled Substances Amendment Bill 20200310

"The Greens enthusiastically support the Drugs, Poisons and Controlled Substances Amendment Bill 2020. It is a bill to reduce harm in the community, and it also sends a message of care rather than the message of deterrence that is inherent in prohibitionist measures."

One of the things the bill does is it allows a friend or someone other than the drug user to pick up supplies of needles and syringes. The supply of clean needles and syringes has prevented decades of infections with bloodborne viruses, and that particular epidemiological pathway would have led to a lot of infections in women with HIV back in the 1980s and 90s, which we did not see in this country. A lot of other countries had a lot more HIV-positive women and therefore HIV-infected babies. We had some of that but far less than, for example, Scotland and the United States, Spain and Italy. Those countries had a lot more children born with HIV and they also had a lot more people co-infected with HIV and hepatitis C, something that is less common in Australia. The reason for that is the establishment of needle exchanges and supplies of clean needles and syringes under the federal health minister, Neal Blewett, and he and those who encouraged him should be commended for this public health measure which probably saved many lives and prevented thousands of infections.

I would like to reassure the members for Lowan and South-West Coast that I do not see the provision of needles and syringes as an encouragement for drug use for under-18s. I am not sure if that is what you were concerned about, but if it was, I see it as a bit like vaccinating adolescents for human papillomavirus—it does not encourage them to rush out and have sex, but it prevents them from the consequences if they do—or providing condoms for that matter. I think these things reduce the risk of harm and they make an activity which sometimes we might disapprove of safer, and it means that people are less punished by the consequences of their actions. It is a public health measure. It is not the same as supplying the heroin, for example.

The bill also makes naloxone more readily available by allowing regulations to add to the classes of people who are able to possess or administer naloxone. There is no point just giving an injecting drug user naloxone to take away if, say, their housemate or their partner or their mum cannot use it or cannot have it in the cupboard, because if you are unconscious from a heroin overdose you cannot resuscitate yourself. So these regulations need to be as broad as possible as to the classes of people that can possess it, and I do not really see any reason why anyone should not have access to naloxone. It is not a drug of abuse itself.

Effectively the bill makes injecting heroin and other opioids safer. Really it should have been passed in the 1990s when we had our other heroin epidemic. I worked in a community health centre in Collingwood back in the 1990s, and the joke amongst the staff was that we had hundreds of safe injecting rooms back then—we just called them ambulances. But it was no joke that hundreds of times they were too late to arrive. When you stop breathing you have got 3 or 4 minutes before irreversible brain damage occurs, and I had at least one patient with permanent brain damage because by the time he was resuscitated it was too late.

I first saw naloxone used there, and I used it myself one night late out on the footpath outside the health centre in Hoddle Street. I had to inject it through someone’s jeans. Now, trans-denim injection is not a recommended route, but nevertheless it was highly effective. He got up, swore at me and wandered off into the darkness exactly as the member for Melton described. The other recollection I have from that time is giving someone’s parents some naloxone in case they needed to use it on their daughter at home. I do not think I was even aware that I was breaking the law, so I really welcome the passage of this bill to make what I did a long time ago finally legal.

Ms Britnell: I don’t think it’s retrospective.

Dr READ: It’s a shame it’s not retrospective, but there you go—confessions in the house.

Just to remind people what this is all about, the United States has been experiencing an unprecedented opioid crisis, with around 50 000 people a year dying of opioid overdose. About two-thirds of the deaths involve synthetic opioids like fentanyl and fentanyl analogues. Fentanyl is a more powerful version of morphine and shorter acting. According to the Penington Institute’s Australia’s Annual Overdose Report 2020—looking at the Victorian figures—600 Victorians died from overdoses of pharmaceutical opioids like fentanyl or morphine in the four years ending in 2018. That is double the amount from the corresponding period a decade earlier. Looking at the same two periods, 683 people died from a heroin overdose in the four years to 2018 in Victoria. That is a bit more than double the amount from the same period a decade earlier. We have got an increase in deaths from both synthetic opioids, or pharmaceutical opioids, and heroin over the past decade or so. That is well in excess of the road toll. Therefore this bill is timely.

I also echo and endorse the calls from the member for South-West Coast for more rehabilitation beds. I understand the centre she is calling for is in Warrnambool. It is well recognised that regional Victoria is particularly hard hit at the moment with drug problems, and more drug and alcohol rehab beds in the regions are desperately needed. The member for South-West Coast referred to not just putting the ambulance at the bottom of the cliff but trying to put a fence on the top.

I would like to comment on another use for naloxone. Naloxone in combination with buprenorphine is used in the same way as methadone—as an opiate replacement or substitution therapy for people who want to stop using heroin or other opioids to which they are addicted. Now, this means that they can be given—for example, in the case of methadone—a daily dose which they collect at the pharmacy. They know exactly how much they are getting. They have got a regular supply every 24 hours. They do not have to rob anyone to get the money to buy it. Their life is stabilised, and they can have secure employment. They are at no risk of overdose because we know precisely what dose they are getting, and they have got a physiological tolerance to the drug so they are not going to drop dead from it.

The big risk of overdose is if you have a bit more than you expect or if you have a bit of time off—say, if you have a few weeks in prison and then you get out and you have lost your physiological tolerance and you have your usual dose and drop dead. What is really important, and I think a logical step after this bill, is that the next bill, which I really encourage the government to bring, is one that makes it easier for people to get methadone, naloxone, buprenorphine and other opiate substitution therapy. The two people I referred to that I looked after back in Collingwood in the 1990s were unable to get methadone at our clinic. In fact methadone prescribers are few and far between, and the number of opioid substitution prescribers in Victoria has been diminishing. In discussions with colleagues I have heard that there is only one prescriber in Frankston. There is a real shortage of doctors prescribing this.

But there are other important barriers to accessing opioid substitution therapy, and the most important one is the cost. While some of these drugs are on the PBS, what is not on the PBS is the pharmacy fees, the dispensing fees, for these drugs. They are typically $30–$35 a week, and that fee, I am told by pharmacists, has not increased in 30 years. When you consider the interaction that they have with the patient, the consumables and the time spent, that is not a lot for them to ask. But patients often do not have the money and do not pay. It sets up a tension between the pharmacist and the patient, and patients too often fall off the wagon. I had one patient die almost certainly as a consequence of not being able to pay for her methadone. I think we have a system that puts up significant barriers to people receiving the best treatment to stop their heroin or other opioid use, and methadone, naloxone and buprenorphine are regarded as the best treatments for heroin addiction. There are more than 50 000 people using this kind of treatment in Australia, and every state other than Victoria provides some form of subsidy or access. So I think this is a real challenge for the Victorian government and one that I recommend the government accept.

I think that with these dispensing costs, when compared to the costs of, say, the hospital admission of the patient that I mentioned—who fell off the wagon, used heroin and got a heart valve infection and spent months in hospital—a $30-to-$35-a-week dispensing fee pales into insignificance. This was actually a recommendation of the Law Reform, Road and Community Safety Committee. Three years ago this month they published the report of their inquiry into drug law reform, and they recommended that:

The Victorian Government fund opioid substitution therapy (OST) dispensing fees to enhance access and remove barriers to a person entering and remaining on OST.

That is referring to naloxone, buprenorphine and methadone. That was recommendation 32. Recommendation 33 is also worth reading:

The Victorian Government expand access to opioid substitution therapy (OST) through a range of measures including:

• the provision of financial incentives to general practitioners and pharmacists to prescribe OST, particularly as the current cohort of prescribing doctors is ageing and a shortage is expected—

we cannot help that—

• enhancing the role of nurse practitioners to prescribe OST

• exploring models for hospitals to provide OST to suitable patients as part of emergency department treatment.

I think it is really important to emphasise those last two. It is not necessary for doctors to prescribe this stuff; we could have hospital nurses prescribing it.

The government already pays for it for opioid addicts who are aged 18 and under, and it is paid for people discharged from prison for their first month. Just last Thursday, Coroner Hawkins, in handing down a finding on the death of Shae Paszkiewicz, noted an estimated 32-fold elevation in drug-related mortality amongst recently released prisoners. This almost certainly relates to that loss of tolerance to heroin during their time in prison, which may only be a few weeks. Then when they come out, they take the dose they are accustomed to and die. The coroner recommended a take-home naloxone program post release, and I hope that that goes ahead, particularly after the passage of this bill. She also commented on the shortage of doctors prescribing OST and high daily out-of-pocket costs for dispensing OST after the first four weeks after discharge.

So there we have the Law Reform, Road and Community Safety Committee recommending three years ago the subsidy of OST dispensing fees and predicting a shortage of doctors, and last week we have the coroner reporting on the shortage of doctors prescribing OST and commenting on the high daily out-of-pocket cost for dispensing it. So if we care about reducing heroin addiction and use, the most significant issue that we need to address is not the location of the second medically supervised injecting room; it is getting more people onto the best treatment available by removing cost barriers for opioid substitution therapy and increasing the access to nurses or doctors who can prescribe it. I look forward to government action to address this.

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