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Australia’s Chief Medical Officer responds to GP questions over opioid warning letter


Brendan Murphy


27/06/2019 1:41:15 PM

Professor Brendan Murphy writes for newsGP on last year’s letter warning GPs about high rates of opioid prescribing.

Opioid warning letter
GPs have previously described the warning letter as ‘intimidating’ and ‘unpleasant’.

The current trend of opioid use worldwide, including in Australia, poses a significant risk to the health and wellbeing of individuals.
 
In Australia, approximately twice as many people die from pharmaceutical opioid overdose than from heroin overdose, and opioids are now the most commonly misused pharmaceutical group. The 2016 National Drug Strategy Household Survey found 3.6% of Australians over the age of 14 reported recent misuse of prescription painkillers/analgesics and opioids.
 
Opioids are, of course, extremely valuable agents in the management of acute pain (including post-operative pain), in palliative care, in chronic cancer pain and in a very limited number of people with persistent non-malignant pain.
 
However, cumulative evidence has made it clear there is little evidence for the efficacy of long-term opioid use in persistent non-malignant pain, as well as a high incidence of adverse effects from these drugs, including dependency and fatal overdose.
 
GPs are at the frontline in managing people with chronic non-malignant pain and I fully appreciate the difficulty in managing these patients and meeting their complex needs. It is clear, however, that all doctors must reflect on their prescribing practices if we are to tackle the increasing incidence of harm and death from opioids in Australia.
 
It is for this reason that, in June 2018, I wrote to 4800 GPs who were identified as being in the top 20% of opioid prescribers in Australia – as identified through Pharmaceutical Benefits Scheme (PBS) data.
 
In this process, it was not possible to identify all GPs working in palliative care or prescribing for palliative care reasons. It was also not possible to identify those GPs who have a specialist pain practice or who have a specific oncology bias to their practice.
 
Accordingly, these letters were targeted to a broad group of GPs, many of whose opioid prescribing was entirely appropriate for their clinical case mix.
 
I want to reiterate that we strongly applaud and encourage the work of GPs who are working in palliative care, cancer management and in complex pain clinics. It would be most disappointing and undesirable if any such GPs feel their opioid prescribing practice is anything other than encouraged and supported.
 
Clearly, in this group of nearly 5000 GPs there are also some who are prescribing, at a higher frequency than their peers, opioid analgesics to patients with chronic non-malignant pain, such as patients with chronic back pain. We know, in the great majority of such patients, these patients’ long-term health is best served if they are weaned off opioids and undertake alternative strategies to manage their pain. 
 
Opioid cessation is complex and needs to be undertaken in a planned way. No one is suggesting that sudden cessation ‘at the direction of government is being required in all cases’. We are simply saying that GPs (and, indeed, all doctors) need to reflect carefully on each and every prescription of opioids for chronic non-malignant pain, other than in a palliative setting.
 
Some recipients of the letters have raised concerns they may be sanctioned for prescribing opioid medication or that restrictions have been placed on their ability to prescribe opioids. I would like to reassure GPs and patients with these concerns that this is not the case. 
 
There was mention in the letters that, following continued monitoring of prescribing practices, there may be (in rare circumstances) a consideration of some prescribing practices by the Department of Health’s (DoH) Practitioner Review Program (PRP). This would not be done without considering all prescribing and servicing information.
 
The main purpose of PRP interviews is to understand the reasons for the pattern of prescribing. To date, no practitioners have been referred to the PRP following my letter. Opioid prescribing has come up in only a proportion of cases that have come to the DoH’s attention for other reasons.
 
The DoH will be evaluating the letters in the coming year. This will help to inform me, and the DoH, on effective strategies to communicate the important role GPs have in tackling this and similar public health issues.
 
We are certainly aware that these initial letters did cause some anxiety and distress for some GPs, and I apologise for that. 
 
In conclusion, I assure all doctors that appropriate prescription of opioids for acute pain, palliation and cancer pain is supported and encouraged. The huge complexity in management of chronic non-malignant pain is fully acknowledged but, in the light of the compelling evidence of harm, we should all seek to not commence and, where possible, wean and cease the use of opioids in these patients.
 
For those interested in seeking more information about the letter or resources regarding the use and safety of opioids in clinical practice, further information is available on the DoH website.



chief medical officer opioids prescribing



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Ross   28/06/2019 6:53:15 AM

I did a locum in rural Australua last year and was appalled by the number of patients on long term opiods for non malignant pain. It included all age groups but was predominantly the older patients and those in lower socioecomic groups. It included those with back pain, joint pain and many where I could not determine why they were originally prescribed the drug. Most had no insight into the fact that they were now drug dependent and that in many cases they were no better off. I understand the pressures on GPs in rural Australia but if they think that commencing an opiate is the answer for managing this grouo of patients is the answer, they are deluded.


Elma Loane   28/06/2019 7:56:43 AM

I appreciate the comments of the CMO following an otherwise insensitive and blunt approach to GP prescribers of opioids. I trust that a similar campaign writing to Hospital based prescribers including supervisors of junior doctors and dictors in training to reinforce the same message of restraint and deliberation when discharging patients back to the community. Despite significant cultural improvements in recent years, too often I receive patients discharged with opioids and other inappropriate medications that are "not within prescribing guidelines" but go unchecked out the door of ED under a hospital prescription.
Simply pushing the problem into the GP remit ignores the other 30,000 odd potential culprits registered to practice and prescribe. The single large target of GP is just too easy and too submissive to resist attacking.


Neen Monty   28/06/2019 8:41:39 AM

You say that opioids are appropriate for "very limited number of people with persistent non-malignant pain." But then you finish with "in the light of the compelling evidence of harm, we should all seek to not commence and, where possible, wean and cease the use of opioids in these patients." So you are acknowledging that a minority of chronic pain patients require and do well on opioids, yet you then direct that opioids should NEVER be prescribed for chronic pain. And everyone keeps citing 'evidence' without ever providing the evidence. Please, show us the studies. You are creating policy based on an American problem, and a MYTH!


Nick   28/06/2019 9:35:44 AM

Rural generalists with largely procedural practice are a neglect group within this cohort. Would it not be in the interest of the department to corroborate prescriptions and dispensed medications with their clinical application prior to sending out accusatory letter such as that above. Surely this would be achievable give the vast resources attributed to My Health record.


DS   28/06/2019 11:03:18 AM

There will be top 20 % doctors targeted every year based on their opioid scripts and receive letters. Pain clinic and Palliative care GPs will not get it. Is my interpretation correct?

I am wondering what will happen if my opioid prescribing is genuine and I am not working in pain or palliative clinic but still fall in the top 20. Do I still get a letter.


Dr Glenn Davis   28/06/2019 1:20:26 PM

I was working in palliative care up to 2 weeks ago. I received one of these letters last year. Even prior to that ,in an effort to be responsible about my opioid prescribing I had a "run in " with a relative where I refused to inappropriately prescribe an opioid for her mother. She took me to QLD APHRA who have supported her and not me. They placed restrictions on my practicing in aged care facilities such that I decided to resign 2 weeks ago.


Dr David Alan Wallace   28/06/2019 3:03:15 PM

The problem is, Professor, that you are talking nonsense.

Is the mechanism of pain perception different in cancer patients? No it is not. Do opioids have different mechanisms of action in cancer patients than they do it people with non cancer pain? Apparently not. So why are these medications permissible in one setting and not in another?

Don't patronise us, it is a poor substitute for persuasion. Point to the evidence, give us the references so that we can critically evaluate it like the professionals we are. Show us ways that we can deal with this problem more effectively, because withdrawing a treatment that the patient feels is helping in the absence of a better alternative is simply inhuman.

By the way, if you didn't intend to intimidate us, why was my opioid column coloured scarlet and the comparison blue?

Do you understand why some of us are having trouble accepting your reassurance?


CW   28/06/2019 4:05:24 PM

Very sorry to hear about your story Dr Glen Davis.
Major issue is too many Administrators/ non clinical managers trying to regulate the prescribing without having first hand experience what prescribers face day in day out.


SE   28/06/2019 6:44:37 PM

Faint hearted apology a little too late. I have since ceased palliative care in the community and aged care settings (which resulted in 95% of the scripts that led to my letter). Maybe Brendan would like to get out of bed each night to see these patients.


Dr Mark Fletcher   28/06/2019 11:49:18 PM

Without trying to sound too abrasive, can I ask, have you worked in general practice? Have you had to treat patients who have chronic non-cancer pain? These people are everywhere. Chronic pain disorders are very, very common and they can be difficult to treat. Every GP knows about treating patients first with regular simple analgesia, using non-pharmacological techniques such as physio, rehab, massage, CBT etc. Most GPs do this. Despite this, many patients are still suffering in pain and sometimes regular use of long acting opiate medication such as norspan or targin can be quite effective in these patients. Also, many GPs will simple inherit patients who have been on regular opiates for decades. These people will never get off the drug, and I won't increase the dose but it is not my fault they were prescribed it in the first place. Most of the overt inappropriate prescribing comes from old or overseas trained doctors.


Kate   29/06/2019 1:24:54 AM

I'm not sorry doctors got a letter ...I hit a mother addicted to fentanyl patches prescribed by an idiot doctor for arthritis ..he took her off panadiene forte and now its oxy, endone and fentanyl and despite reporting this doctor he keeps on prescribing these horrible drugs and has turned my mother into a drug crazed zombie. Not a nice way to spend your 70s.


Dru Haywood   30/06/2019 12:52:01 PM

I agree we need to see the evidence that these drugs don't work for chronic non-cancer pain. Right now the evidence of my experience is that there are many (mostly elderly) people with chronic pain who need these drugs, whose life is better with them - and they cannot participate in non-drug control of pain and they cannot take "simple" pain relief. NOT fentanyl, rarely Endone, but they definitely more than paracetamol


Rod W   30/06/2019 7:29:53 PM

More criticism from those seated in the ivory tower rather than the coal face.
Agree with the comments targeting GPs when Specialists, Hospital Doctors etc regularly uptitrate opioids or initiate opioids based on a brief clinical encounter. A very difficult situation to manage.
Wean he says. Mmmmm. Ignorant I say.
Yes I received one of these letters.
I did a search of my database. I have 11 patients on long term opiates. Rarely do I prescribe any others. But I do have one, just one, patient on a dose that probably hit the morphine equivalent dose qualifying me for one of those friendly letters. And just for the record. I tried down titrations many times over the years. But alas, almost every hospital stay the patient has had for unrelated reasons resulted in a discharge on higher doses. But no. It’s #just a GP that is the problem.


Do as I say not what I do   2/07/2019 5:09:22 PM

How long has this been going on ? Years & years yet we have on one hand the law punishing recreational users of marijuana ,cocaine,amphetamines ,by recycling criminals or (humans)I should say back into the population over and over and on other hand prescription drug overdoses now Outnumber heroin overdoses!!? That is extraordinary !!
But I believe it ,
Yet everyone will brand all drug users with the same brush but hipocrites will defend dr prescribed drugs as manageable and not that big of a deal
Maybe we should use a database that only the police can access so they can pick n choose ,those, without life threatening illnesses, who gets thrown into the already cramped criminal recycling system for punishment . Every human on this earth can become addicted to any drug no one is excluded yet prescribed addicts keep believing they are different to recreational drug users because of who gave them the drug ?? Explain that ??


Michael Rice   6/07/2019 8:16:55 AM

I was almost disappointed NOT to have received such a letter; but perhaps reassured that my pain management practices are more likely in the middle quartiles.

I commend the Professor to direct his attention to where I find some opioid problems commence: in postoperative pain management. I'm seeing increasing numbers of patients transition to the community, especially after orthopaedic procedures, on multiple opioid products including (to me, bizarre) combinations of especially oxycodone and tapentadol in immediate- and slow-release formulations that may all be marked as "prn". There seems to be none of the Professor's beloved "evidence" for these polypharmaceutical pain management strategies. Indeed, advice from ANZCA tends to recommend against routine use of slow-release opioids in these settings.


Michael Rice   6/07/2019 8:22:34 AM

Further, the Professor would serve communities and patients well with a review of the availablility, accessibility and affordability of "alternative strategies to manage their pain". Future letters can be more nuanced, tailored and targeted by postcode, and could actually provide helpful advice for pain management within the constraints of public and private resources that actually exist on the ground.

The town could do with some practical help from the gown that adds value beyond "GPs oughta..."


Wendy   6/07/2019 1:29:27 PM

Post op hysterectomy 1997, I was given a morphine pump for post op pain, was told I had to push the button, yet my pain wasn't even a 5. It made me feel sick and asked for it to be removed, they did but not until the next day when I still hadn't used it. Fast forward to today.. I have chronic whiplash, constant muscle spasms throughout my body and some nerve pain.. in particular I feel T2, thus hadn't responded to anything in the past and when I was initially given tramadol SR I was so relieved something worked. Unfortunate I developed symptoms of serotonin and was advised to try palexia, I had a reaction so didn't continue, went cold turkey then went yo my GZp who then suggested 5/2.5 Targin. Worked just as well as the Tramadol but the pain specialist has reduced the dose to 2.5/1.25. I have reduced pain, but it's uncontrolled and intractable pain. I recently ended up in ED with bp of 200/107. It settled with endone, given for pain.


ToktaDog   6/07/2019 6:43:54 PM

Yes a small proportion of the population will always misuse any medication but the majority should not be penalised. I suffer from chronic non malignant pain and require slow release opioids to enable me to function relatively normally and to contiue to work. I've tried all other alternatives, including exercise, with minimal effect. I'm aware my GP recieved an 'opiate prescriber warning letter' and she feels her practice is in jeopardy. To protect my GP I attended a pain specialist clinic to further support her pain management practices. I do not smoke, drink alcohol or use any ilict drugs but need slow release opiates to function. The pendulum has swung too much in the opposite direction and people, like me, who genuinely need opioids are now made to feel guilty.


Dr.Abdullah Alsharik   8/07/2019 3:50:55 PM

The Opiod issue is to complex to be discussed here in writing and there should be more comprehensive support prograame to people with chronic pain from specialist input AND more regional pain clinic where people waiting list can be reasoble not years .

just regarding one of the comment made by one of the dr DR Mark Fletcher ,,I don't agree with your statement about prescription mostly by doctor from overseas or IMG ,this sound very premature to me as I saw many local doctors prescribed them as well as IMG .actualy if you go overseas and see whats the rate of opiod compare many developed counties you will be amazed its much less and many IMG doctors did never prescribe those before there .the reason of over prescription is many including one most importantly the oversupply by pharmaceutical companies and its availability I think rather being blaming overseas or IMG doctors we have to think more logically .


Ruth Elbon   12/07/2019 4:43:42 AM

I was on 50mg fast release Tramadol once to twice a day for about five years. I am sorry Professor that you do not find my shoulder crunching in and out of the joint not worthy of opioid pain relief given it wasn’t “cancer” related. Oddly enough I did not seek out an escalating dose, break into pharmacies or meet with dealers on the street for a fix. I maintained work & engaged or rehab. And when my pain reduced I stopped and I am now on regular Paracetamol. So I guess I am some kind of oddity who found pain relief beyond “simple” over the counter remedies helpful.

It is sad how much stigma there is around pain relief medication. Where prescribers and their patients are treated like pariahs. Absolutely there should be care around opioid prescription but it should be evidence based. To write this type of correspondence without a single research citation is bizarre by my reckoning.


Darsidhe   12/07/2019 3:23:00 PM

Any real concern for patients being prescribed pain killers for longterm pain would be to explore the CAUSE of that long term pain and why it has not been, or cannot, be addressed, not simply insisting on a change of management of the pain, for no good reason.

Many, many people are on long term pain management because they cannot afford the specialist care they need, and/or are waiting - often for years- for public clinic access.

This is nothing more than a performative jump upon a bandwagon. Increase health funding, make specialist care (our system's worst bottleneck) and then you'd have an actual health care improvement.


Dr Rodney Paul Jones   22/07/2019 12:01:26 PM

The occasional drug screen doesn't hurt. If it comes back negative one has to ask them why a prescription should be continued.
There is a Prescription Shopper Hotline , although it appears to have a very high threshold i.e. low sensitivity , and reverts to zero every 3 months. I think our Chief Medical Officer could exert influence to do something about this instrument.


Valerie   9/09/2019 1:26:34 PM

I have been on all sorts of opoids for pain left knee hip replacement restless legs no sleep in bed but in chair and put on Panadeine Forte 8 a day. Then got 4 plain Codeine 30 mg for night to sleep and felt so much better. Could do meals and jobs except for vacuum. Now since cut off 1st PF 8 - down to 4 Codeine 30 mg tabs but managing as hi done but knee severe arthritis - cant replace surgeon said have to let it wear down for pain to go as had left knee. Now none at all - was down to 4 lost the PF last year but managing as knee + leg muscles balance problem - but could go out using 2 tabs still days before walk almost normal . Now none as doc told seemingly lose license by ABC and I didnt want him to refuse me as others had so emailed dont need them. Now nauseous cant sleep in bed had runny nose since last year lost 8 PF a day - google and see this is withdrawal as suspected. Abuse to just cut us off and threaten dos with licence loss . Elderly alone suffering mostly


Dr Isaac   9/06/2020 9:59:11 PM

on 28/06/2019 Dr Mark Fletcher wrote "..Most of the overt inappropriate prescribing comes from old or overseas trained doctors."end of quote
1- Mark Fletcher , you wrote a disgusting inappropriate comment on a public forum .. and you open the door for nearly 50% of overseas doctors on the register to criticise you publicly as well .. you either naive or ignorant . 2- From what I see and available to me as I did lots of locum work all over Australia in all states , it is actually the local doctors who start patients on opiates with no good reason to start these medications. I usually tell the patients, its not their fault because you are on opiates , it is the fault of the doctor who started it. To be honest, lots of patients started on opiates by the ED where the Australian graduates are practicing " wink,wink " 3- Instead of criticising your fellow doctors who you might be under their knife at some stage of your life,it is better to tell us how to tackle the problem. Thanks


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