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GPs are continuing to “prescribe in the dark” as states and territories negotiate the detail associated with wider implementation of a real-time prescription drug monitoring, says a leading GP and medical advisor.
Dr Walid Jammal, Senior Medical Advisor, Advocacy, at Avant Mutual Group, said the profession had been calling for the national rollout of real-time prescription drug monitoring for many years.
“Coroner after coroner has called for this. The states and territories are working on it – and it’s a huge task – but some would argue that it should have happened many years ago,” Dr Jammal told MJA InSight.
“No one argues with the need for responsible prescribing and that that responsibility ultimately lies with the prescribing doctor. But real-time monitoring really sheds light on the issue because GPs are currently prescribing in the dark.”
Dr Jammal’s comments come as the MJA published a short report analysing the capacity and coverage issues associated with wider implementation of a real-time prescription drug monitoring program.
- Related: MJA InSight – Walid Jammal: Real urgency
- Related: MJA — Real-time monitoring of Schedule 8 medicines in Australia: evaluation is essential
The MJA authors highlighted challenges for policy makers such as the information that would need to be collected, how long it would be held, and the increased demand for professional development and specialist support for addiction and pain management.
Lead author Dr Rowan Ogeil, an NHMRC Peter Doherty Early Career Fellow at Monash University and Turning Point in Melbourne, said it was “extremely important” for states and territories to consider the issues raised in the paper as plans for implementation progressed.
“We have nominated a couple of key areas – capacity and coverage – which cover everything from privacy and how long records would be kept, to who’s going to respond and how they are going to respond to any issues that are flagged,” he told MJA InSight.
Dr Ogeil said there had been a proliferation of opioid medications available since the early 1990s, with just 11 preparations available in 1992, and 146 available in 2013. There had also been a 15-fold increase in the number of Pharmaceutical Benefits Scheme opioid prescriptions dispensed, rising from around 500 000 in 1992 to more than 7 million in 2012.
“It’s more important now to monitor what’s going on – to look into prescribing trends and trends in harm,” Dr Ogeil told MJA InSight.
In 2013, the Coroners Court of Victoria reported that more than 80% of drug-related deaths involved prescription drugs, mostly opioid analgesics and benzodiazepines.
Last year, the Royal Australasian College of Physicians and the Australian Medical Association joined with other peak medicine, pharmacy and consumer bodies to call on federal, state and territory governments to implement a national real-time monitoring program as a matter of urgency.
A spokeswoman for the Australian Government Department of Health said the Commonwealth Government had designed the Electronic Recording and Reporting of Controlled Drugs (ERRCD) system, and it was now operational.
“The Commonwealth has offered the ERRCD system to all jurisdictions via a royalty-free software licence agreement (SLA). All jurisdictions, except the NT, have executed an SLA with the Commonwealth,” she told MJA InSight.
“The Minister held discussions on progress with ERRCD implementation with state and territory colleagues at the November 2015 meeting of the COAG Health Council.”
The ERRCD is an enhanced version of Tasmania’s DORA (Drugs and Poisons Information System Online Remote Access), which was rolled out across Tasmania from 2012. Tasmania remains the only state with a real-time monitoring program.
MJA InSight contacted all states and territories that have signed up with ERRCD, and most signalled that work was underway to implement programs. However, Queensland said it was considering if the ERRCD provided advantages over the state’s current drug monitoring system.
- Related: MJA InSight — Gordian Fulde and John Raftos: Opioids need controls
- Related: MJA InSight — Real-time Schedule 8 monitoring stalls
“The Queensland Department of Health presently operates a prescription monitoring program, however it is not in real-time. This database is used to monitor all dispensed prescriptions for Schedule 8 medicines and allows the Department to monitor for doctor shopping, patients with drug dependence and prescribing practices of medical practitioners,” a Queensland Department of Health spokesperson said.
“The Department is still in the process of assessing appropriate due diligence on the ERRCD program to assess if it meets the business and regulatory needs of the Department and if it will improve health outcomes. This assessment must occur before considering full implementation or whether the existing Monitoring of Drugs of Dependence System used in Queensland could be modified to achieve the same functionality of ERRCD given the significant costs that would be involved in rolling out the new system.”
Dr Jammal said implementing this “very important tool” would require a collaborative effort from doctors, regulators, pharmacists and government policy makers.
He said resources and education were also needed to ensure the program was effective.
“Let’s just make this a safer and more effective system because, right now, it can be argued that the system is not safe,” Dr Jammal said.
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We have had PharmaNet in British Columbia, Canada for many years, with realtime information related to every prescription dispensed by community phramacies, not just opioid prescriptions.
Any physician can access patient records, if they obtain their patient’s consent. Access can be obtained in special circumstances, for instance in emergency departments, if the patient is unable to give consent.
Physicians who do not have direct access to PharmaNet through their electronic medical record service can obtain printouts from any friendly local pharmacist.
PharmaNet can improve safe prescibing of any prescibed medication, not just prescribed opioids.
Further information about PharmaNet can be obtained from http://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare…
Even before this initiative the path is plain. There is no evidence of benefit of opioids in chronic non-malignant pain. There is however ample evidence of morbidity and mortality caused by doctors prescribing opioids for chronic non-cancer pain, in both patients for whom these medications are prescribed and also in those who receive them after “diversion” (I think that’s the term for onselling or giving to friends, relatives etc). So each doctor cna do their part and stop prescribing medications for which there is no good evidence of benefit.
Is there any other intervention by doctors in our community with no good evidence base which is involved in so many deaths in the community?
“Current evidence does not support the long-term efficacy and safety of opioid therapy for chronic non-cancer pain.”
http://www.safetyandquality.gov.au/wp-content/uploads/2015/11/SAQ201_06_…
As well as being a 53 year old country GP, I am also a pharmacist and a computer scientist.
We have plenty of good programs that would address all of our needs. Any of the mainstream GP clinical programs could easily be installed into any of the regional base hospitals AT NO COST, and the users of that flavour of prescribing program could then have a locally-relevant database from which to prescribe.
Or you could provide the prescribing program to the GP, say at half-cost, $500 per doctor per annum, and save millions of dollars on the PCEHR/My Medical Record fiasco – and have it working from day one.
This would address a host of problems, including the majority of doctor shopping. Discharge Summaries? There on the database. Medication Lists? There on the database for all to see. Correspondence? Ditto.
But what would I know?
Dr Julian Fidge BPharm, Grad Dip App Sc (Comp Sc), MBBS, FRACGP
What this needs is to get started – not finessed to death by bureaucrats. In the first instance they need only start with the “three wise people” test. They wouldn’t be worried about whether someone was getting 56 pills per fortnight rather than 28 – they’d be worried about those who are getting 28 per day and who was prescribing in a way that made that easy.
Let’s start with the obvious and worry about the fine print when we get to it. First up we need the answers to only two questions:
1. Who is at risk of dying because of their consumption pattern? And
2. Who is at risk of helping them because of the way(s) they are prescribing.
Let’s start with the 2% who cause 98% of the harm and intervene. We can worry about how long to keep records and what font to use down the track.