Prescription monitoring and helping people at risk

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There's an increasing understanding in the community that prescription medicine harm isn't just an issue in general, but specifically is an issue in Australia. We may not be in the same strife as the US as yet, but as healthcare practitioners, we know that there's an increasing number of deaths in Australia from overdoses from prescribed medicines like opioids, benzodiazepines, and zed drugs. But what can we do about it? Part of the issue relates to communication within our complex system of medical records and multiple healthcare providers to make sure we're all on the same page, and real-time prescription monitoring programs are increasingly being discussed as part of that solution, giving us information that might be helpful. It does raise a question though. What do we do with this information? And how do we actually do better by our patients?

I'm David Liew, your host for this episode. And I'm joined today by Malcolm Dobbin, a senior medical advisor at the Victorian Department of Health and Human Services, but also a public health physician known for his tireless work in codeine regulation. He's written in the October 2020 edition of Australian Prescriber about this very issue. What is real-time prescription monitoring? And how can it help people at risk of prescription medicine harm? Malcolm, welcome to the program.

Thanks David.

So a lot of people will be at home thinking, why is this an issue? Why do we need, in the current climate, another system? What kind of problem does a real-time prescription monitoring programs solve for? So where's the issue here, Malcolm?

Well, the issue is that, as you've said, we've also recognised that there's been an increase in the number of overdose deaths. We've seen coroners reviewing different cases where people have been obtaining high-risk medicines from different prescribers without each being aware of supply by others. And there's a problem with dose as well in that, whilst probably many of us were trying to think that "Well a patient on chronic opioid treatment would develop tolerance and would need a higher dose", many of us have escalated that dose, but now as time's passed, we've recognised that there is a very serious hazard associated with high opioid dose.

There's also hazards associated with combinations of CNS depressant medicines and alcohol. So in the past, we haven't been able to coordinate treatment from different prescribers and pharmacies, but now real-time prescription monitoring enables us to do that and find that perhaps the patient might've been seeing numerous prescribers, which you may have been unaware, or that your dose that’s calculated over the previous 90 days exceeds the recommended safe dose of opioids and those risky combinations. So this is a real-time system that gives each prescriber or pharmacist immediate access to real-time information about supply to individual patients and enables them to make an assessment about the safety of ongoing supply.

Well, Malcolm, I'd say it seems to me that the thing that we're worried about is running into the kind of situation that the US is in. Perhaps you can tell us a little bit about why that might relate to Australia. I mean, is that something that we should be concerned about here? Or is that just a specifically American problem?

Well, I think it's more extreme in the United States and it's actually an indicator that, when America sneezes, the rest of the world catches a cold. We've seen that with the global financial crisis in the past, and we're now seeing escalating supply of opioids and inappropriate prolonged prescribing of benzodiazepines in Australia. We're seeing escalating doses here too. And we're seeing different cases. Coroners are seeing cases like the case of James, a young man who used to get up in the morning and go out and get medicines from different prescribers, come home, go to work, come back at night and start using his drugs to get intoxicated, and tried all kinds of things, went into multiple rehab treatments, asked his friends to keep his medicines in a locked cupboard so that he could cut down. But in the end, he lost hope. When the coroner reviewed the case, he'd seen 19 different doctors in the preceding year, and got medicine from 32 different pharmacies. And he lost hope and overdosed, and he was 25 years old. So those kinds of cases led coroners to recommend that real-time prescription monitoring be introduced.

But this case of James, is that just a one-off? Are there really a large number of deaths coming out from prescription medicine overdoses?

Well, James's case was one of about 30 different cases that coroners investigated and made that recommendation to the Department of Health and Human Services for real-time prescription monitoring. But there are many, many more deaths that don't involve multiple prescribers. And several of those involve very high opioid doses, but the biggest feature is the risky combinations with other CNS depressant medicines, particularly benzodiazepines, but also including some antipsychotics and antidepressants. But the ones we're most concerned about are the ones that are sought because of their psychoactive properties and the ones that are sought for the euphorigenic effects, or the contribution in combination, particularly with opioids, both licit and illicit.

The other problem is that the number of deaths involving prescription opioids exceed the number of deaths involving heroin. That's information from the Victorian coroner's prevention unit. So now there are more deaths involving prescription drugs than from illicit drugs or from the road toll. So, it is now quite a serious problem already in Australia.

Hmm. So it makes sense that we try and give a little bit of throttle to the issue of prescription medicine overdoses. So tell me a little bit about how real-time prescription monitoring services have evolved, and why they might be something that might be helpful in this situation.

Well, in the past, these systems are set up to coordinate treatment, and they've evolved steadily over the last 20 or so years in the United States to the point now that 49 of the US states have them. Now we know that there are certain features of prescription monitoring programs that enhance their ability to have an effect. So the science about assessing these is evolving, and we know now that if they have certain features such that there's no delay in entering data into the system, their use is made mandatory. That's integrated into the workflow, that enhances people's ability to use it. And also if it provides proactive alerts about particular risky prescribing or risky supply, such as exceeding an opioid dose threshold or obtaining medicines from multiple providers, or risky combinations, those proactive alerts have been found to actually have an effect.

And Australian, I'm expecting... Well the Victorian SafeScript real-time prescription monitoring includes all of those features, and we've seen a reduction in the number of multiple provider episodes or patients experiencing those episodes, and also a slight decrease in the total amount of opioids supplied in Victoria. So I think now that we know the more evolved science in this area does indicate that they can be effective.

I'd really like to know a bit about what our frontline colleagues should be doing about this in practice. Because having been in the situation where unexpectedly, I found a patient in front of me who has more prescribers than I expected or imagined, it can be hard to know what to do. Maybe if you can talk me through a little bit about what you might advise, Malcolm, as a former GP and as someone with enormous insight into medicines-related harm.

Well, if I found that one of my patients had seen four or more different prescribers, or obtained medicines from four or more different pharmacies without my knowledge, I think my natural instinct would be to think, "Well, this patient's seeking drugs, and I feel a bit angry because my relationship with a patient is based on trust." That's the nature of a good doctor–patient relationship, is mutual trust. So I think there is a risk that people might feel "Well, I've been betrayed by this patient." And particularly in view of the fact that over many years now, there's been a lot of publicity in the media about doctor shopping and pharmacy shopping and prescription shopping, I do worry that some prescribers or pharmacists might assume that the patient is just doctor shopping to obtain drugs for their own misuse or to traffic. But I think we've got to be careful not to throw the baby out with the bath water and not just discharge a patient from our care without trying to understand the origin of this problem.

So if the patient had seen numerous other doctors, I would think we need to try to understand what has happened, and I think the first thing is to establish "Well, if I'm seeing that this patient's seen numerous different doctors, I need to check with the patient if this is actually the case." Because pharmacists occasionally, like doctors, can make mistakes and enter the wrong doctor's name into the prescription record. So I think the thing is to take into account what the patient's response is. And I think you take the approach as, "Look, it appears to be that you've seen other doctors and I need to understand what's happening. Can you explain this to me?"

And there may be a very good explanation for that. "Well, I ran out of scripts, I was on holiday. I was in another town for work." Or,"I got the script from a hospital and another one from my specialist." So in that case, you need to say to the patient, "Look, I need to understand what's happening here. And in future if you could let me know when you do get another script, but I need to coordinate your treatment." And I think you pitch that in the terms of, "These can be risky medicines and we need to reduce that risk and I need to have full control of your supply."

Malcolm, do you think that that goes against a lot of instincts for people? Because I think that... A lot of people think that, "Well, there are multiple prescribers. I am not someone who deals with patients like this. This is a great time for me to step back here and leave it to people who can deal with this better."

Yeah. So I think that's true. The monitoring systems provide a screening tool. So in treatment of drug and alcohol issues, there's a phenomenon called SBIRT, S B I R T, which is screening, brief intervention, referral, or treatment. So it's true, you could say to this patient, "Look, I'm happy to continue treating you, but I can see you've seen a number of other doctors. Who is the doctor you would like me to refer you to? I'll give them a call and arrange for that doctor to take over your treatment." So you could do that. So that's the referral component. You could do a brief intervention, which is to say, "I'm just a bit concerned about this. In future, could you just let me know about this?" Or you could open up the idea as, "Do you think you have problems with these medicines? Have you tried to stop? What happens when you try to stop?" Just to sort of elicit whether there's any evidence of withdrawal syndrome for the medicine, whether it's a benzodiazepine or an opioid and open up that discussion.

If it's a high-dose opioid, you could open up the idea of tapering and work towards a consensual arrangement with the patient to taper very slowly. So I think that you just enter a discussion with the patient, seeking their point of view, and reaching some agreement about how you're going to manage the patient. But it wouldn't be appropriate to abandon the patient. But I think the point is we need to engage with the patient and just try to understand what's happened and offer treatment because these may be patients that are extremely high risk of opioid overdose.

It almost sounds like any other medical issue, that patients come to their general practitioners and clinicians for help with, right?

Yes, exactly. I think that most of these patients need our professional help. And I think now that we've got real-time prescription monitoring, I think we need to move away from the use of the term doctor shopper, prescription shopper, pharmacy shopper, because it tends to prejudice our view of the patient as just cynically seeking to deceive us and obtain medicines from multiple providers. Whereas in fact, the vast majority of those patients might be people who've drifted into an addiction and/or dependence, and have tried to control it or rationalise their attending different doctors and getting them from different prescribers, just thinking that, "Well, I just need more." I think we need to take a more sympathetic attitude. And if it is somebody who's cynically seeking these drugs for misuse or to traffic, they're not going to remain in your treatment if you're going to offer a controlled supply.

It's like a lot of things, until we start to review the way we look at things, it's hard to get patients to review the way they look at things.

Yes. Look, I think one of the other things is I think we all feel a bit of stigma about drug addiction. I mean, many of us have experienced, either when we're young doctors in the emergency department we've seen street drinkers or street addicts and formed very negative views of them. And we've also been deceived and felt a little bit angry. So we tend to have this unconscious bias and prejudge these patients. Whereas I think we have to cast those aside now. This is a new era. We're seeing more overdose deaths. We're seeing more problems with addiction. We're seeing an increased supply of opioids, more patients on opioids than have ever been on opioids before. We're entering a new era. We've now got a new tool that can help us sort through this and provide the professional response that people might need.

Fantastic. Malcolm, thank you very much for joining us on the program today.

Thanks David. Thank you.

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The views of the guests and the host on this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm David Liew. Thanks for joining us once again. Stay safe and we look forward to seeing you next time.