News

RACGP President raises concerns after palliative care GP targeted in opioid crackdown


Doug Hendrie


14/03/2019 2:40:57 PM

Dr Harry Nespolon has called for a rethink on the DoH’s campaign on opioid prescriptions, warning palliative care patients may be at risk of not getting adequate pain relief.

Hands opening letter
The Department of Health warning letter has previously been described as ‘intimidating’ and ‘unpleasant’.

The call comes in response to news that a high-profile GP who works in palliative care and aged care facilities has been targeted in the controversial crackdown, in which GPs with high rates of opioid prescriptions are sent a warning letter.
 
The GP – who does not want to be identified – told newsGP they were surprised at having their prescribing patterns interrogated in a compliance meeting when there were warranted medical indications for prescribing opioids in palliative and aged care.
 
The GP must now reduce their prescribing within six months or risk potentially career-threatening consequences under a Professional Services Review.
 
The GP had only recently taken on four new patients whose GPs had also received the letter, and were now refusing to see them.
 
‘I’m worried that the letter will stop doctors working in the aged care and palliative care space,’ the GP said.
 
‘GPs are already reluctant to work in that space, and this is yet another reason why GPs may stop or reduce their commitment to this type of work.
 
‘At the end of the day it is a vulnerable population who will suffer from reduced access to medical care.’
 
The news led RACGP President Dr Harry Nespolon to call for a rethink on the controversial letter due to the ‘collateral damage’ to patients, and the risk of scaring GPs away from doing much-needed work in palliative care and aged care.
 
Dr Nespolon warned that the situation could lead to palliative patients not receiving the best possible care.
 
‘This letter has unfortunately scared a whole lot of doctors who are doing the right thing and giving their patients adequate pain relief,’ he told newsGP.
 
‘When they ring the Department of Health [DoH], what’s even more concerning is that [the department] has not been reassuring about what the next steps are going to be. It’s caused significant collateral damage.’
 
Dr Nespolon said the DoH needs to either become more sophisticated in how it sends out the letters, or introduce a separate Medicare line item for patients receiving palliative care to improve the quality of data. 
 
‘There’s evidence that patients with non-cancer pain don’t benefit from high doses of opioids, so we should all be reviewing our practice in that area. But those who are in the palliation stage should be getting more,’ he said.

The RACGP last year warned the DoH that GPs working in palliative care and aged care could be wrongly targeted due to their need to prescribe opioids for these patient cohorts.
 
Following this, newsGP reported that several GPs had – or were considering – pulling back from palliative care out of fear for their livelihoods after receiving the letter.

harry-hero-01.jpg
RACGP President Dr Harry Nespolon has called for a rethink of a controversial DoH letter warning GPs about high rates of opioid prescription.
 
After the letter campaign rolled out last year, the DoH moved to reassure GPs that areas in which higher rates of opioid prescription are common – including palliative care and aged care – would be taken into account.
 
The high-profile GP presented the DoH with evidence of their case mix, as well as detailed evidence from a clinical audit showing quality process for prescribing.
 
‘Patients with complex and chronic conditions, people who are housebound because of physical issues, palliative care and end of life, and aged care – these are the only patients I see,’ the GP said.
 
‘I outlined my approach, my practice, and the reasons for prescribing opioids and that almost all of the patients had input from other appropriate clinicians such as a geriatrician, or from an RMMR [Residential Medication Management Review] and pain assessments.
 
‘I got a letter back saying they still had concerns around my opioid prescribing based on the fact that my peers may consider my prescribing to be inappropriate. Ironically, many patients are increasingly referred to me by my peers to take over their care. 
 
‘The comparison was with all active GPs, not those with a specialised practice such as mine.’
 
The GP was told that comparison data for GPs with a similar practice was not available.
 
‘The context around palliative care needs of this cohort of patients appears not to be appreciated. My prescribing for the majority of my patients on opioids is very low dose and all in residential aged care settings,’ the GP said.
 
‘Of course we need to address the opioid problem and ensure quality of our prescribing – but in a formative way, not a heavy-handed policing that risks potential unintended consequences. 
 
‘The issue we want to be addressing is unwarranted variation, not warranted variation. It’s an important distinction that seems to be completely overlooked.’
 
If the GP’s prescribing does not change after the monitoring period, a referral to Professional Services Review may occur.
 
‘The potential consequences are pretty significant,’ the GP said.
 
The news comes after a survey last year found more than a third of doctors planned to cut back or stop aged care facility visits due to concerns about poor staffing ratios and low remuneration.
 
A DoH spokesperson told newsGP the warning letters were a one-off, and that the RACGP and Australian Medical Association (AMA) and other professional bodies were consulted on the design of the letters.
 
‘The letters were intended to promote reflection on each GP’s prescribing, with the clear message that in many cases prescribing was appropriate. It is unfortunate that some GPs may have misinterpreted the letter as a definitive criticism of their prescribing practice,’ the spokesperson said.
 
‘Though palliative care-specific items were excluded from the exercise, the [DoH] noted at the time that it was not possible to identify all GPs working in palliative care from the available data.
 
‘The letters therefore specifically acknowledged that practitioners working in this area who received the letters may decide that their prescribing was appropriate and need take no further action. The letters were intended simply to promote reflection on each GP’s prescribing.
 
‘The [DoH] always welcomes input from the RACGP and other stakeholders, and would welcome the opportunity to discuss ways to support appropriate GP care in aged care and palliative care settings.’
 
The DoH does not yet have data on whether the letters have led to a reduction in opioid prescriptions.
 
Palliative Care Australia (PCA) nurse practitioner clinical adviser Kate Reed told newsGP her organisation is becoming increasingly concerned that palliative patients are getting caught up in the crackdown.
 
‘GPs will pull out, and there are just not enough specialist palliative care practitioners to pick it all up. It makes an under-served population more vulnerable,’ she said.
 
‘Palliative care is a human right, according to the World Health Organization.’



aged care department of health opioids palliative care



Dr Mahavir Prasad Gupta   15/03/2019 6:38:43 AM

It is my impression that one of the root cause of problem of increased prescription is that majority of patients are started and discharged on S8 medication. Since the 'effective analgesia' is already implanted in patients' minds, it becomes difficult to convince the patient about the alternative analgesics!


Vadeen Chandura   15/03/2019 9:11:40 AM

I ALSO LOOK AFTER A HUGE BULK OF NURSING HOME POPULATION WARRANTING PRESCRIBING MORPHINE / HYDROMORPHONE / METHADONE ETC. FOR END OF LIFE ISSUES. I HAVE ALSO RECEIVED A SIMILAR THREATENING LETTER REGARDING ME BEING REFERRED TO PSR IF I DO NOT STOP PRESCRIBING NARCOTICS. RACGP COLLEGE NEEDS TO STAND UP FOR GP'S LIKE ME WHO CARE FOR THE FRAIL AND ELDERLY AND GIVING THEM THE DIGNITY OF PAIN FREE DEATH AT THE END OF LIFE.


Dr Geoff Shannon   15/03/2019 9:21:28 AM

As a recently retired GP I agree that the "crack down" on opioid prescribing has a large unwanted flow on. I was seeing this in practice with in nursing homes and in the surgery and discharge situations.

This is a major problem in rural areas where appointments with GP's is difficult and GP attendance at residential care is also a problem.

The issue is that many doctors fear prescribing opiates where is appropriate especially young GP, registers, and recent arrived overseas doctors.
There is a need to cut down on over prescribing but not at the risk of people living with pain and the consequences. The regulators need to be aware of the reality of every day life in the population, especially residential care and in rural areas ( and probably outer metropolitan areas but I have no experience there).


Dr Jan Sheringham   15/03/2019 9:28:05 AM

The old data story - the GIGO effect! If DoH cannot develop an appropriate data collection tool, nor accept the responses of these practitioners working in sub-specialty areas and still threaten PSR review if prescribing patterns persist, the responsible bureaucrats should be fired! How dare they put the terminally ill at risk? This is just so typical of beancounters pushing an agenda relatively unfettered by appropriate professional guidance - it might even become known as the Boeing effect!


Ian Truscott   15/03/2019 9:54:46 AM

If the letter is just a warning that the PSR might review the prescribing, surely one ought just continue as is. The review should confirm the Dr’s practice as reasonable, in his/her situation.
....”should”!


Well well!   15/03/2019 12:00:23 PM

Working in rural area, having many NH Pts, after receiving letter, I spent full week reading about current literature on this topic, then completed an online training on opioid prescription. Over next 4 months, I tapered down 90% of my NH Pts to 50% of their previous doses, got 2 severely dependant pts completely off narcotic analgesics, overall 40% less scripts issued, without any complaints from any of those pts. One pt changed to other GP quietly and one after abusing me.


Dr Peter j Strickland   15/03/2019 2:25:19 PM

My advice is simply to send a letter back to the PERSON from the DoH who sent the letter in the first place, and advise them that their warning will be simply ignored. As long as there are good clinical reasons to prescribe opioids to one's patient group, then there is no ethical problem faced. If one is asked to attend a PSR, then have the DoH official who wrote the original letter present, and have them justify their position, and how they investigated any excessive prescribing, and your possible compensation payout.


General Practice   15/03/2019 9:28:26 PM

I received a caution from AHPRA for prescribing 12 mcg fentanyl patch in patient in severe pain in nursing home. Even though I could justify my choice and I hardly use opioids -it made no difference. The regulators are trying to fix a severe opioid problem in community. They are starting by targeting us. Prescribe even slightly outside the guidelines at your peril. We all need to stop prescribing opioids and get with the program. Doesn’t matter if you think you can justify it. You’re fooling yourself if you think they are interested in why you do it. Guidelines guidelines guidelines. I am weaning to cease all my patients. The pain clinics are telling us to do it.


Dr Chris Kear   18/03/2019 1:13:14 PM

Don't worry. The Government will sign up the Chemists to prescribe all the opiates. Apparently, they can do no wrong. They also have better union representation than us, and they lobby better than our College does, too.


Dr Rodney McConnell   19/03/2019 6:04:30 PM

I have fortunately not received any such letter yet. However, I am currently looking after the bulk of nursing home patients in my town due to refusal of other practices to do so. I am also getting a lot of patients with genuine severe chronic pain coming to me from other practices that have made a policy to no longer prescribe opioids under any circumstance. I fear receiving a warning letter. When that day comes, it will be yet another stress for an already overworked GP to address it.


odette spruijt   21/03/2019 5:02:18 PM

I am a palliative care specialist. I have been concerned about the potential for this 'unintended consequence' in Australia, as we seem to be convinced that Australia is the same as the US and on the brink of an opioid crisis. There are reports of similar problems of legitimate opioid prescribing crackdown in the USA with potential to reverse much of the good work done over recent years in Australia to improve pain management using opioids when indicated. Cancer Pain guidelines in Australia clearly recommend strong opioids for severe pain. What we don't know is what is the 'appropriate' population level of opioid prescribing. This therefore leads to assumption that increase in opioid prescribing across our population automatically means overprescribing. But this increase comes from a baseline of gross underprescribing. Refer you to 2016 article by Berterame et al "Use of and barriers to access to opioid analgesics:a worldwide, regional, and national study"


A Geriatric Nurse   21/03/2019 9:31:37 PM

I have seen firsthand the effects of ‘blanket weaning’ of opioids for residents of RACFs implemented by seemingly well-meaning GPs with scary, detrimental effects. Residents who previously enjoyed quality of life all of a sudden suffering crippling pain that reduces them to tears and reduces their functional status. It’s very cruel.


Dr Bahman Ranjbar   21/03/2019 10:42:39 PM

I am currently looking after the bulk of patients in my clinic due to refusal of other GPs to prescribe opioids. I am also getting a lot of patients with genuine severe chronic pain coming to me from other practices that have made a policy to no longer prescribe opioids under any circumstance. Some of them has been seen by pain management clinics before and I just follow the specialist opinion about them.I fear receiving a warning letter which will be another stress for an already overworked GP to address it. What should I do??
Should I send all the patient to ED in a very busy hospital and add the load to our colleagues in hospital??
What will happen to those patient who really need to be seen in ED??


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