Real-time prescription monitoring can’t work alone

A LEADING addiction specialist has warned that introducing the proposed Commonwealth developed and funded Electronic Recording and Reporting of Controlled Drugs (ERRCD) system across Australia, without improving access to addiction services and agreement on the “flags” of misuse, has the potential to do more harm than good.

In September 2016, at a Council of Australian Governments Health Council meeting, Federal Health Minister Sussan Ley urged all state and territory Health Ministers to adopt a national real-time prescription monitoring system that alerts doctors and pharmacists to people who are misusing prescription drugs by doctor or pharmacy shopping.

However, Professor Nick Lintzeris, Clinical Professor, Discipline of Addiction Medicine at the University of Sydney, said that prescription monitoring was an important component in a response to prescription opioid misuse in Australia, but warned: “On its own – don’t do it.”

“It will be an expensive model, and all it will be doing is inconveniencing doctors and patients. To introduce a system without clarity about what are the ‘flags’, who can use that information, and what are the responses to these patients would probably cause more harm than good,” Professor Lintzeris told MJA InSight.

“Many of us would like to see a national consensus as to what we would consider safe or unsafe.”

The Commonwealth developed and funded an ERRCD system in 2013, and licensed the system to jurisdictions. The system is based on DORA (Drugs and Poisons Information System Online Remote Access), which Tasmania implemented in 2012, and is the only such system operating in Australia.

“The implementation of [ERRCD] would enable a nationally consistent electronic process to collect and report data relating to the prescribing and dispensing of controlled drugs for prescribers and pharmacists,” a Department of Health spokesperson said.

The states and territories are at various stages of implementing real-time prescription monitoring using the ERRCD, with Victoria and WA both allocating funding to implementation in their 2016–17 budgets.

A spokesperson for NSW Health said the state was also working towards a national rollout of ERRCD, and had recently completed the upgrade of its regulatory software and authorisations processes for Schedule 8 drugs using the system to enable it to support real-time monitoring in the future.

A spokesperson for the Victorian Department of Health and Human Services said the state’s $29.5 million over 4 years would not only ensure that doctors and pharmacists had access to a database to obtain real-time information about patients’ dispensing histories for medicines at risk of misuse, it will also provide for workforce training and initiatives to ensure that clinicians were “able and ready” to more safely prescribe and dispense these medicines.

Western Australia expects its modified, state-based ERRCD system to be completed by late 2018, with training and support available to pharmacists and prescribers closer to that date. A WA Department of Health spokesperson said the state was exploring opportunities with the Commonwealth and other Australian jurisdictions to work towards a single, shared national system.

SA Health has provided in principle support for the real-time electronic monitoring system, and is also working with the Commonwealth and other states and territories to address concerns around prescription drug misuse, a spokesperson said, but added that “funding is an issue”.

Queensland Health has baulked at swapping its existing prescription database for the ERRCD model.

A Queensland Health spokesperson said that while real-time reporting of prescription opioids had the potential to improve patient safety, an analysis by the Queensland Department of Health found that the ERRCD system was costly to implement, did not meet regulatory standards and required significant improvement.

“Queensland’s Department of Health continues to operate its own prescription database, plus a 24/7 telephone enquiry service for medical practitioners to ensure patient prescription information is available for doctors who make decisions about the safe prescribing of opioid medicines,” the spokesperson said.

CEO of the Penington Institute Mr John Ryan said a nationally consistent approach to prescription monitoring was crucial.

While applauding the Tasmanian initiative and the funding allocations of states like Victoria, Mr Ryan said that some jurisdictions were “dragging the chain”.

“If we don’t have a linked, national system, it will not be successful,” he said. “In the border regions of Victoria/NSW or Queensland/NSW, people will just trip across the border and get around the prescription monitoring system. We do need a national approach and it’s terribly slow coming, considering the number of deaths we’ve had in the past decade from pharmaceutical drugs.”

In August 2016, the Penington Institute reported that prescription opioid deaths in Australia had increased by 87% between 2008 and 2014, jumping from 406 to 762 deaths. In rural Australia, prescription opioid deaths increased by 148% in the same period (131 to 326 deaths).

“The real challenge is to combine real-time prescription monitoring with other proven measures, such as better access to drug treatment, earlier intervention in relation to escalating drug-related problems, and better access to the overdose reversal drug naloxone, which requires education about risks,” he said.

Mr Ryan also pointed to the “elephant in the room”, which was the cost of supervised dosing in opioid substitution programs.

“If a patient is on opioid substitution therapy drug treatment, they are paying $5–7 every day,” Mr Ryan said of the supervision cost, which was not subsidised. “In a way, it’s cheaper for a patient to be addicted, than to be on treatment.”

Professor Lintzeris agreed, but noted that there were a range of options to consider when treating a patient with prescription opioid dependence.

“We need more specialist pain clinics, and more addiction specialists working in those clinics,” he said. “The vast majority of pain clinics do not have an addiction specialist working within them – it would be like saying we’re going to have a pain clinic without a psychiatrist or physiotherapist.”

Professor Lintzeris said that more research into the treatment of concomitant pain and opioid dependence was also needed.

“We don’t have enough evidence about how to treat the patient in pain who has become dependent on their prescription opioid – there are no guidelines anywhere in the world – so we need more research in this space as well.”

The states and territories are due to report on their progress to the Australian Health Minister’s Advisory Council in December 2016.

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