Lintzeris et al. [1] provide the first analysis of changes to opioid agonist treatment (OAT) programs and patient outcomes in response to COVID-19 in New South Wales (NSW). We commend the authors for undertaking the analysis, especially considering the additional challenges involved in offering complex care to people with opioid use disorder during the COVID-19 pandemic.

The findings were generally positive [1]. The number of people receiving six or more takeaway doses (TAD) a week increased from 6% in March 2020 to 31% following COVID-19-related service delivery changes, with no major adverse outcomes for recipients. In fact, increased rates of alcohol or other drug use over the study period may have been related to more frequent supervised dispensing. The lack of adverse outcomes associated with increased TADs will likely resonate with the experience of many people enrolled in OAT. However, we feel that there is one major implication that is not sufficiently addressed in this paper, that is, the cost to consumers associated with community pharmacy dosing may be prohibitive and limit a person's ability to access treatment and these costs remain despite the changes to service delivery.

The OAT service delivery model in NSW consists of a mixture of limited, no-cost programs available through public clinics, and fees-based programs via either private clinics or general practitioners and community pharmacy dispensing [2]. The current model requires consumers at public clinics to attend for daily dispensing of methadone or buprenorphine, while consumers at pharmacies and private services generally receive at least one TAD each week after a period of stabilisation. Current NSW guidelines recommend to limit consumers to four methadone TADs per week or 28 buprenorphine TADs per month [2]. Weekly and monthly depot injections of buprenorphine have recently become available in Australia, although most patients remain on oral OAT.

Lintzeris et al. [1] found that the number of patients transferred from (free public) clinic dispensary to private community pharmacy for dispensing during the COVID-19 pandemic increased from 25% to 49%, almost doubling the number of people attending pharmacies. This shift to the private system could have profound impacts on the finances of clients. The study period ran until September 2020, a period in which unemployment benefits were exceptionally and temporarily raised (approximately doubled) in response to the pandemic. This temporary change lifted many out of poverty as the pre-COVID unemployment benefit rate in Australia was below the poverty line, at about $560 per fortnight [3]. Other income support such as the Disability Support Pension, which some OAT clients receive, is not significantly higher with 41% of Disability Support Pension recipients in 2017–2018 reported as experiencing poverty [3]. Although ultimately unemployment benefits have been raised by $40 per week from pre-COVID levels, it is generally agreed that this amount is insufficient, particularly for those who are required to pay fees for pharmacy-based OAT dispensing. We agree with Lintzeris et al. that ongoing evaluation of the COVID-related impacts on clients is needed in this shifting financial environment [4, 5].

Retention rates in OAT depend on a number of factors but affordability is a central reason for low-income people leaving OAT [6, 7]. The cost has always proved a major barrier to OAT treatment for consumers in Australia [8]. As indicated, the program in NSW includes a limited number of free places provided through public clinics but average fees associated with private dispensing range from $134.82 to $354.70 per month in NSW (or up to $4256.40 per year) [9]. These fees are a significant financial burden for clients, particularly as the best outcomes for OAT consumers appear after long-term treatment, over months to years [10]. One Australian study indicated high levels of personal debt among people attending OAT programs [9]. The resulting poverty makes it hard for consumers to make the changes they would like to make in their lives, as well as meet the requirements of the OAT program [11-13]. A range of adverse events may ensue if a consumer misses a dose and experiences withdrawal, such as using other opioids such as heroin or contracting a blood-borne virus if the person cannot access clean injecting equipment [14, 15]. Notably, the risk of overdose is highest when ceasing OAT, signifying the importance of retention in treatment [16].

There is an expectation from some quarters that consumers at a public program ought to move on to private clinic or pharmacy once they have stabilised, in order to make place for people entering the program [17]. This expectation ignores the fact that consumers may want to move to pharmacy-based dispensing and have access to TADs, but it is not always possible for those of limited incomes who may be living in poverty. Access to TADs leads to a range of benefits, including reduced travel time, potentially better protection of confidentiality, as well as less tangible gains related to feelings of ‘normality’ and having flexibility in daily life patterns [13]. In the UK, services that offer flexibility and allow people to self-regulate their doses, have significantly helped their consumers move towards achieving their goals [18]. The restricted provision of TADs has the potential to reduce personal autonomy as a result of a person's socioeconomic status. The decision to provide clients with TADs should be based on clinical indication and client goals. However, the utilisation of TADs in NSW often appears to be based on a consumer's ability to pay. One simple way to address this issue would be to shift our models of care to allow public clinics to provide TADs. This is not to say that there is anything inherently wrong with private institutions like community pharmacies charging for services, but the anomaly of direct payment of OAT dispensing fees (unlike other medications) for clients who often experience poverty means that more needs to be done to ensure that these more vulnerable clients have equitable access to services without the pressure to move to a user-pays service.

Lintzeris et al. [1] propose a departure from a model of care based on supervised dispensing, something that Australian OAT consumers have been suggesting for some time [19]. Unlike other countries, the OAT program in Australia is heavily reliant upon supervised daily dispensing. But the NSW OAT Clinical Guidelines also state that supervised daily dispensing is ‘intrusive and not compatible with community reintegration through activities such as work or study’ [20]. Daily dispensing provides little flexibility, as one OAT consumer said, ‘It is not normal to have come to a clinic every day’ [12].

Lintzeris et al.'s [1] analysis supports the safe provision of six or more TADs a week as no adverse events were recorded, and we agree with their conclusion that the existing risk assessment process is working well, although the review does not specify whether TADs were being supplied through community pharmacy or public clinics. But the framework to assess the appropriateness of providing TADs should also include a financial assessment to ascertain whether consumers can afford the fees associated with pharmacy-based dispensing, particularly, in the context of the reduction in unemployment benefits at the start of 2021.

Provided that ongoing reviews are carried out with consumers, and that consumers are aware of the reasons why their TADs might be reduced, there appears to be sufficient reason to allow multiple TADs each week via public clnics. There also needs to be more training and guidance around the provision of TADs as many clinicians are risk averse, for example, some believe that the NSW Clinical Guidelines are legislated [20]. Currently, OAT services in NSW are expected to bear the cost of increased patient numbers while receiving no functional increase to their funding by government. A number of calls have been made to increase funding of drug treatment services [19, 21].

Australia's public health system is based on ensuring that health care is available free of charge to those in need. The OAT program caters for one of the most vulnerable groups of people in our society, yet they are expected to pay for their medication. While it is unfair to expect OAT programs to address structural inequality such as poverty, health service providers cannot ignore it either. Services should be modified to meet the needs of clients, including those without the financial freedom to pursue fee-based care.

Ultimately, TADs should be decided based on clinical assessment, and dispensing point should not be a factor. We acknowledge the important role that private clinics and community pharmacies play in the provision of OAT in NSW; however, most consumers cannot afford the associated fees, nor should people of limited means be expected to pay such large proportions of their income for medical treatment. This expectation reduces the ability of the most vulnerable clients to choose the best care for themselves, otherwise, we risk leaving them behind. Future research to assess the feasibility of expanded TAD programs must ensure questions around client ability to pay for TADs are included, and methods allow for those living under the poverty line to be represented.

We hope that the upcoming post-market review of OAT medications will result in them being protected by co-payments and the safety net, to provide parity with other medications provided under the Pharmaceutical Benefits Scheme [22]. However, we would argue that an entirely independent review of how the program is administered across Australia is required. In the meantime, we believe that public clinics in NSW should offer takeaways in accordance with the guidelines until such a time that OAT products, and the people receiving them, are no longer stigmatised and treated differently.

林策里斯等人。[ 1 ] 首次分析了新南威尔士州 (NSW) 针对 COVID-19 对阿片受体激动剂治疗 (OAT) 计划和患者结果的变化。我们赞扬作者进行分析，特别是考虑到在 COVID-19 大流行期间为阿片类药物使用障碍患者提供复杂护理所涉及的额外挑战。

调查结果总体上是积极的 [ 1]。在与 COVID-19 相关的服务交付发生变化后，每周接受六次或更多外卖剂量 (TAD) 的人数从 2020 年 3 月的 6% 增加到 31%，并且对接受者没有重大不利后果。事实上，研究期间酒精或其他药物使用率的增加可能与更频繁的监督配药有关。缺乏与 TAD 增加相关的不良结果可能会与许多参加 OAT 的人的经历产生共鸣。然而，我们认为本文没有充分解决一个主要影响，即与社区药房给药相关的消费者成本可能过高，并限制了一个人获得治疗的能力，尽管改变了这些成本，但这些成本仍然存在。服务交付。

新南威尔士州的 OAT 服务提供模式包括通过公共诊所提供的有限、免费计划，以及通过私人诊所或全科医生和社区药房配药的收费计划 [ 2 ]。目前的模式要求公共诊所的消费者每天参加美沙酮或丁丙诺啡配药，而药房和私人服务的消费者通常在稳定一段时间后每周至少接受一次 TAD。当前的新南威尔士州指南建议将消费者限制为每周 4 次美沙酮 TAD 或每月 28 次丁丙诺啡 TAD [ 2 ]。最近在澳大利亚可以每周和每月注射一次丁丙诺啡，尽管大多数患者仍在口服 OAT。

林策里斯等人。[ 1 ] 发现，在 COVID-19 大流行期间，从（免费公共）诊所药房转移到私人社区药房进行配药的患者人数从 25% 增加到 49%，几乎是药房就诊人数的两倍。这种向私人系统的转变可能会对客户的财务产生深远的影响。研究期一直持续到 2020 年 9 月，在此期间，为应对大流行，失业救济金被异常临时提高（大约翻了一番）。这一暂时的变化使许多人摆脱了贫困，因为澳大利亚在新冠疫情之前的失业救济金率低于贫困线，约为每两周 560 美元 [ 3]。一些 OAT 客户获得的其他收入支持，例如残障支持养老金，并没有显着提高，2017-2018 年有 41% 的残障支持养老金领取者报告说经历过贫困 [ 3 ]。尽管最终失业救济金比 COVID 之前的水平每周增加了 40 美元，但人们普遍认为这个数额是不够的，特别是对于那些需要支付药房 OAT 配药费用的人。我们同意 Lintzeris等人的观点。在这种不断变化的金融环境中，需要对与 COVID 相关的影响进行持续评估 [ 4, 5 ]。

OAT 的保留率取决于许多因素，但负担能力是低收入人群离开 OAT 的主要原因 [ 6, 7 ]。对于澳大利亚的消费者来说，成本一直是 OAT 治疗的主要障碍 [ 8 ]。如前所述，新南威尔士州的该计划包括通过公共诊所提供的数量有限的免费名额，但与私人配药相关的平均费用在新南威尔士州每月从 134.82 美元到 354.70 美元不等（或每年高达 4256.40 美元）[ 9 ]。这些费用对客户来说是一项重大的财务负担，尤其是在经过数月至数年的长期治疗后，燕麦消费者的最佳结果会出现 [ 10 ]。一项澳大利亚研究表明，参加 OAT 计划的人的个人债务水平很高[9 ]。由此产生的贫困使消费者难以做出他们希望在生活中做出的改变，以及满足 OAT 计划的要求 [ 11-13 ]。如果消费者错过剂量并出现戒断反应，例如使用其他阿片类药物（如海洛因）或在无法使用干净的注射设备时感染血液传播病毒，则可能会发生一系列不良事件 [ 14, 15 ]。值得注意的是，停止 OAT 时过量服用的风险最高，这表明保留治疗的重要性 [ 16 ]。

一些方面的预期是，公共项目的消费者一旦稳定下来就应该转移到私人诊所或药房，以便为进入该项目的人腾出位置[ 17 ]。这种期望忽略了消费者可能希望转向基于药房的配药并获得 TAD 的事实，但对于那些可能生活在贫困中的收入有限的人来说，这并不总是可能的。使用 TAD 会带来一系列好处，包括减少旅行时间、可能更好地保护机密性，以及与“正常”感觉和日常生活模式的灵活性相关的不太明显的收益 [ 13]。在英国，提供灵活性并允许人们自我调节剂量的服务极大地帮助了消费者实现他们的目标 [ 18]。由于个人的社会经济地位，TADs 的限制性提供有可能降低个人自主权。为客户提供 TAD 的决定应基于临床适应症和客户目标。然而，在新南威尔士州，TAD 的使用通常是基于消费者的支付能力。解决这个问题的一个简单方法是改变我们的护理模式，允许公共诊所提供 TAD。这并不是说像社区药房这样的私人机构对服务收费有什么本质上的问题，

林策里斯等人。[ 1 ] 提出了一种基于监督分配的护理模式的偏离，这是澳大利亚燕麦消费者一段时间以来一直在建议的[ 19 ]。与其他国家不同，澳大利亚的 OAT 计划严重依赖受监督的每日配药。但新南威尔士州 OAT 临床指南也指出，受监督的日常配药是“侵入性的，与通过工作或学习等活动重新融入社区不兼容”[ 20 ]。正如一位 OAT 消费者所说，每日配药提供的灵活性很小，“每天都来诊所是不正常的”[ 12 ]。

Lintzeris等人的 [ 1 ] 分析支持每周安全提供六个或更多 TAD，因为没有记录到不良事件，我们同意他们的结论，即现有的风险评估过程运行良好，尽管审查没有具体说明是否通过社区药房或公共诊所提供 TAD。但评估提供 TAD 的适当性的框架还应包括财务评估，以确定消费者是否能够负担与药房配药相关的费用，特别是在 2021 年初失业救济金减少的情况下。

如果对消费者进行持续的审查，并且消费者知道他们的 TAD 可能会减少的原因，那么似乎有足够的理由允许每周通过公共诊所进行多次 TAD。由于许多临床医生厌恶风险，因此还需要围绕提供 TAD 进行更多培训和指导，例如，一些人认为新南威尔士州临床指南已立法 [ 20 ]。目前，新南威尔士州的 OAT 服务预计将承担患者人数增加的成本，而政府的资金不会增加。许多呼吁增加对戒毒治疗服务的资助 [ 19, 21 ]。

澳大利亚的公共卫生系统建立在确保向有需要的人免费提供医疗保健的基础上。OAT 计划迎合了我们社会中最脆弱的人群之一，但他们需要支付药物费用。虽然期望 OAT 计划解决贫困等结构性不平等是不公平的，但卫生服务提供者也不能忽视它。应修改服务以满足客户的需求，包括那些没有财务自由来寻求收费护理的客户。

最终，TADs 应根据临床评估决定，分配点不应该是一个因素。我们承认私人诊所和社区药房在新南威尔士州提供 OAT 方面发挥的重要作用；然而，大多数消费者负担不起相关费用，也不应指望经济能力有限的人支付如此大比例的收入用于医疗。这种期望降低了最脆弱的客户为自己选择最佳护理的能力，否则，我们就有可能将他们抛在后面。未来评估扩展 TAD 计划可行性的研究必须确保包括有关客户支付 TAD 的能力的问题，并且方法允许代表那些生活在贫困线以下的人。

我们希望即将进行的 OAT 药物上市后审查将使它们受到共付额和安全网的保护，从而与药物福利计划 [ 22 ] 下提供的其他药物相提并论。但是，我们认为需要对该计划在澳大利亚的管理方式进行完全独立的审查。与此同时，我们认为新南威尔士州的公共诊所应该按照指南提供外卖服务，直到 OAT 产品和接受它们的人不再受到污名化和区别对待。