In a contributing opinion piece, three of Australia’s most respected leaders in harm reduction and drug policy, Annie Madden AO, Executive Director of Harm Reduction Australia, Dr Jake Rance, Senior Research Fellow at UNSW’s Centre for Social Research in Health, and Dr Richard Di Natale, former Senator, Greens leader and practising ODTP prescriber, argue in support of an updated policy brief that despite some positive reforms, Australia is running out of time to fix one of its most neglected areas of public health.
Australia’s Opioid Dependence Treatment Program (ODTP) is one of the country’s most important, yet most neglected, public health systems.
Each day, more than 56,000 Australians receive life-saving treatment for opioid dependence (AIHW, 2024). These treatments, methadone, buprenorphine, and newer long-acting forms, are recognised by the World Health Organization (WHO) as essential, and their impact is profound, preventing overdose deaths, reducing blood-borne virus transmission, and improving people’s health and social stability.
Yet opioid-related deaths continue to climb.
The latest government data show more than 1,200 Australians die each year from opioid overdose (AIHW, 2024). And a new threat is already on the horizon. Potent synthetic opioids like fentanyl and nitazenes are beginning to appear in Australian drug markets, echoing the early signs of North America’s catastrophic crisis (AFP Release. 2024). We know it’s coming, but we remain dangerously under-prepared, much as we were before the pandemic.
The ODTP is one of our best defences against that future. But despite its proven success, the system is straining under outdated policies, workforce shortages, inconsistent regulations and persistent stigma that limit access, compromise care, and leave thousands without treatment. It’s time to reimagine Australia’s opioid treatment system for the challenges ahead.
A fragmented system that fails those it serves
Australia’s ODTP operates under a patchwork of state and territory rules that shape how treatment is prescribed and dispensed. The differences are stark. Access can vary wildly depending on where someone lives, creating inequities no national health system should accept.
This fragmentation leaves people and providers navigating unnecessary hurdles. Someone moving interstate may have to “start again” and wait weeks for approval, disrupting care and putting them at risk. For clinicians, differing rules and prescribing requirements add red tape and make participation less appealing.
But it’s not just regulations that differ from state to state. The level of investment also differs. Victoria, for example, funds almost no public pharmacotherapy services and relies heavily on private GPs and pharmacies. In 2021, Victoria had only 50 publicly funded patients receiving pharmacotherapy, compared with 8,498 in New South Wales (MSIR Final Report, 2023). The report also found that Victoria treated 14,804 people, far fewer than NSW’s 24,340, despite comparable levels of need, a clear sign of high unmet demand and chronic under-resourcing.
Australia needs a nationally consistent policy and regulatory framework, backed by equitable public investment, to ensure the ODTP can meet current and emerging challenges.
Outdated care models and entrenched stigma
Despite major advances in other areas of medicine, many aspects of Australia’s ODTP still reflect punitive and paternalistic attitudes rather than modern health care practices. Rigid ‘take-home’ dose restrictions, supervised urine testing, and inflexible supervision requirements persist in some jurisdictions. Such measures would be unthinkable in other treatment settings. Indeed, research shows that instead of reducing harm, these measures devalue service users, eroding the trust and engagement required for effective therapeutic engagement.
During COVID-19, temporary policy relaxations, such as expanded take-home doses and home delivery options, demonstrated that flexibility can be implemented safely, effectively, and quickly. Research conducted during the pandemic described the life-changing differences afforded to some individuals by simply relaxing restrictions on take-home dosing (Rance, J. et al., 2023). The evidence is clear.
When the ODTP operates with compassion and trust, outcomes improve for everyone, as this participant in the study by Rance et al. highlights. “I have a wonderful doctor, wonderful pharmacist and I go in one day a week and I pick up my takeaways for the week and because of that, that I actually managed to go back to TAFE [further education] last year. [I]t totally changed my life … Better than sliced bread." (Liz, 50, regional)
A workforce under strain
Only around 7 per cent of Australian GPs prescribe opioid treatment, and the cohort is ageing (Wilson, H. et al. 2022). Many cite ‘associated stigma’, workload and poor remuneration as reasons for opting out, but an uncomfortable truth sits beneath this. Negative attitudes toward people on opioid treatment are a significant reason many GPs refuse to participate in this essential area of healthcare. It forces us to ask. Would we accept doctors refusing to treat any other medical condition?
A GP we spoke to for this article, who wished to remain anonymous, explained some of the barriers from a GP perspective.“I’m not opposed to prescribing opioid treatment, but some of my colleagues don’t want ‘those patients’ in the practice, which already sets the tone. Then there’s the reality that a standard MBS consult isn’t enough time to properly support someone with complex needs and then hearing about GPs being contacted by regulators and having their clinical decision making questioned. There’s little training or support for new doctors, and the permits and paperwork are endless. It’s no wonder so many GPs decide the risk simply isn’t worth it." (GP, metro)
Expanding and reforming the ODTP workforce is a priority. This includes stigma training to change attitudes, mentorship programs to expand the workforce, fair remuneration models, and workforce planning that anticipates the needs of an ageing treatment population. Without urgent investment, inequitable access will persist, especially in regional, rural, and remote areas, where many communities have reduced and/or poor access to local ODTP services. Aboriginal and Torres Strait Islander people and other highly marginalised groups also face additional barriers to culturally safe, stigma-free care.
To bridge these gaps, governments must invest in telehealth prescribing, community health hubs, mobile dosing units, and peer-led outreach models. These are all proven strategies for extending reach and improving engagement. Empowering Aboriginal Community Controlled Health Services (ACCHOs) to deliver OTP care is another key reform that aligns with principles of cultural safety and self-determination.
Expanding choice and aligning with global best practice
While Australia has made important progress by introducing long-acting injectable buprenorphine (LAIB), and more recently conducted a small feasibility study into injectable hydromorphone in Sydney (Rodgers, C. et al. 2024), the range of treatment options remains extremely narrow compared with many other countries. Nations such as Switzerland, Canada, Germany, Spain and the UK provide access to a broader range of opioid agonist medications, including injectable hydromorphone and diacetylmorphine (heroin-assisted treatment) that have proven effective for individuals who do not respond well to methadone or buprenorphine (Strang, J. et al. 2015).
A national reform agenda
With climbing overdose rates, most involving opioids, and potent synthetic opioids appearing in Australian markets, the stakes could not be higher. The system must move from punishment to partnership, from control to care.
A reformed, modern and ‘fit-for-purpose’ ODTP would:
- Harmonise regulations across jurisdictions;
- Update national clinical guidelines;
- Relax take-away ,and supervised dosing restrictions;
- Expand the workforce;
- Ensure equitable access in regional and Aboriginal and Torres Strait Islander communities; and,
- Increase medication options.
The ODTP must evolve from a fragmented, rule-bound relic into a national model of person-centred, rights-based care. Reform is not just urgent; it is long overdue.
Harm Reduction Australia has launched a new Opioid Treatment Program Policy Brief to advocate for the urgent reforms needed. The full brief can be found online.
