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THE rollout of a proposed national reporting initiative to help curb “prescription shopping” and opioid misuse seems to have stalled, with experts calling for action on a real-time monitoring system of Schedule 8 drugs.
A Perspectives article in this week’s MJA says the introduction of a national real-time reporting system promises health professionals “better information for decision making”, despite the mixed benefits of prescription monitoring programs operating in the US. (1)
The authors wrote that the number of opioid prescriptions in Australia had increased by about 300% between 1992 and 2007, with growing professional concern about the appropriateness of prescribing these drugs for people with chronic non-cancer pain.
Currently in Australia the regulation and monitoring of Schedule 8 drugs differs in each state and territory, although the federal government last year committed $5 million to establish the Electronic Recording and Reporting of Controlled Drugs (ERRCD). The real-time reporting system is modelled on a program pioneered in Tasmania that automatically collects details of all Schedule 8 prescriptions at pharmacies and sends them to state health departments in real time.
A spokesperson for Health Minister Tanya Plibersek told MJA InSight that the initial version of the ERRCD system was made available to the states and territories from July last year.
The spokesperson said further modifications to the system, to enable full real-time reporting capabilities and cross-border information sharing, were completed last November and software licence agreements were recently provided to the states and territories.
“The department is keen to see the ERRCD system implemented as soon as possible. This is dependent on states and territories signing [the licence agreements], making changes to relevant legislation and migrating data from current systems to the ERRCD system”, the spokesperson said.
However, Queensland’s Chief Health Officer Dr Jeannette Young told MJA InSight the federal government had not yet released the ERRCD software. She said Queensland would participate in a trial of it when the software was released in about two months.
A SA Health spokesperson said it was also waiting for the delivery of the final version of the software, but was committed to implementing the ERRCD system. A spokesperson for NSW Health said it was currently assessing the system.
Dr Simon Holliday, visiting medical officer with the Drug and Alcohol Clinical Services department at Manning Rural Hospital in NSW, said he believed the ERRCD had become “bogged down in privacy laws and state/federal squabbling”.
“We may have to wait until 2014 or later”, he said.
“It’s mad that the real-time reporting system is not embedded with the e-health system”, Dr Holliday said. “It’s not going to make everything perfect, but there is no question it will pick up a lot of stuff.
“At the moment we have a farce of a system. [The ERRCD] would be public health CPR — really essential”, he said.
However, the authors of the MJA article cautioned that there could be unintended negative consequences of a real-time reporting system such as overly cautious prescribing of indicated drugs, a shift to other drug classes or illicit drugs, unsanctioned procurement, stigmatisation and poor uptake of the system by doctors.
Dr Holliday agreed that a real-time reporting system would miss identity fraud, and people who hoarded prescriptions or when drugs were stolen or resold.
“Overall, though, it will be a plus, given its limitations”, he said. “It will help detect the top level of misusers and save lives.”
The MJA authors said full evaluation of any real-time reporting (RTR) system was absolutely essential.
“Australia is introducing one of the world’s first national RTR systems”, they wrote.
“An evaluation of this experience will provide important lessons for other countries struggling to effectively regulate appropriate medical use of opioids for pain.
“A well designed RTR system has the potential to make a significant contribution to the quality use of medicines in Australia.”
– Cate Swannell
Posted 4 February 2013
As an Addictions specialist I can tell you that I see a regular flow of people who have addictions to prescriptions drugs which are easily appropriated through legal means. When a patient walks into a doctors surgery requesting, for example, Oxycodone for back pain, the Doctor should then berequired to simply check the patient’s name at his desk for details of this particular individuals recent prescription acquisitions. If the patient has recently acquired any opiate drugs then the Dr is not permitted to prescribe further opiates without taking certain measures – this means the Doctor does not have the discomfort of saying no to a possibly agitated person who may be presenting with the beginnings of withdrawal. This request is then automatically noted in the database. Simple steps that will at least start to address the growing numbers of wonderful people who, for whatever reason, are struggling with substance abuse.
The ERRCD could as a starting point primarily be utilized to stamp out the most obvious offenders/doctor shoppers that are procuring amounts of S8 prescriptions that cannot be sensibly taken by any given individual without chronic pain. This could be an arbitrary figure such as in the case of e.g. morphine more than 100-200mg of oral extended-release tablets per day without consultation of a pain specialist. Secondarily, the system could actually help GPs achieve better patient outcomes by having other specialists becoming involved once a certain time has lapsed, certain amount of prescription strength/dosage reached or number of scrips dispensed.
The article is primarily about prescription shopping and opioid misuse, not acute nor chronic pain.The former includes drug-dealing in prescription opiates including via stolen identity, stolen prescriptions sold to support gambling, alcohol, OTC, street and prescription drug addictions, completely separate issues from acute/chronic pain. While the former addictions warrant treatment according to the PBS and other guidelines, prescribing opiates to patients who are suffering from neither acute nor chronic pain to sell is not a recognised treatment for addiction. The challenge is to design and implement a workable system which allows appropriate prescribing for pain, while limiting the increasing prescription of opiates for non-pain use.
The preceding comments lose site of one important factor, the patient. Patients have either acute or chronic pain, which varies from mild to excruciating, and of different types. It is a doctors professional duty to clearly determine the type, nature and severity and prescribe appropriately. The Commonwealth registers analgesics. It could be argued that this should be accompanied by mechanisms to monitor there use. The mechanism must permit both timely and appropriate prescribing as well as monitoring. Alongside this is that many practitioners and law makers have an irrational fear of S8 drugs, and a poor understanding of what and when to use them. It is time that we as a profession take control of these types of issues and others. Organisations such as the AMA, RACGP etc could lead the initiative however this is unfortunately unlikely for many reasons. The focus should not be on those small minority that misuse S8’s, that is a secondary consideration and should not interfere with the legitimate use of S8’s. An efficient system, with easy access, supported by education for both practitioners and patients/carers which doesn’t interfere with timely use is what is required – a challenge to the profession and its representative bodies – who will step to the plate?
A simpler solution may be for the PBS authority system to restrict all opiates with a street value to appropriate use including palliative care in a weekly dosette . The opiates with no street value could be PBS authority restricted to include GP + available Pain or other Specialist or another GP if in a rural/remote area. .
I would concur with colleagues above. I recall as a second year RMO working in A+E being anxious about handing out Panadeine Forte and now patients leave ED after simple sprain injuries with a quantity of S8 more than a day or two supply. To change this is hard once a patient believes an S8 is a baseline for any pain relief.
Society has become conditioned to believe any discomfort must not be borne at all, this aided by strong marketing of these medications.
Early education of young graduates around acute pain management seems needed
Dr Bailey
Some of the problem originates in Emergency Departments. The last revision of the “Triage Score” added “pain scores” in spite of absurdity of using these scores to compare one person’s pain to another’s (a misapplication with NO data to support it). So patients with sprained ankles or chronic back pain telling the waiting room nurse that they have severe pain, or pain unrelieved by simple analgesics, are given nurse-initiated narcotics.
Once that has happened, it’s very difficult for medical staff to explain that they can’t be given more at discharge, since its clear that the narcotics they want are readily available.
This system leads to true under-treatment and slower response to the patients that triage is supposed to detect – those whose outcome is altered by prompt treatment. And to more narcotics in the community and I suspect, for sale.
How many coroners’ reports will it take before the Federal Government and all GPs stop being naive about this public health issue/
Unfortunately a half baked idea. ALL prescription medications should be part of a real time PRESCRIBING system not picked up by the dispenser after the “prescription shopper” has already wasted taxpayers $ and doctor’s time.
There are currently millions of dollars being spent by Medicare in payments to pharmacies dispensing Schedule 8 drugs to “patients” who are on selling them for an enormous return on funds invested, This has to stop. The only way is for Real Time Reporting. It is essential for there to be a system whereby this can happen. Back in 1999 in the Northern Territory there was a plague of doctor shoppers going around with the NT at the time using more of a particular brand of morphine tablets 100mgm than the whole of NSW for a fraction of the population.
It has taken 14 years to get the Commonwealth to agree to putting money into the initiative and one would hope the States/Territories are not going to play politics with this important public health menace.
Pharmacies must be equipped and each jurisdiction has its own requirements for reporting back on S8 dispensing so it should not be too hard to accommodate a new system. The Tasmanian model has been in operation for a number of years and should by now have proved its worth.
Rollo Manning
Pharmacist
Darwin
I agree with Tim Bailey – opiates seem to be used too frequently for first line pain management and for pain that is not severe. In our region, this is often the case with patients discharged from hospital for injuries & post-op analgesia. Many of these drugs/scripts are not used by the patients because of opiate side effects. This also reflects the absence of a “sensible, middle strength” analgesic on the PBS schedule – panadeine forte should be removed & panadeine (500/8) placed on schedule instead. This would result in much more sensible use of codeine/paracetamol combos & perhaps reduce the rapid progression/excess use of opiates.
I am wondering whether there will be information gathered with the software which will enhance our ability to provide professional accountability? Over the past 2 years or more, I have noticed a rapidly accelerating trend to provide opiates as a sole first line agent for anything from a wry neck to a sprained ankle, cellulitis or back pain and headache. Where is this phenomenon originating?