Richard Hallinan: Prescribing a disaster

FEW doctors can have missed the disturbing reports in the media and medical literature about enormous increases in the consumption of prescription opioid analgesics and their unsanctioned use, including prescription shopping, diversion and injection, and harms including addiction and overdose deaths.

This trend began with the legitimisation of prescription opioid use for chronic non-cancer pain in the closing decades of the 20th century. It has been most marked in the US and Canada, where prescription opioids kill more people than heroin and cocaine combined. Australia is not far behind.

From the public health perspective, with our strong track record in drug policy and harm reduction, Australia ought to be well positioned to avert this crisis in the making.

The nub of the issue is how to reduce harms from prescription opioids without losing their benefits.

Simple supply reduction is not an answer: we risk throwing the baby out with the bathwater. With an ageing population and increasing prevalence of chronic pain, we must not swing the pendulum back to the days of under-treatment of chronic pain.

The 2009 RACP Prescription Opioids Policy made a number of key recommendations for dealing with the problem. It is worth reflecting on the progress (or lack thereof) made since then:

• We still have no real-time comprehensive information service for doctors and pharmacists about previous supply of opioids to patients, despite the potential for the Pharmaceutical Benefits Scheme monitoring systems to be adapted to this purpose. GPs and pharmacists are flying blind in the face of prescription shopping.
• There is still no standardisation of opioid regulations across the states and territories.
• There are still no generally endorsed guidelines for use of opioids in chronic pain.
• Despite the need to extend addiction treatment services to meet the needs of a new and largely hidden population of opioid-dependent people who have never used heroin, waiting times for opioid pharmacotherapies remain long and the large costs of supervised dispensing are still unsubsidised.
• Waiting times for treatment at pain clinics remain unacceptably long around the country, and there are very few pain specialists in private practice.
• Despite Medicare recognising addiction medicine as a medical specialty in 2010, it provided Medicare Benefits Schedule rebates so low that virtually none of the 150 or so addiction medicine specialists practising in Australia have registered with Medicare. This has left referred private practice virtually dead in the water, while the public sector, where most specialists remain employed, has little capacity for accepting GP referrals.

Although GPs can refer to specialist colleagues in most other areas of medicine, in managing people with chronic pain they are left high and dry, with little access to specialist support.

Some tips for GPs:

• Take a systematic and “universal precautions” approach.
• Only prescribe for patients well known to you, and seek information about those you don’t know from the Prescription Shopping Information Service, the State/Territory Pharmaceutical Services or the PBS.
• Given that many people don’t respond to opioids for chronic pain, commencing opioid treatment should be considered to be a trial and end points of treatment should focus on improvement in function. Set a trigger dose for specialist review, maximise opioid-sparing non-drug and drug treatment, recognise and manage the psychosocial aspects.
• Discuss safe storage and disposal of unused opioids to minimise diversion.

This is not a public health disaster waiting to happen — it’s already happening. And the authorities have been given ample warning.

Dr Richard Hallinan is an addiction medicine specialist practising in Sydney.

Posted 31 October 2011