GPs pulling back from palliative care over opioid crackdown fears

Doug Hendrie

25/10/2018 2:27:36 PM

GPs are reducing palliative care services due to fears their opioid prescription rate will trigger a Department of Health investigation.

Scrutiny of palliative care medications is causing concerns for GPs.
Scrutiny of palliative care medications is causing concerns for GPs.

A number of GPs have written to Palliative Care Australia stating they will no longer risk prescribing opioids for palliative care patients.
One of those GPs, Adelaide’s Dr Peter Ford, told newsGP he had reduced his palliative care work in aged care facilities after receiving a letter from the Department of Health (DoH) earlier this year stating his rates of opioid prescribing were very high.
‘I’m an older doctor now and my cohort of patients is old, with multiple morbidities,’ he said. ‘I’ve reduced the nursing home work.
‘It’s all very well for people in bureaucratic positions to take a superficial view, but when you’re face to face with patients in pain and distress, those who require palliative care require palliative care.’
‘Extricating yourself from an onerous investigation of you is quite intimidating, time consuming, and expensive. No one wants to go into it lightly.
‘I’m sure there are many doctors who would rethink their position on palliative care.’
The news underlines the RACGP’s early concerns about a letter the DoH sent to almost 5000 GPs around the country in June, warning them that their rates of opioid prescription were in the top 20% of all GPs in Australia.
The letter stated that the DoH would monitor their opioid prescriptions over the following 12 months.
A DoH spokeswoman previously told newsGP that a small number of GPs with very high rates could be asked for an interview as part of the Practitioner Review Program to understand the reasons for their prescribing.
Immediate Past RACGP President Dr Bastian Seidel warned the DoH that while the campaign may be well intentioned, the college has significant concerns for GPs who work in palliative care, aged care or rural hospitals, all of whom have legitimate reasons for high rates of opioid prescribing.
‘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 wrote to the DoH.
Palliative Care Australia nurse practitioner clinical adviser, Kate Reed, told newsGP her organisation is encouraging concerned GPs to contact Australia’s Chief Medical Officer Dr Brendan Murphy.
She said DoH officials had moved to reassure her that GPs will not be in trouble if they are within the guidelines for palliative care patients.
‘We’re trying to feed back to [concerned GPs] that this prescribing for palliative care is not going to be of concern,’ Ms Reed said.
According to Ms Reed, a key factor in the issue is that oxycodone hydrochloride – a potent opioid – is not listed as a palliative care item on the Pharmaceutical Benefits Scheme (PBS). That could mean GPs working in palliative care have been sent the letters unnecessarily.
‘[Oxycodone] is a commonly used opioid in palliative care and may not be being captured properly in the data around palliative care prescribing,’ Ms Reed said.
‘We will be asking for a review of PBS items for palliative care. They have agreed to have further discussions as to what is classified on the PBS as palliative.’
The DoH did not respond to requests for comment.

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Dr Rod Street   26/10/2018 12:52:31 PM

I hope the boffins who make these decisions do not need palliative care for themselves or their families. What experts were consulted before making such an inane decision?

DR Trump   26/10/2018 1:51:58 PM

I do not think that GP should over-prescribe opioid Medications for the Palliative patients, because GP is not really Specialist in Medicine, although the Government recognize Fellowship of RACGP is specialist, however from Medicine point of view, GP is not specialist in any division of medicine, therefore GP should not be permitted to over prescribe Opioid drugs for the patients.

Dr. SF   26/10/2018 2:41:45 PM

I used to have 250 residents under my care and I stopped seeing all nursing home patient since I got the letter in earlier this year. Not worth risking at all.

Dr Spencer   26/10/2018 2:43:32 PM

DoH made no allowance for age of patients or size of practice, only morphine equivalent doses related to number of medicare services .
As a result I now rarely allow patients any followup care without being seen given the average GP load is 600 patient equivalents and I have over a 1000, with an overload of elderly.
The broad brush they use to choose who to threaten , risks change care of suffering /palliative patients as per Dr Ford above who sounds like he provides a good, necessary and cost effective service to his elderly patients .

Chris D Hogan   26/10/2018 2:44:32 PM

What an utterly stupid situation. Surely it is better to float into the next world on a sea of morphine than to lie on a bed of nails.
I expect that the relevant special interest groups of the RACGP special interest Faculty will send out a strong statement

Dr Spencer   26/10/2018 2:48:29 PM

I am also annoyed that patients are sent home from acute care hospital on massive doses of opiod are GP's are left to clean up the mess . I had a patient with a history of alcohol abuse discharged after shoulder surgery from a large teaching hospital on Palexia 150mg BD Targin 40mg BD and endone 2 every 2-4 hours over 6 months ago and I am still having to slowly wean that down.

Dr Peter j Strickland   26/10/2018 4:55:53 PM

Just ignore the Health Dept. about your high opioid prescribing if you are visiting elderly patients or anyone needing these strong analgesics. The only worry is if one is prescribing them unethically to drug addicts and doctor shoppers, and that should be evident to any competent Health Dept bureaucrat to see by the returns from the pharmacies. Many years ago one of my elderly GP colleagues was "counselled' for visiting too many of his elderly patients at home , i.e above the average --- he had been in practice for 50 odd years, and was visiting his loyal patients at home because they had become too old or informed to make surgery visits --- I gave the Medicare counsellor an enormous "rocket" of reality of the actual ethical and pragmatic work of this GP, and his asset to the local community, and sent him away with his tail between his legs ! Just know you are doing the right and professional thing in relieving patients' pain, and simply ignore any uninformed letter from any bureaucrat, OR inform them to get off their bum and come and visit you for a lesson in reality.

Dr Dan   26/10/2018 9:38:06 PM

doesn't somebody always have to be in the top 20% even if these doctors, in theory, were to reduce their prescribing?

Dr Alby   27/10/2018 7:10:52 PM

I am a country GP who has admitting rights at the local palliative care unit , as well as caring for many palliative care patients in the community . Sure, I received one of those letters , but I refuse to compromise care of my patients , so I will not change my prescribing habits . If the DoH wants to to investigate me all I say is ......BRING IT ON !!

Charlene Chideme   28/10/2018 12:14:17 PM

Indeed pain management is fraught with many challenges. As GP's we are face- to -face with patients in genuine pain on a daily basis and it can be so hard to strike a balance. I suppose at the end of the day , what we really need are improved community based palliative care services and more support for GP's with greater palliative care load.

Geoff Mitchell   28/10/2018 8:00:45 PM

Please folks, stand by your decision and skill. You need to do is to feel confident enough about your clinical judgement regarding prescribing that you can justify it if asked. It's not about punishment, its about appropriate prescribing. So if you can show you have thought about a patient's problem and decided that opioids were the best or perhaps only choice, then don't think that you have to be pushed into changing what you do! Dr SF- 250 patients now don't have you as their GP - who will they be cared for by? I really don't think you will be risking all...

Dr. Faika Jappie   29/10/2018 2:25:33 PM

Why are they making such a fuss about prescribing in palliative care?
The abuse of opioids in NON -palliative settings is a much bigger problem.
I am debating scaling down my hours, or even retiring altogether, because I am sick and tired of all the young "arthritics" and "Low back Pain"s on S8's. There is a veritable epidemic of young (Under 60) patients on S8's for back or joint pain.

Barry Arnott   23/11/2018 10:41:00 AM

The government can't deal with illegal drugs and won't deal with the alcohol issue, so instead they will create an opioid epidemic which they will show us how effectively they will deal with by bullying GP's into prescribing less. I recently walked past a GP clinic in a major shopping centre with a large notice in the front window which says "we do not prescribe narcotics". We are heading down the American road where doctors are so afraid of loosing their registration that they refuse to write scripts for opioids. Tell the government pen pushers to get out of medicine and leave it to the doctors.