Opioids [South Africa] Update: progress to getting methadone onto the essential medicines list for OST maintenance at primary care level.

[Imaginarium]

In South Africa, Opioid Substitution Therapy (OST), the agonist medications methadone and buprenorphine (± naloxone) are registered for use and only methadone is listed on the essential medicines list (EML) for use at hospital level for detoxification and neither medications are available in the public sector for maintenance. (i.e. neither medication is available in the public sector for maintenance). OST (as maintenance) boasts higher retention in treatment and reduced use of un-prescribed opioids than managed withdrawal (detoxification); however, despite this detoxification is still widely used. Given South Africa's socioeconomic context, the high cost of methadone (10 - 30 times more expensive than other low- and middle-income countries) makes it unattainable for the majority of people who need it. In the private sector, OST is provided as maintenance as part of out-patient services through private practitioners and self-funded civil society programmes.

Despite the increasing need, none of the medications suitable for OST are listed on the EML for maintenance prescribing. However, I am pleased to let other South Africans (and those interested) that significant progress has been made!

The National essential medicines list committee (NEMLC) has reviewed the evidence and motivations when they met on 9 December 2021. They have provided us with the following feedback and their decisions.

For methadone:

• The decision is: "Methadone may be made available for pilot sites selected and monitored by the NDoH Programme. Data from such sites should inform further decisions regarding inclusion on the national essential medicine list for universal access."
• There is a draft standard treatment guideline (STG) for opioid dependence management as well as a checklist to guide implementation at the district level.

For buprenorphine:

• The decision is: "buprenorphine is not included on the national essential medicine list. The service delivery platform is currently insufficient for national implementation of OST with buprenorphine, considering the risk of diversion to illicit drug markets. There is insufficient local data to inform a cost-benefit decision vs methadone."

Comments on the relevant documents are due by 9 February 2022. I urge all those committed to this to make submissions.