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Opioid pack sizes halved, new annual checks for patients
Doctors will have more oversight over potent but addictive 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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