Readers are invited to write in with their questions about decisions of the Pharmaceutical Benefits Advisory Committee (PBAC). Australian Prescriber publishes selected questions from readers, together with answers from the PBAC. Questions may address issues such as regulatory decisions, pharmaceutical benefits listings and withdrawals.
This exclusive arrangement helps Australian Prescriber readers understand how the contents of the Pharmaceutical Benefits Scheme (PBS) are determined.
Letters and responses are reviewed by the Editorial Executive Committee and may be edited before publication. It may not be possible to reply to all individual questions.
Sir, - One of my patients has a psychiatric condition which requires 10 x 5 mg diazepam tablets daily (as prescribed by her psychiatrist). I visit her at her supervised accommodation weekly. As the Pharmaceutical Benefits Scheme (PBS) only allows a script of 50 tablets and no repeats, and it is illegal to write more than one script for the same item on the one day, I telephoned for an authority prescription. I was told by the pharmacist that this patient could not get a larger quantity of tablets on authority, that it was not the role of the PBS to cover all situations for medicine requirements and that I should just write more scripts (but not on the same day). I am sure that, when faced with this situation, most general practitioners probably resort to an illegal solution and back-date or pre-date the second script. I also feel sure that the PBS is aware of this, but chooses not to think about it. To make a second (home) visit in a week just to leave a script seems a waste of time and Medicare resources.
My solution to resolve this problem would be for special allowances for authority prescriptions to be made in some situations after discussion with a pharmacist. However, I doubt this commonsense answer will occur.
Dr Hayes' letter raises two important issues.
The first of these relates to the appropriate use of benzodiazepines and the problems of tolerance and dependence associated with long-term use, especially at higher doses. The product information states that the maximum dose should be 40 mg/day and that diazepam should only be used for 2-4 weeks.
When the current restrictions on prescribing were put in place, it was against a background of widespread use, much of it inappropriate. The PBAC recognised that there were many benzodiazepine-dependent patients in the Australian community who had been taking these drugs for many years. It wished to introduce restrictions which would avoid, as far as possible, creating new cohorts of dependent patients. The PBAC recognised that restricting benzodiazepines to short-term use could result in many patients ceasing treatment and risking severe withdrawal syndromes. The current restrictions represent a compromise. They allow continuing subsidy for long-term treatment in some circumstances, but recognise that such long-term treatment shows the patient is dependent. The restrictions encourage attempts to withdraw benzodiazepines in a medically appropriate way (gradually), but recognise that this may often be difficult to achieve.
The second issue relates to the possibility of allowing flexibility to suit the circumstances of individual patients. Under the National Health Act, the Health Insurance Commission cannot approve authority prescriptions for restricted drugs where these do not conform with the restrictions in the Schedule. This is a reasonable provision, as the PBS would rapidly become unworkable if separate decisions had to be made about individual patients. The PBAC is aware of the issues raised by Dr Hayes, and does its best to recommend sensible and workable listings that recognise clinical, value for money and equity considerations.