Opioid pack sizes halved, new annual checks for patients

Doug Hendrie

1/06/2020 4:55:44 PM

Doctors will have more oversight over potent but addictive opioid-based medications.

Opioid tablets
Pack sizes have been slashed for many opioid based medications.

New restrictions on opioid-based medications for non-chronic pain have come into effect, with a halving of pack sizes and an end to repeats.
The changes do not affect chronic pain patients, cancer patients or those in palliative care.

Patients using opioids for more than a year will also have to be assessed by a pain specialist or alternate prescriber, leading to fears from people with chronic pain who use opioid-based medications that the changes will make life harder for them.
Many GPs are supportive of the changes, which are aimed at reducing deaths and harm from the potent medications, but warn that non-opioid alternatives must be available. 
Chair of the RACGP Specific Interests Addiction Medicine network Dr Hester Wilson told newsGP the smaller pack sizes make sense, given these packs are intended for immediate relief, such as after surgery.

‘What we know from the data is that the pack size – which was usually 20 tablets – was too many for most people,’ she said.
‘Given these are risky medications, it’s much better to have smaller packs. If people need more than a day or two relief, they need to be reviewed so we can see what’s going on.’
A complicating factor, Dr Wilson said, is that patients share their opioids around one third of the time.
‘People are kind – they say this helped me, it might help you,’ she said. ‘But these are risky medications.’
Dr Wilson told newsGP the introduction of the annual review is very positive, given the other doctor could be any other prescriber, including GPs, addiction specialists or pain specialists.
‘If someone has chronic non-cancer pain, it’s complex. It can change,’ she said. ‘So it’s really great for me as a prescriber to say to the most appropriate person “can I get you to review this person to make sure the best plan is in place?”.
‘Longitudinal relationships are incredibly important in general practice, but sometimes you need fresh eyes.
‘People with chronic non-cancer pain are much more likely to be using sustained release medications. I worry when there is a huge focus on opioids – they are not central to the management of chronic pain. They are useful for some people, but they are not central. Your non-pharmaceutical and non-opioid options can be more useful.’
According to Dr Wilson, part of the issue is that many opioid medications are subsidised via the Pharmaceutical Benefits Scheme (PBS), making them affordable, while alternatives that may be a better option such as physical or hydrotherapy are generally more expensive and sometimes harder to access.
‘Patients who require long-term treatment of chronic pain with opioids will still be able to access larger pack sizes and prescribers will be able to prescribe repeats where they meet the new restrictions requirements,’ an explanatory statement on the PBS website reads.
‘To be eligible for treatment with opioids, patients will need to be unresponsive or intolerant, or have achieved inadequate relief of their acute pain, to maximum tolerated doses of non-opioid treatments.’
The changes apply to potent opioids fentanyl, morphine, oxycodone and hydromorphone, as well as tramadol, tapentadol, codeine and buprenorphine.

Chair of the RACGP Specific Interests Addiction Medicine network Dr Hester Wilson believes smaller pack sizes are justified.

Despite the reassurances that chronic pain is a legitimate use, the changes have caused concern for some people who use opioids to manage their pain.
Opioid-based medications are the main way Alison – who wanted only her first name used – has been able to contain the pain from a chronic condition.
‘There are people who believe that unfixable pain must be stoically endured, but this is a misguided moral position and it is immensely unfair to people with chronic pain,’ she told newsGP.
‘My use will be more heavily scrutinised. I will have to jump through more hoops and prove myself worthy. I will have to have more interactions with the medical world.
‘My medical problems leave me with very little capacity in life already, and I would rather spend what capacity I do have engaging in useful activities and being with my loved ones. 
‘I get exhausted easily and I do not recover easily – I need fewer demands on my time and energy to keep my pain under control, not more.’
Alison is also reliant on other non-opioid medications to manage different medical issues.
‘As for the increased risk of death [with opioids], I am on a number of non-pain medications that have serious side effects,’ she said.
‘One of [these] has even caused the disease which will probably eventually end my life, but my doctors and I have weighed up the risks and the benefits of those medications and have decided to use them.
‘I see my use of pain medication much the same way. Yes, my pain meds carry risk. But I am at peace with that risk. The alternative is uncontrolled pain.’

Another patient, Allie, who relies on tapentadol for endometriosis pain told newsGP that her main concern is how she will physically be able to get to the doctor or pharmacist if telehealth does not continue.
The Department of Health (DoH) has been trying to bring down the rates of prescription opioid use over a number of years due to fears that Australia may be heading down the same road as the US, where prescription opioids have led to an epidemic of dependency and many avoidable deaths.
Pharmaceutical opioids are present in over 70% of opioid-induced deaths as of 2018, according to the Australian Bureau of Statistics, with the rate of opioid-induced deaths with synthetic opioids jumping significantly over the past 10 years.
PBS data analysed by the Australian Institute of Health and Welfare shows opioid prescriptions rose by 11% in just four years, from 2012–13 to 2016–17. Oxycodone was the most commonly dispensed opioid, with 5.7 million prescriptions dispensed, followed by codeine and tramadol. 
Recent efforts have ranged from the successful rescheduling of codeine, to prescription drug monitoring services such as Victoria’s SafeScript.
In 2018, Australia’s hospital pharmacists raised the alarm over high rates of opioid prescribing after surgery, with a number of hospitals moving unilaterally to reduce opioid pack sizes for patients being discharged.
But not all efforts have been well received, with a 2018 ‘nudge’ letter from the DoH aimed at GPs prescribing opioids triggering a major backlash from the profession.
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Rural GP   2/06/2020 8:48:47 AM

Yes opioids are a problem and represent a dangerous threat. So, what do academics and bureaucrats do? Throw GP’s under the bus. We already have to endure endless propoganda messages on hold, designed to frustrate us enough to just give up. Yesterday wait times On Authority phone line were horrendous. I get there has to be checks in the system, but lets be clear the approach is to make it maximally frustrating for doctors and patients , to put busy frazzled GP’s under time pressure , And face the indignity of electronic tick boxing. “ that will put them off”
Why not just get out of the way, pay us due respect and just get out of the way. Rather then create road blocks for those trying to help these patients, why not address the real problem with more pain specialists and patient support and education.
DoH: You are not fixing the problem, you are just getting us to move it on.

Rural doctor   2/06/2020 7:35:00 PM

I found as a rural doctor that there were often no other options than to assist patients with a low dose opioids. The opioids were not central to the management. And whilst under my supervision no patients overdosed or abused. One of the reasons that some people ended up on opioids were long wait times for treatment trying to avoid centerlink. There is simply not enough access to physiotherapists, psychologists, social workers and the pain specialists for specific pain treatments. It's true opioids are the cheap solution for underlying issues too often. But if as GPs we cannot fix the underlying issues, what else can be done?

Dr Gursel Alpay   2/06/2020 10:16:47 PM

This is not a right way to tackle the addiction issue while opioids only means of pain relief for a lot of chronic pain sufferers. We have patients, who are on the waiting list for knee and hip replacements for more years. Do we have a perfect hospital system? Could these patients access surgery whenever they are in need within a reasonable time frame?
This move is going to place further stress on primary c are providers who are already been under considerable red tape and bureaucratic pressure for the day to day running of their practices.

GP   6/06/2020 7:38:35 AM

22 minutes of questioning to get authority for a script for a 77 year old patien with chronic pain.
Seriously?!! All chronic pain patients will be passed on to pain management clinic.
Why all and I mean all patients attending ED leave with opioid handed out to them Creating expectation that they are needed..

Dr Richard William Wright   6/06/2020 10:04:07 AM

To add to the wait on authorities, including the latest waste of time preamble, what about the time to access safe script?
Who designed this log in nightmare?
No wonder there are doctors calling out to for us to ignore it.

Dr Cynthia Filipcic   6/06/2020 10:51:30 AM

Absolutely agree with Rural GP. Chronic pain is a complex multifactorial problem. The powers that be have done nothing to address the problem, all they are doing is trying to reduce opioid prescribing. Fair enough but can you please also do something to help our patients? More pain clinics offering actual assistance.
In our local area we are not allowed to send the referral to the pain clinic in the usual streamlined way, instead there is a horrendously long template that we are required to fill out. Then the patient has to wait 6 months. They then get an ‘education session’ about chronic pain. Once they have jumped through these hoops they then wait another 2-3 months to see a ‘pain specialist’ who in fact may be a registrar.
Please improve the system! Please provide more outreach clinics in rural and regional areas.

Dr Uma Bhatta Prasad   8/06/2020 1:52:56 PM

Totally agree with Dr. Filipcic I am in the same boat! we need quicker access to Pain clinic or bulk billing Pain specialist . Physiotherapists are fine while either W/Cover pays their bills or patients access through CDM but once that runs out what next ???

Another frustrated rural GP   4/07/2020 2:13:36 PM

The government should be embarrassed by this "initiative" (if you can even call it that given that there was no patient or doctor education and absolutely NO increased support for chronic pain patients) all amidst a once in one hundred year PANDEMIC! GP clinics were already severely impacted due to COVID, especially rural GP practices who were already suffering for decades due to doctor shortages & dwindling resources. So well done Canberra, we've had to cancel a huge amount of consulting time last month to audit our patient base, notify those patients affected & arrange reviews with GPs who have never been involved in their care. All for what? Tick a few boxes then repeat again in 12 months??
If you want us prescribing less opioids, provide more education to us & patients, provide more allied health support, provide more mental health support, shorten surgical waiting lists & for crying out loud get some pain specialists into rural areas!!!