Government to warn almost 5000 GPs over high rates of opioid prescribing

Doug Hendrie

8/06/2018 11:44:00 AM

RACGP flags concerns over campaign to reduce opioid overuse.

The letter is being sent to the 20% of GPs who have the highest rate of opioid prescriptions in Australia.
The letter is being sent to the 20% of GPs who have the highest rate of opioid prescriptions in Australia.

Almost 5000 GPs will be warned that their rates of prescribing opioids are very high relative to their peers, following a similar 2017 campaign targeting overuse of antibiotics.
The 20% of GPs who have the highest rate of opioid prescriptions will be sent the Department of Health (DoH) letters, signed by Australia’s Chief Medical Officer, Professor Brendan Murphy.
More than 3400 urban and 1400 rural and remote GPs will be targeted.
While the RACGP broadly supports the initiative and approves efforts to rein in opioid overuse, it has concerns around how these GPs have been identified.
RACGP President Dr Bastian Seidel outlined those concerns in a letter to the DoH in March.
‘While the proposed campaign is well intentioned, the RACGP is concerned about … the methods used to identify practitioners who are considered to be prescribing more opioids than their peers [and] possible unintended consequences of the suggested approach to reducing opioid prescribing,’ he wrote.
‘The RACGP remains significantly concerned about this approach.
‘GPs working in palliative care, rural hospitals or aged care may be more likely to prescribe opioids than GPs working in other contexts. These GPs are therefore more likely to be identified in this campaign as problematic prescribers when they are in fact providing suitable care.’
Dr Seidel noted that particular effort should be made to ensure GPs providing care to patients in residential aged care facilities were not caught up in the sweep.
‘This cohort of patients is complex and often require a palliative care approach,’ he wrote.
The DoH may refer issues of potentially inappropriate prescribing to the Practitioner Review Program.
Dr Evan Ackermann, Chair of the RACGP Expert Committee – Quality Care (REC–QC), told newsGP that GPs who feel they have been targeted inappropriately should write back to the DoH.
‘Take the opportunity to say they’ve got this one wrong,’ he said.

Evan-Ackermann-Hero.jpgDr Evan Ackermann believes the letter can act as an opportunity for GPs to reassess their opioid prescribing practices.
However, Dr Ackermann said that for many GPs the letter would be a useful prompt to reassess opioid prescription in their practice, and follows on from the RACGP’s 12-point opioid challenge to reduce opioid prescriptions.
‘This is about prescribing opioids responsibly and becoming accountable prescribers. If you use your clinical judgement and make fair decisions, you won’t get into trouble,’ he said.
‘It’s a chance to look back at opioid prescribing and review the current [RACGP] guidelines, to discuss the acute use of analgesics, to reduce fentanyl patches for acute pain.’
The Government’s initiative is the latest use of nudge theory, the concept that a small ‘nudge’ from authorities is often enough to lead to behaviour change. Similar letters have been used in the US and UK, often with success.
While a strong proponent of responsible prescribing, Dr Ackermann cautions GPs not to abandon opioids entirely.
‘This is part of a trend towards appropriate treatment of long-term pain,’ he said. ‘Some people get a lot of relief [from opioids], so we don’t want the pendulum to swing too far.’
The DoH campaign will monitor opioid prescriptions over the next 12 months.

department-of-health opioid-overuse opioids prescribing

Dr.Vinod   8/06/2018 1:26:15 PM

Wrong to say age care facilities doctors may fall in the clamp down.Except palliative there is no need for patients to be on opiate lifelong or any more than few weeks or acute pain duration.
The is not much place for opiates in chronic pain.
No need for elderly in nursing homes to be on opiate if there is no real indications like acute pain--definitely not for Osteoarthritis as many are in age care facilities

Nick Bretland   8/06/2018 2:30:38 PM

Disagree with Dr Vinod. Pain in aged care residents is difficult to assess and may present only as behaviour problems. NSAIDs frequently contraindicated, codeine causes costipation ( already under diagnosed), tramadol has unacceptable rates of delirium. That leaves non pharmaceutical, tapentadol, and opiates. Patches for those with severe dysphasia available only as opiates

Dr Peter J Strickland   8/06/2018 2:46:08 PM

The other target should be the hospitals and specialists who prescribe opioids for intractable and post-operative pain from such clinics as pain, rheumatic and orthopaedic areas for chronic backpain, other joint pains, and chronic neurological pain with other adjuvants. This leaves the GP often in a position of trying to reduce sometimes large doses of opioids--both oral and patches. For those GPs dealing with a lot of serious cancer pain, and often terminal patients --leave them alone in my opinion, as sometimes stats. can be downright wrong for these certain good and compassionate GPs!

Dr. Sharma   8/06/2018 3:13:23 PM

I will now be asking my patients to contact their Pain Specialists for their S8 scripts.

Sovan   8/06/2018 3:33:17 PM

I wonder how much is the time limit used? ? is it more after Feb 2018 when OTC codine is now by prescription? Other day I heard in news, that, recent GP visit in last 6 months has significantly increased. Some gov study. and they are pleased bec more people are using GP services and Bulk billing services. Is it because of codine has become prescription med. How much this has effect on both the studies, it will intesting to know. If any data available please share.

The observer   8/06/2018 4:40:37 PM

1. From now on prescription of any opioid other than Codeine must come from a specialist.
2. GPs should be allowed to prescribe only upto 10 tablets/capsules or 2 patches of any stronger opioid.
3. Only regular GPs of the patients should prescribe opioids to them.
4. Minister must ensure patients get seen by the pain specialists within a period of 10 days for ongoing pain management plans.
5. All must realise pain management is a very complex issue.

Dr David Jones   8/06/2018 8:56:12 PM

My problem is the appalling public access to pain clinics or other specialties (ortho/rheum) for the uninsured in chronic pain. E.G. 77yr old, Bone on bone hip pain - put up with it until the pain was so intense she confessed later to me she had thought about killing herself. The extent of her OA disease was (obviously) severely advanced, yet it was a further 8 months to get her hip replaced (and that was after begging the surgeon for an earlier TKR). For pain clinic to assist/review pain management she would have been waiting 18/12 so naturally the intermin management fell to me. I titrated analgesia until she was as comfortable as possible. post op (8/12 later), she was off all opiates within 3 weeks. (I could give several more examples of impossible situations like the above where the GP prescribes or oversee unnecessary and often suffering).

I dare to suggest the DoH data might be skewed to pick up GPs who work in bb/mixed billing practice where access to services is appalling so the amelioration of pain falls, rightly, to the GP.

I have no problem with tackling the problem of over prescription of abx, but opioid analgesia is a completely different issue and cannot be viewed in the same way with such a generalised sweep.

Dr.Susan   8/06/2018 10:32:39 PM

This means more aggressive and abusive patients when their scripts are declined and other alternative analgesia is discussed. As it is we are facing so many problems in this area.Anyone with a suitable solution to this issue will be very much appreciated.

Tony Ferris   9/06/2018 11:50:37 AM

The indication for analgesic use in nursing home patients so often relies on the history & assessment of the nursing staff therein making it even less objective of the situation. Tedious as it is , all opiates need to be prescribed after examination of the patient & thorough questioning of the staff as well as the patient.

Dr Duncan MacKinnon   9/06/2018 8:22:41 PM

Very happy to tow the line- fewer long term opiates can only be a good thing!
Unfortunately, the reality is that no one has provided a satisfactory alternative management regime for those trying to manage the tsunami of chronic pain that GPs face everyday.
If we weren't compassionate- then we could manage easily.
I would be very happy to be involved in working on a pain management strategy that is effective if there is the opportunity.

Ravi Bundellu   9/06/2018 9:11:02 PM

Well done, it is high time GP's involved in Over Prescribing of Opiates are pulled and questioned
I have come across total disregard to all conventional advise ,just to make money

Diana   10/06/2018 3:04:22 PM

Sadly yet another reason to depart from providing care in aged care facilities. If this policy means one is getting audited and threatened with misuse GP's will be scared to provide pain relief and patients will suffer. Upset families watching their loved one suffer whilst the GP is fearful of being reprimanded.

Mike Jones   12/06/2018 7:06:37 AM

Interesting comment - so you're of the belief that opiates have no place in chronic pain management? If function and QoL can be improved with opiates then prescribing them should be appropriate - but they are definitely NOT the great panacea and reviewing there ongoing use is essential

Tasmedic   13/06/2018 12:53:32 PM

If the top 20% of opioid prescribers are being targeted, then, even in their prescribing reins in, there will still be a top 20% to gripe at next Year. It's a stupid approach.

Robert Hoffman   14/06/2018 8:17:26 PM

I work in aged care. Most of my patients who arrive in Aged Care come from an Acute Hospital. They usually arrive with an opioid, usually Targin or Norspan. I use Hospital Outreach and HIH and they often add or increase opioids for my patients. However I am the one who provides the ongoing prescriptions - so it is all reflected in my statistics.

When it comes to Palliative Care, I provide this to 70 patients a year. All my Morphine scrips are for palliative care. Because the need for Morphine is at the end, only a few prescriptions are needed. I seldom use Authority Scrips. The DoH excluded Authority Scrips for Palliative Care Morphine in their statistics - therefore my statistics are artificially inflated. In addition, I only use Endone on a PRN basis. As a result most Endone pills will be returned to pharmacy as being past their expiry date - when a replacement scrip is consequently required. The statistics counts them as all used. I estimate 25 to 30% only are used. Again my statistics are misleading.

Everyone is on Paracetamol. In the elderly we cannot often safely use NSAID's. Tramadol is not a good drug in this age group. Pregabalin is helpful but only for a limited population. All the non-pharma options are underfunded in the public system (Pain Clinics anyone?) and not easily accessible in any case in Aged Care facilities.

This process of DoH is worthy but its design is blunt, its targeting is not focussed and not well executed.

Dr Dilip   15/06/2018 8:45:16 PM

Me too have that letter saying I am prescribing more than my peers without auditing to which patients are involved Most of my patients are with me for last45 years I have fair praportion of Cancer others waiting for hip and knee replacements sometimes they are sent home from Emergency with endone or other opioids they may get one repeat from me that may be all I don’t know how that makes me a high prescriber
Dilip Chauhan

Dr Nigel Dormer   16/06/2018 1:35:13 PM

I have just been contacted, but I'm a community Palliative Care Dr & GP. The methods to screen I think are inaccurate eg unable to determine if dying patient, and the length of time opiates prescribed. There are about 30 of us who work in Perth as part of Palliative Care Service.

Dr Richard Gordon   23/06/2018 8:18:33 PM

Another ham-fisted attempt to blame GPs for the inadequate provision/funding of pain management clinics and over-prescribing of Endone in A&E depts and post-op.

Dr Nicholas A. Cooper   24/06/2018 11:29:29 AM

The DOH have tarred us with a very broad brush on this issue. GP's looking after Aged Care Patients, either in Residential Care or in the Home are often stuck with the decision of what to prescribe for chronic non cancer pain. NSAID's are often contraindicated (PU, Triple Whammy etc), pain is frequently not neuropathic and Lyrica is often poorly tolerated. The Government in their wisdom recently took Panadol Osteo off the PBS. These patients often have multiple co-morbidities including obesity, non-operable joint disease etc. Opiates prescribed responsibly in the lowest effective doses can provide a massive improvement in QOL. Even with a Care Plan they often cannot afford to see Physio's. We are keeping people alive longer, OA is going to become more of a problem, and with the obesity epidemic will start to affect younger patients.
It does horrify me when younger patients present on often high dose opiates for some past injury and it can take years to reduce and ultimately wean these patients off. It is important to get Drug of Addiction Approval for these patients, use contracts, nominate a Pharmacy and begin a reduction plan, all of which I have done, yet I have still got a letter. I will be calling the DOH for a please explain..

dr bruce flegg   8/07/2018 3:40:28 PM

Unfortunately this again shows the ignorance of the beaurocrats running our health system.
Like medicare audits it will overwhelmingly target one group. Those that work fulltime.
It will also target low ses communities which continually are ignored or neglected.
We have a high concentration of the disabled and chronically ill (they dont live on the northside of sydney or the west of brisbane)
The services that might help reduce opiod dependance are just in the imagination of policy makers. If we had a chronic pain clinic (which we dont) they would be using the opiods for chronic pain just as GP's in low SES areas need to do at present.
Then to make matters much much worse the makers of opiods have marketed so well to the government that paracetamol for example which is described as a potential first line treatment for conditions such as rheumatoid arthritis and OA is no longer supported by the PBS and in very disadvantaged areas patient frequently come back with their non PBS script for Osteomol and say I dont have the money I need something I can get free on the PBS
To make matters worse we also have to tell them they could have it free if they were aboriginal
Further the government basically banned di-gesic a drug used safely for 50 years with little abuse in favour of opiods that are associated with more deaths than motor vehicles.
In Short Don't target doctors working with the poor and give us some alternatives

Dr. John   16/11/2018 11:43:07 AM

Dr.Vinod's comment "The is not much place for opiates in chronic pain" (sic) clearly demonstrates a complete lack of empathy & knowledge of chronic illness that causes severe debilitating pain for the patient. The qol for people who receive no respite from severe pain often spirals downhill. They lose their job, their relationship, their home & develop mental illness becoming even more burdensome on society. People have the right to quality health care which includes having their pain managed in the best possible way. It is the year 2018 & there is no place for Doctor's who do not like to see people feeling better. Stopping the use of opiates for chronic pain might have a slight decrease in related deaths however the suicide rate will sky rocket I assure you. There must be a better way.......

Barry   23/11/2018 11:05:53 AM

So Doctors just need a gentle "tap", which has been so successful in the USA. Hate to rain on your parade but my colleagues in the USA are telling me that many GP's are refusing to write opioid scripts and sending patients back to their specialists who are now being threatened with or actually having their prescribing rights suspended for writing more scripts than the beaurocrats deem are appropriate. How long before the gentle nudge becomes jack boots?

Patient   1/04/2019 4:56:49 PM

I have ankylosis spondylitis and for the last 3 years the symptoms have been severe while I have tried 2 biological drugs, every non steroid medication available and was not responsive to the medication. I was also on steroids for 18 months. I work as a National Manager for a large multinational company and want to stay in the workforce as long as possible, I also get to pay high tax rates rather than have the government to pay me to stay home. I suspect that my doctor has received or these letters, as I am made to feel like a druggy when I need a Targin refill or endone for my frequent flare ups. The pain is that bad that I sometimes fantasise about suicide and to be without pain. If I didn’t have a family and the pain medication, I wouldn’t continue to keep going. I feel like I and others are the unintended consequences of these letters. The comment that opiates are not needed unless it’s for palliative care is uninformed, damaging and need of a job in a clinical trial for arthritis..

Gail Putland wife/mother/grandmother of chronic pain patients   5/06/2019 10:44:37 AM

I have multiple family members in chronic pain. The same doctor was prescribing pain medications for four years, with the consent of a pain management specialist. Since these letters have been sent out this doctor's practice has placed a blanket ban on S8 drugs being prescribed, choosing instead to refer to an "addiction specialist". For three months my family has unsuccessfully been sourcing a new GP to manage their complex health issues. They have a pain management specialist. The method for this initiative has been appalling and cruel. Lives are being ruined and at risk of being lost. The Government's approach has been very unprofessional.

Chris   25/07/2019 8:01:39 AM

Wow..I was blown away by Dr vinods wow wow...get out of medicine if you have that little compassion or empathy or go study a pain clinic fellowship..IV worked in critical care nursing for over 20 years and suffered chronic pain myself.. get of drs backs and put more funds into pain clinics and support services, including addiction management


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