Script for an opioid strategy
Australia’s Chief Medical Officer has put GPs on notice about opioid medication prescribing practices.
Concern about the abuse of opioid medications has prompted Australian Chief Medical Officer Brendan Murphy to write to 4800 GPs about their prescribing practices.
Since codeine products were made script-only in April, the Therapeutic Goods Administration and other health authorities have sought a broader approach to curtail prescription drug abuse.
The 2016 National Drug Strategy Household Survey found 3.6 per cent of Australians over the age of 14 reported recent misuse of prescription painkillers, analgesics and/or opioids.
According to a report last year from the National Drug and Alcohol Research Centre, the rate of accidental opioid deaths has more than doubled among Australians aged 35 to 44 since 2007.
Seventy per cent of the deaths involved strong prescription painkillers.
Every week there will be a news report or gossip item about someone addicted to painkillers, sometimes fictionalised in a television drama or film.
For health practitioners, this experience is real.
Australian Medical Association president Tony Bartone recently spoke of the “slippery slope” from a patient having legitimate pain to a dependency that brings other health risks.
“They’re prescribed usually in the first instance appropriately for certain severe pain, or a pain medication treatment, and then unfortunately because of pain and poor management, or unsupervised continuing reliance on them, they become dependent on them to try and manage that pain,” Bartone said.
“And so sometimes it’s a bit of a vicious circle, the pain is not being tolerated well. You reach for more, and you seek more, and you actually need to have more, and it’s a bit of a slippery slope.”
What to do about this problem has been a topic of discussion for some time and, with International Overdose Awareness Day last week, there are calls for a national pain strategy. The proportion of Australians who experience pain is on the increase with an ageing population and more chronic illness, a trend that undoubtedly has contributed to opioid dependency and addiction.
In June, a workshop involving various stakeholders discussed whether the TGA should revisit regulatory options for opioids such as smaller pack sizes, better warning labels and education campaigns on alternatives for the management of chronic pain.
The lack of progress on such options was used to justify making codeine script-only.
Another reason for the change was the absence of real-time monitoring of drug sales; governments recently agreed to implement a national prescription monitoring system to prevent so-called doctor shopping.
A Department of Health spokeswoman said pharmaceutical opioid deaths exceeded heroin deaths by a significant margin and authorities were responding to the problem
Murphy wrote to the GPs in the top 20 per cent of prescribers of opioid medications to raise awareness of the problem and encourage them to reflect on their prescribing practices.
The letters came with such gravitas that a Medicare investigations body, the Professional Services Review, had to clarify publicly that they were sent out by the Chief Medical Officer.
The department spokeswoman said prescribing practices would be monitored and, in a small number of cases, a GP might be interviewed and possibly referred to the director of the PSR.
“The intent of the letters is to raise awareness and have GPs reflect on their prescribing behaviour and to see if there are any opportunities in their practice to reduce prescribing where clinically indicated,” the spokeswoman said.
“After self-reflection, a GP may determine that they are prescribing in an appropriate manner for their patient group.”
The use of such letters has become a powerful — and cheap — means of influencing doctors, drawn from behavioural economics or so-called “nudge theory”.
In June, The Weekend Australian revealed the impact of carefully crafted letters from Murphy to the 6649 GPs whose antibiotic prescribing rates were in the top 30 per cent for their geographic region.
Four letters were trialled, and the one that contained a graphic peer comparison reduced antibiotic prescribing rates by 12.3 per cent in the six months that followed.
A report on the trial raises the question of how long the effects may last, how to achieve sustained improvements and whether similar letters can be used elsewhere.
“There are other prescribing issues of public importance where trialling a peer comparison feedback intervention may be appropriate,” the report says.
“For example, several overseas jurisdictions are facing crises in the widespread misuse of prescribed opioids and there are concerns Australia is trending down a similar path.”
Before the antibiotics trial, the department tested the impact of letters on the 1200 doctors claiming the most urgent after-hours items on Medicare.
That experiment delivered a 19.5 per cent reduction in billing, saving the government about $12 million.