Avoidable loss of life is always a tragedy. On December 26, Craig Whitall veered onto the wrong side of the Princes Highway when driving from Nowra to Ulladulla resulting in four deaths, including his own.
The details of this tragedy have been reported widely not only because the crash involved an actress but because Whitall's trip was made in the context of his receiving methadone treatment.
There are a number of questions that need to be asked after this accident but the one that should not be posed is "should people on pharmacotherapy for opioid dependence be allowed to drive?".
In line with an accepted evidence base, the national guidelines relevant to methadone state that people who are in stable treatment for opioid dependence do not have a greater risk of a crash and, like all other motorists, should be subject to jurisdictional guidelines.
The assessment for fitness to operate heavy machinery is done in consultation with a person's prescriber on a case-by-case basis. Prescribers of methadone undergo specific training and ongoing scrutiny by a committee of peers and as sole prescriber to their patients – sometimes over years – usually know them well.
When patients are on a stable dose and are not under the influence of unprescribed drugs or alcohol, they prove as safe in driving as the general population.
While research indicates that methadone cannot be blamed for auto accidents as a rule, we do not have enough information to know if Whitall's treatment was a factor in this very sad event.
One part of the story that we are sure of is that he was required to travel for close to an hour to access treatment. This is the clearly preventable element in this tragedy.
People on treatment are in most ways like anyone else – we work, have families and contribute to our communities. Treatment allows people who become dependent on opioids to live normal, productive lives – we are for the most part no different from someone who may, for example, use insulin to control their diabetes. The difference is in how we are treated.
In spite of medically assisted treatment for opioid dependence having a substantial evidence base for its benefits, with more than 20,000 people in NSW on treatment, the program remains difficult for people to access, especially in rural areas.
Where it is possible to get onto treatment, patients are often treated poorly. Many of us who have been on treatment for years must attend unnecessary medical appointments – as often as fortnightly – not because we are unstable or need additional care but because it is a billing opportunity.
Many of us, like Whitall, need to make long journeys on a daily basis to access the medication because we cannot access it from a service closer to home.
There are often severe restrictions on takeaway doses that mean we are locked into arrangements that make work difficult or impossible, eat into time with our families, make travel difficult and, in some cases, mean that we miss out on parts of life that others take for granted, such as the ability to attend family funerals and weddings.
Why is treatment so restrictive and difficult to access? For many years, people who use opioids have been regarded as morally weak, even evil, a "scourge".
Pharmacies – a necessary health-care service – have the option of refusing to dispense methadone. Relatively few doctors are willing to take on patients requiring medically assisted treatment for opioid dependence, and those that do have limitations on the number they can take on.
In many settings where treatment is dispensed, service users are treated like an underclass, like criminals. Treatment is dispensed from behind a barrier after passing through an iron gate. We are forced to wait, rules can be oppressive and often the worst is assumed and we are treated with casual and unfeeling disdain by those that purport to be our health-care providers.
All of this is before we get to the question of the fees, which can be prohibitive. Many members of our community pay $85 each week on dispensing fees for a treatment that is provided free of charge by the Commonwealth. No subsidy is available. Is there any other evidence-based and life-saving medical treatment where access requires many patients to experience severe financial hardship?
Reform, nationally and in NSW, is badly needed. In NSW we have new treatment guidelines due to be released that will, hopefully, increase the number of prescribers, with further work to be done on supporting access to treatment through pharmacies.
But the main issue to be tackled is the stigma that people on treatment experience – stigma that is fuelled by headlines linking a road tragedy to methadone treatment.
In February 2018, over-the-counter codeine products are due to become dispensed by prescription only, a move that is likely to result in many members of the community requiring treatment. Instead of assuming that everyone who requires treatment is at best weak, or at worst morally corrupt, we need to assume that they are like everyone else who needs the support of the health system – a person with perhaps a chronic condition whose life can be improved through medical care.
We need to stop the judgment, stop blaming people for their health conditions and move on to a world where we are afforded the same care and respect as any other member of the community by medical practitioners who are paid to provide medical care.
Mary Ellen Harrod is the Chief Executive Officer of the NSW Users and AIDS Association.