News

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Opioid prescriptions are down – but is dependence?

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New research has confirmed a reduction in the number of opioid prescriptions following landmark changes to opioid listings on the Pharmaceutical Benefits Scheme (PBS) in 2020.
 
Addiction medicine experts, however, have called to normalise and adopt clinically proven treatments for opioid dependence in addition to the PBS revisions.
 
The independent study is the first to have evaluated the impact of the 2020 opioid revisions according to co-author, Dr Benjamin Daniels from University of New South Wales (UNSW).
 
Key changes included: 

• new PBS subsidies for smaller quantities of opioids for acute pain
• authorities required for the subsidising of repeat opioid prescriptions for chronic pain
• a mandatory second clinician review of a pain management regime for opioid use for more than 12 months.

Importantly, Dr Daniels maintains, the study analyses datasets of both PBS-subsided prescriptions, totalling over 81,000 mg oral morphine equivalents (OMEs), and private prescriptions.
 
‘We found an overall 4% decline in OMEs dispensed through the PBS in the year after the policy changes,’ he told newsGP.
 
‘[This] equates to around 9000 20-tablet packets of codeine-paracetamol, or 4000 fewer 20-capsule packets of 50 mg tramadol dispensed annually.
 
‘We were [also] able to analyse national wholesale data, ie the number of sales of opioid medications to community pharmacies. This allowed us to see what was happening with private prescriptions as well as PBS-subsidised ones. As a result of restricting PBS-subsidies for opioids, some recipients went to the private market, but not a lot.
 
‘The bottom line is that overall, we do believe there was a small but true decline in opioid prescriptions nationally.’
 
Opioid overuse remains a substantial health problem globally. In the year preceding the PBS changes, the World Health Organization (WHO) reported opioids were responsible for 80% of drug related-deaths internationally. Currently, an estimated 110,000 Australians struggle with opioid dependence, with three dying from opioid use every day.
 
Victorian GP and Medical Educator, Dr Paul Grinzi, counts the downward trend in opioid prescriptions as a positive change but feels there is more to be done.
 
‘While we can’t make too many assumptions, the overall trend is good news’ he told newsGP.
 
‘We used to be second only to North America in the number of opioid prescriptions per capita. But things have improved in Australia, even in the last few years, and that’s great.
 
‘PBS changes have allowed prescribers to reflect on choosing an appropriate packet sizes [and] how much will be left over. Leftover opioid medication in the home poses a substantial risk of unintended overdoses when used by other family members.
 
‘It is, however, complex to determine what is causing this change. It is probably a combination of multiple factors alongside changes to PBS listings, such as the impact of the COVID-19 pandemic but also the rollout of the RACGP’s Alcohol and Other Drugs GP Education Program around the same time.
 
‘Also, what we don’t know from this study is what the opioids were prescribed for and in what populations.’
 
Dr Grinzi commended the Australian regulatory system for its continuous improvement, but added that ongoing clinical education and normalisation of harm reduction measures are vital.
 
‘One key area for improvement is naloxone,’ he said.
 
‘We [Australian prescribers] under-prescribe naloxone for opioid reversal in high-risk individuals, ie those that consume over 100 mg total OMEs per day. It would be great if there was some sort of PBS system to prescribe parallel naloxone scripts to minimise the harm of overdose.
 
‘We should seek some sort of normalisation of naloxone as a reversal so that it is treated a bit like an Epipen for allergies for people to have it in the household just in case. There is international evidence for this.
 
‘The rest is really about disseminating clinical information and having more clear discussions around the indications of opioids … ongoing education and support, not just one-offs.
 
‘Treatment of opioid dependence is not just all doom and gloom.’
 
Dr Hester Wilson, GP and Chair of RACGP Specific Interests Addiction Medicine, agrees that the 2020 PBS changes have had positive effects but importantly should be implemented alongside other initiatives.
 
‘The majority of patients don’t need a full pack of opioids so they have led to less medicines sitting in household cabinets not being used and then potentially being shared amongst family,’ she told newsGP.
 
‘They have also potentially prompted GPs to ask, “does this patient actually need opioids for this pain or can other treatments be considered?’’
 
‘It is crucial, though, to consider the PBS changes as part of a bigger suite of changes in how we look at pain management.
 
‘It is also important to point out that while there has been a shift away from the number of opioids prescribed, whether or not there has been a shift in dependency is not entirely clear. In fact, there is a limit on good data on how many people are addicted to opioids in Australia.’
 
Dr Hester encourages more GPs to get involved in the treatment of opioid dependence, particularly given the strong evidence base behind successful treatments such as opioid substitution, which are clearly under-utilised.
 
‘Once a patient is stable, opioid substitution works extremely well and it’s a really rewarding area of practice,’ she said.
 
‘Sadly, there is an estimated 35–50% unmet need for opioid dependency treatment in Australia and a risk that people resort to informal markets like heroin.
 
‘GPs should link in with their local drug and alcohol service and our RACGP addiction medicine special interest group. We’re more than happy to meet you and find someone in your local jurisdiction who can support you.’
 
However, she concedes that more could also be done at a systemic level to support GPs in addressing the major health issue.
 
‘Medicare funding for treatment of opioid dependence is appalling,’ she said.
 
‘The Medicare freeze is a barrier and frustratingly the patients that need services the most are unable to access them because they are often vulnerable and afflicted by poverty.
 
‘GPs are forced into making soul-crushing decisions about whether or not to engage patients as you can only take on so many complex patients at a time.
 
‘The Government should step up and pay clinicians to get involved, eg with more generous item numbers, more nurse practitioners or more item numbers accessible for nurse practitioners.
 
‘It’s about building the capacity to work in teams and ensure good peer engagement to solve the problem.’
 
More educational resources are available at the RACGP AOD GP Education Resource Library.
 
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opioids PBS Pharmaceutical Benefits Scheme

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