GPs critical of ‘intimidating, unpleasant’ warning letter over opioid prescribing

Doug Hendrie

22/06/2018 12:20:45 PM

One in five of Australia’s GPs has – or will shortly – received a warning letter over their level of opioid prescribing. Many are not happy.

Almost 5000 Australian GPs will be warned that their rates of prescribing opioids are very high relative to their peers.
Almost 5000 Australian GPs will be warned that their rates of prescribing opioids are very high relative to their peers.

GPs who have received the Department of Health (DoH) letter regarding opioid prescribing have hit back over the tactic and called for GPs upset by the process to write to the DoH.
One GP, who wished to remain anonymous, told newsGP the DoH letter was ‘very much the stick and no carrot.’
‘[The letter] was intimidating and unhelpful. I find it odd, because the Department’s role previously has been to inform and guide,’ the doctor said. ‘This is a very strange tactic and it’s overstepping the mark.
‘The stress and the worry: it makes you anxious to think they’re monitoring you over the next 12 months.
‘This is not helpful, not supportive and they’re not listening to doctors. It’s just unpleasant.’
The RACGP made its concerns known in a letter sent to the DoH before the letters were sent out last week.
In the letter, RACGP President Dr Bastian Seidel warned that the wide scope of the letter risked unfairly targeting doctors who had legitimate reasons to prescribe opioids, such as those working in palliative care.
The anonymous doctor echoed those concerns, stating that their rural area has a high proportion of older people, many of whom have legitimate reasons for being prescribed opioids.
‘I do a lot of palliative and aged care,’ the doctor said.
The doctor called on all GPs who receive the letter to contact the DoH to register their concerns.
‘We should be letting them know it was an inappropriate letter and an inappropriate use of data,’ they said.
‘Everyone knows about opioids, and we’re all trying to do the best we can to look after patients.’
The doctor said that alternatives to opioids for chronic pain, such as pain management clinics, often have very long waiting lists.
‘We don’t have a lot of alternatives, and putting the blame on GPs is totally unhelpful,’ they said.
A number of other GPs have commented on a previous newsGP article on the letter, supporting the principle of reducing opioid use but expressing their concern with the approach.  
Some GPs said that alternatives to opioids, such as pain management clinics, often had long waiting times. Others who work in palliative care questioned whether the DoH was able to chart the length of time the opioids were being used, and whether the patient was dying.
Another GP said that hospitals and specialists should also be targeted. He said that he often had to try to help patients reduce their high doses of opioids after being discharged from hospitals.
One GP wrote that his main concern was the ‘appalling public access to pain clinics’ and other specialties for uninsured patients suffering chronic pain.
He gave the example of a 77-year-old patient who experienced such great pain from her osteoarthritis that she considered suicide. His patient was looking at an eight-month wait for a hip operation, and a 12–18 month wait for a pain clinic. He wrote that the only solution was careful use of opiates until the operation.
The doctor asked whether the DoH’s data might be ‘skewed to pick up GPs who work in [bulk billing or] 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 [antibiotics], but opioid analgesia is a completely different issue and cannot be viewed in the same way with such a generalised sweep,’ he wrote.
Another GP observed that fewer long-term opioids is undoubtedly a good aim.
‘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 every day,’ he wrote.
A DoH spokeswoman told newsGP that the campaign came from concerns that Australia is trending down the same path as other countries facing opioid crises.
She said that while no further action would be taken for the large majority of GPs who received the letter, a small number of GPs whose prescribing of opioids was very high relative to their peers may be asked for an interview under the DoH’s Practitioner Review Program to understand the reasons for the pattern of prescribing. 
‘The Chief Medical Officer, Professor Brendan Murphy, has written to GPs who prescribe more opioids than others – the top 20% – to raise awareness and encourage self-reflection about prescribing practise,’ she said.
‘The intent of the letters is to raise awareness and have GPs reflect on their prescribing behaviour and to see if there are any opportunities in their practice to reduce prescribing where clinically indicated.
‘After self-reflection, a GP may determine that they are prescribing in an appropriate manner for their patient group.
‘The Department looked closely at the Pharmaceutical Benefits Scheme [PBS] data and excluded PBS items that were identified as palliative care. Codeine was also excluded given recent changes in scheduling.’ 
The DoH spokeswoman said that the department would continue to monitor prescribing practice.
The DoH website for the campaign notes that pharmaceutical opioid deaths now significantly exceed heroin deaths.

department of health opioid prescription prescribing

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Sue   22/06/2018 2:58:21 PM

1 in 5 Gp’s got this letter. If you, like me, have an older patient population and have nursing home patients it is very likely that you will end up in the top 20% like me with very appropriate prescribing. Surely they should have examined an individual GP’s patient statistics prior to sending this letter?

Julie   24/06/2018 1:41:47 PM

DoH have provided NO ALTERNATIVE to prescribed codeine for chronic pain sufferers & the exhorbitant costs of pain clinics and consults at $350/session is unaffordable for all sufferers and most do not have GOvt Health Cards. Hunt's reasons are flimsy and scaremongering and he & TGA admit cannot validate their claims re codeine with any hard evidence which TGA admit are inconclusive. Hunt's heavy handedness and inteferring with private doctor-patient relationships is cruel and erodes trust and does not comply with Medical Board Aust code of ethics. Hunt has not offered any other proven affordable and easily accessible alternative and his assault on GPs is this Liberal Fed Govt abusing people's privacy and right to manage incurable diseases which Govt has not found cures or proven solutions and pain clinics are not total answer only "complimentary" providing a few rudimentary sessions of physio, psychology and GP prescriptions. Overbooked long waiting pain clinics admit they can only do so much and prescribe far worse drugs with far worse side effects. The current Health Minister Hunt is way out of his depth on this subject and it shows by his aggressive attitude without proof or offering proven alternatives. Hunt will be his Fed Lib Govt downfall with blood on his hands due to increased suicides - will he report those? This Lib Fed Govt should be held publicly accountable for its unfounded unreasonable claims immediately.

Dr. Sharma   24/06/2018 9:11:41 PM

Its high time that Pain Specialists ONLY are allowed to write S8 meds! If the DOH is so concerned, why not ban it so Gp are NOT able to prescribe at all! S8 even codine based products ONLY to be prescribed by Pain Specialists and those who are discharged on it from the Hospitals should only get ample supply to be reviewed later till their review in the specialist clinic...humbug!

Robert   25/06/2018 9:10:17 AM

Like most GPs who are in the top 20% I see a lot of elderly patients and nursing home patients. This letter goes against the principle of supplying quality of life to our elderly. Are we supposed to treat the elderly as second class citizens and let them suffer!

HD   30/06/2018 9:08:33 PM

I have the same issues as everyone else. I service two nursing homes with 40+ residents, in addition to having a special interest in palliative care. As everyone else have pointed out, nursing home patients have complex needs with the focus on mainly symptomatic treatment and quality of life. The usage of opioids is unfortunately a necessary evil in achieving the above goals.
Furthermore, I do note that it is opioid dosage generated PER consult. Correct me if I am wrong, but many of us generate scripts owing to the pharmacy without necessarily billing a consult item. As such, our opioid dosage prescribed will be inflated due to no consult items billed- a huge flaw in the DoH’s way of identifying over prescribers!

Maureen   10/12/2018 4:38:02 PM

Having worked in Homebased Palliative Care with Patients dying not only with Cancer but other diseases such Endstage MS and Kidney Disease including children only Oppropriate Opioids are able to give them the comfortable as possible end to their lives. It's Not these patients who kill
Themselves and overdose with Opioids it's drug addicts who are only wanting to get a HIGH not those who want some quality to be able to live until They die . Those making these draconian policies probably have never met a dying patient in pain imcluding children. On the one hand prople including Drs are pushing for Euthanasia and on the other hand they are trying to prevent anyone having decent pain management that works!! Their total ignorance and throwing out the baby with bath water approach shows they are NOT FIT to be in any position to be making decisions about pain management! As for Pain Clinics that's a total joke!! They have waiting lists of 8 months to a year and then often what they prescribe is ineffective and who among our Aged care and other Chronic severe pain
Sufferers had the money to go to one!'?!?! I think of the day down the track when the likes of the arm chair policy makers and Politcians will be in severe chronic Pain and have at best
Tramadol and I would like to see them then!!!! Getting some of their own medicine.

Leo Jones   12/10/2019 6:47:05 AM

It seems doctors are trained to treat pain appropriately, whilst politicians are trained to misuse data to inflict it. They have generally had no medical training and have not experienced chronic pain. A quick look at Ted X talks might assist, but you can only lead a horse to water:(

Alison Carnicelli   21/12/2021 11:57:41 AM

I am one of these chronic pain patients and was born with a diseased crumbling spine which as I age has become much worse. I have a regional gp who just now has decided he will not prescribe my opiod meds from my pain specialist because A, pain spec too old and then must be an overprescriber! B, the pain specialist can do scripts C, he is worried about his medical license, even though he tells me he knows I need these meds he doesn't want to lose his license, he spent AN HOUR in his office with a waiting room full of patients, telling me about the govn regs, how scared he his about having it on his record and losing his license and how he is telling all his pain patients this that no longer will he do it and if the pain specialist wants to evaluate then they can write the script. How is this caring about me and what I go thru every single day!! I do feel for him but do I need to cop it from him every time im in his office "even tho he tells me he knows I need it" its depressing