Hello I'm Lynn Weekes and I will be your host for a series of four podcasts about managing chronic pain in this new era of SafeScript. My background is in clinical research, pharmacy, quality use of medicines and for 20 years I led NPS MedicineWise. The podcasts will explore a range of scenarios with Victorian-based clinicians and patients where SafeScript can improve patient safety today. We will look at the benefits of SafeScript and how you can fit it into everyday clinical practice.
Joining me today is Julian Rait, President of the Australian Medical Association (AMA) of Victoria, Anthony Tassone, President of the Pharmacy Guild of Australia (PGA) Victoria, and Malcolm Hogg, a pain specialist at Royal Melbourne Hospital. They will give us their insights into how SafeScript can and should work.
Julian I’ll come to you first, no doubt AMA Victoria has looked very closely at SafeScript, what's the overall reaction and how can it contribute to patient care?
Julian Rait (JR): Well Lynn the attitude of the AMA has been that we have always supported real-time prescription monitoring and the reason why is we've been particularly reassured about SafeScript is we think that in many ways its security and its integration into practice software systems has been very good and so therefore we feel that it's not only an important safety initiative for patients but it's also something that we think can be integrated into the workflows of doctors with as little inconvenience as possible compared to other approaches we've seen and as you quite rightly allude. I mean the problem we have with this particular problem of opiate dependence is very much a concerning issue for the medical profession and for Victoria in particular. We understand of course that over the past 10 years there's been an increase in the unfortunate occurrence of opiate-related deaths and you know with a doubling over that decade, we feel that it's imperative that we take steps through SafeScript and other means to reduce the possible morbidity, mortality from this problem and hopefully avoid some of the more extreme situations that we see in other jurisdictions including the United States and Canada.
Lynn Weekes (LW): That leadership is really to be commended I think you've said in fact in the past that you hope 90 percent of GPS will be on board with SafeScript by the time it's compulsory in April 2020. What would you say to the doctors who haven't signed up yet although I understand something like 16,000 doctors and pharmacists are already signed up so we’re well on the way.
JR: That's right Lynn now we're about 60% of GPs at the beginning of September 2019 I think that's a very remarkable and laudable achievement so if we can get the remaining 40% signed up in the next six to eight months that would be fantastic. I think that I would encourage as many doctors as possible to be involved not least because it will obviously become compulsory at some point but I think that at this point we're trying to engage with doctors and make sure that they understand how much better the care that they can deliver will be if they involve themselves with the system. In fact just this week I've heard some remarkable compliments from quite a few prominent GPs from in the AMA section of general practice who've really been evangelists almost for SafeScript and the reason is that all of a sudden they can actually see quite clearly what the pattern of prescribing has been and therefore intervene more appropriately and more intelligently in people's problems. So I think that there's actually quite a lot of momentum behind this you know if the leadership of our general practice group is any guide I think that there will be greater enthusiasm as the time for the full rollout approaches.
LW: Yes I think those positive stories about how SafeScript is actually making a difference are really powerful aren't they, they're helping people see what can be different.
JR: Oh absolutely and I think that the personal stories that GPs share amongst themselves are just so empowering that I'm very optimistic we can reach that target.
LW: Starting a conversation with a patient who's using more of their opiate than they should be or perhaps you're asked to write a prescription and when someone's left hospital who was taking some opiates or was being prescribed by another doctor can be pretty tough for a general practitioner or for any doctor really. What advice would you give if you see a notification in SafeScript and you are not expecting to see it?
JR: Well I think that if GPs feel that they're ill-equipped to have these conversations, but I should say that many GPS do feel capable having these conversations because there's not an unusual situation I have to say where someone's been commenced on opiate medication perhaps after elective surgery and there's no clear rationale that couldn't be assumed by the GP. So these conversations happen every day. But for those that aren't confident with that, there is a telephone support line that is available that involves very highly trained GPs who have done particular courses and are very skilled at having these conversations. So there is advice immediately available to GPs who feel ill-equipped. But equally I'm sure that the AMA and the College of GPs and others are going to be talking more in the next few months about how to have those conversations and how to encourage people to consider alternatives for their chronic pain management.
LW: Anthony, as president of the Pharmacy Guild you must have had quite a lot of discussions about SafeScript over the last few months, how do you see it helping patient care, helping pharmacists to provide good care?
Anthony Tassone (AT): I think the experience with SafeScript from a community pharmacy perspective is sometimes that you don't know what you don't know, and it has helped make more informed clinical decisions around appropriateness of supply and this helps reduce that possibility of profiling patients or subjectivity. We're making more objective decisions when it comes to dispensing and supplying medicines that may unfortunately have risks of dependency.
LW: Yes I think we all think we're quite good at guessing which patients may be having problems and in fact we can be quite wrong about that. In fact, what about your advice a pharmacist when they're approaching this situation in a busy pharmacy? It can be a quite a difficult environment to have hard conversations. What advice would you give to pharmacists?
AT: The first thing I would do, if I may, is not call them hard conversations because if we talk about hard or difficult conversations, we immediately put barriers up or we’re setting ourselves for potential failure. I like to call them honest conversations, if I may say, from my experience it's really really useful to do it in a consultation room. What I've done is actually print up the screenshots from SafeScript and sit down with the patient and actually front up and say: I wanted to let you know there’s this new system that we have that gives us a greater understanding for your care, about what doctors are prescribing for you and what pharmacies are supplying to you. And I go through the risks, I've said to some patients: unfortunately more people die from prescription medicine overdose than the road toll. And I frame it in respect of: I'm worried about you and this is what all your history shows. And in a private consultation room, I've gone through that and I've had a case where a gentleman has listened to me and pretty much broken down crying, sobbing in tears and said: at least I don't have to lie anymore now you know. And I said: well this is not about me catching you out or anything, this is about wanting to help you because I'm worried what could happen if this continues. And we work through a plan of choosing one doctor and one pharmacy and I said: it doesn't even need to be our pharmacy but it needs to be a doctor in a pharmacy that you're comfortable with, working together for your care. And that will always stick with me I think til the end of my practice, that conversation. So it's about trying to have honest conversation with dignity in privacy, centered on the patient safety and care.
LW: Yes I think that's really important that it is about patient safety and it is about giving them quality care and continuous care so that they don't fall through the cracks somewhere as well.
AT: Absolutely and language is so important and we can fall into the trap of using terminology like: doctor shoppers and I caught something. We are not medicine cops, we are health professionals trying to help care for patients. Drug addiction is a chronic disease, it's about training and supporting patients who need help.
LW: So we've heard from some of the peak bodies, the AMA and the Pharmacy Guild, that they're very supportive of SafeScript but Malcolm, I guess there's questions about whether we should be using opiates in the first place and there's you know a recent study of veterans in the US with hip / knee / back pain treated with opiates or non-opiate analgesia. Those on the non-opioid analgesic had similar function with their pain but less pain intensity and fewer side effects. So what is the place of opiate analgesics? There's certainly a group saying we shouldn't be using them for chronic pain but in fact, we still do. So what's your view?
Malcolm Hogg (MH): So I think the place of opioids in chronic pain management is being reviewed and that's based around new evidence showing significant harm over the longer term and at a population level. That's not to say that there are not patients who do respond well and maintain that response. We know that opioids work well for acute pain in that sub-acute phase, but there's a failure rate over time and there's various reasons for that which I can talk about shortly. The Krebs paper you mentioned did take it out to 12 months and whilst it wasn't clearly indicating opioids with a multi-modal approach, using paracetamol, non-steroidals and gabapentinoids, it didn't show inferiority either and it did show some improvement from baseline in that sub-group. What I found interesting was this was a group of people with musculoskeletal pain, they’re a group that you would expect opioids to be most effective with. And it did show some benefit but they were using opioids alone and we know that using opioids alone can lead to opioid failure. So whilst it's not a positive study, it's not clearly negative either to say there's no role. So I would be saying it's a more nuanced approach that needs to be taken where you do a full multi-dimensional assessment, looking at the psychological and social factors as well as the physical and structural side of the patient's pain complaint. And then setting about a strategy of pain management that may include an opioid, rather than using an opioid up front or using an opioid as the predominant mechanism.
LW: I think that will be the approach many people take, that there’ll be a place for opiates and if you decide there is a place and you decide to prescribe, how do you set up expectations at the start, how might you use SafeScript in that situation?
MH: So I think one of the problems is we haven't had that clear discussion, as Anthony was saying, about an honest discussion with the patient to say: this is a trial, this is not going to remove all your pain and it's a shared decision. It's not just the patient's right to the opioid but it's also the doctor and the pharmacist needs to be happy with the prescribing and the dispensing. And so it's a shared team approach to a decision. You'll likely inform not only the patient but also their family members and other clinicians involved in their care and then do a trial. You may take a measurement of their pain and their function before the trial, you define that when the trial is and you set up your structure so that they have an appointment. So many patients don't book their next appointment. You need to ensure that they've got a follow-up plan so that you can reevaluate the effectiveness of the opioid. And then if it's not effective, you need to make a decision on how you withdraw the trial or you change it to potentially an alternative open alternative treatment.
LW: How long would you leave for that first appointment, between those first two appointments?
MH: Well I think in general practice, we often have quite short appointment times so having multiple short appointments builds that rapport and builds the knowledge base. You may focus on different aspects of their pain experience at different appointments so I'm quite comfortable with quite frequent appointments if that's possible. I wouldn't be going more than two weeks from the initial trial before reviewing the patient and once they're stable, you may push that out to a four-weekly sort of review. But again the same concept, you're reviewing for a benefit, improvement in function and looking for any adverse events.
LW: And Anthony, then the pharmacist is in a great position to help monitor the patient through that period, talk with them when they're coming in to get their prescriptions. What advice would you give the pharmacist so they can really excel in that role and really use that potential?
AT: I think my advice is, don't underestimate your role or our role and value as medicine experts as part of the broader team. As Malcolm referred to, chronic pain and in some cases drug dependency is complex and we need a multi-faceted approach and that need that needs multiple players on the team, working together for the same cause. So it is really an opportunity for pharmacists to display their knowledge, to work with prescribers and be another player for the same cause and on the team for the patient's benefit and having another touch point with the primary care team. So Malcolm referred to the importance of frequent review and then there's also those opportunities in between, whereby patients get the opportunity to ask questions about their medicines. And frame realistic expectations of what benefits they can receive from medicines, put into context, likelihoods of adverse effects or discuss issues that are relevant to them. So you know a consumer medicine information leaflet can be really useful to a point, but then we need to tailor our information and delivery of other material in detail that is relevant to the patient in their circumstances.
LW: I think the other thing the pharmacist often will do is to encourage someone to go to see their doctor. I mean, that referral back to the doctor is a very common pharmacist activity so that again in this situation, it would be quite a useful strategy. There could also be a small number of patients in most practices who have been taking opiate analgesics for chronic pain for an extended period of time. Those long-term patients, some of them may be requiring escalating doses of their analgesia, either because of tolerance or hyperalgesia and some people could even be going on to develop opiate use disorder. The recommendations from the guidelines are that hyperalgesia is rarely distinguishable from tolerance and so dosage reduction is the right response to escalating needs for opiates, but they're not always easy to manage. So Malcolm, if you see a patient in that situation, long-term therapy say two to three years using high doses of 100 milligrams equivalent of morphine, how would you go about discussing the tapering of the dose or reduction of dose over time?
MH: So a revaluation of the person's pain experience is important in this setting. You've mentioned a couple of reasons why an opioid might fail, the hyperalgesia and the tolerance but also the disease can change. So the predominant mechanism can change from being a structural or what we call nociceptive type, to being one of sensitisation and that's less opioid responsive. And so it's worth reevaluating the pain and the pain experience and the impact of the pain, so what are the functional impairments from the pain experience. The second approach is to also look at the opioid use and that is where SafeScript can be helpful to look at the compliance of the prescription and the dispensing, the dosing, how it has changed over time. Because if there's been a rapid dose escalation, you also need to look for alternative diagnoses such as substance use disorder but also anxiety, depression, social stressors that can increase an opioid intake. Once that's sort of been reviewed you then look at the value of the opioid. Is this the right opioid for the right patient? And you open that discussion to say: I believe there can be some adverse effects, we need to clear you for you infection risk. We look for hormonal effects, sleep, disordered breathing is very common in people on moderate dose opioids. So you do sort of a medical screen and lead into the psychological, social screening aspect. So that you can open that discussion to say: in your long-term benefit, we believe an opioid dose reduction would be appropriate and this would be the ways to go about it. By doing that, you have to engage or you are engaging the person in their own management plan and you have to motivate them to say: yes I can see the value of that. And that then drives compliance in the new plan. If you can't engage the patient in that respect, it may take more than one event and more than one contact. So you may agree to continue prescribing at that dose with a view to giving further information, engaging other people within the healthcare team, the family members, to identify these issues and discuss it. So that you're leading towards better compliance of a treatment plan that may include opioid tapering.
LW: Yes because you do need that compact to be successful with the tapering.
MH: And the risk is if you challenge them to a greater extent, as Anthony said, if you challenge that from the discussion point, you may lose contact with the patient. And we know for many patients who had adverse outcomes with opioids, there's been points of care with the health system that have been opportunities to intervene but they've been lost. In that there may have been a conflict and conflicted or difficult conversation rather than a well-managed interaction.
LW: So developing that rapport and having the agreement to move forward, practically what do you do then? Because you know, tapering a dose is going to be a bit individual.
MH: So I look at the total dose and I look at the duration of the dose. So in the very high dose range, you can reduce quite quickly the top range. It's more going from a hundred or eighty morphine equivalents a day down, that's the harder component. You look at setting a schedule, it may be a 10% dose reduction every two weeks. It may be even quicker than that if it hasn't been long duration of an opioid. And then you look for adverse effects, so bowel disturbance, sleep disturbance, mood disturbance. We utilize Clonidine 50 to 100 micrograms in an adult three times a day to try to blunt some of those neuronal responses to withdrawal. It can also be helpful for pain management and anxiety. One of the lesser-known side effects of opioid withdrawal is mood disturbance, anhedonia and even agitation in the acute setting. So in people who have an anxiety disorder, opioids can settle those symptoms so if you’re withdrawing the opioids, they can have a flare of anxiety and distress. And so that needs to be looked for and managed appropriately. And that may not mean transferring to benzodiazepines or others but there can be referring to psychology, referring to psychiatry or holding the tapering plan at that point until those symptoms settle.
LW: So looking for that proactively is really important and Anthony Tassone, as a community pharmacist you can be really helpful in working with the person through that taping regime as well because you're going to be seeing the prescription, seeing the changes over time. You’re a really key point on a daily basis perhaps even to help people through that.
AT: That's absolutely right, through pharmacies we can do something called staged supply whereby patients may pick up a certain quantity of medicines on a certain interval as you alluded to. It could be daily, it could be weekly and it's tailored to the patient and their circumstances and needs. And doctors can use the prescription itself, particularly electronic prescriptions, It's easy to read more complex instructions that way. To actually help give an insight into their plan for a tapering of a dose or managing the pain medication. And the pharmacist is there to be that touch point with the primary care system, as I said before, in between appointments to help reinforce what the prescribers intentions are. And what I found from my experience is where it is most effective is where the patient understands the goal, understands what the plan is, that we're not reducing a medication for reduction’s sake. There is a clear, you know for want of a better term, method to the madness and there is a goal in mind that's going to either manage an outcome or in the long run improve an outcome overall but it's going take some time.
LW: And I think even though it's good to have pain specialists like you Malcolm, that's an excellent thing to have in the system. a lot of this will occur or this management occurs in primary care, in general practice and with the community pharmacists where you have that holistic ongoing consistent care. In your view is that the best place to manage patients where you can?
MH: Yes because I think that's where patients are most comfortable, they're most well supported, they've got access to people whether it be through their pharmacy, through their allied health team and their general practitioner. So I feel it's the most appropriate way to manage this condition. Persistent pain does involve ongoing care and so intermittent access to a specialist group is not ideal in the longer term. They're really there to guide and support and direct some major management decisions, but most of the management activation occurs in the community. One of the questions is where the SafeScript fit in there? SafeScript is really just part of the armamentarium of your strategies and it's meant to be a clinical support tool. It probably should be utilised earlier than the time of prescription. So early in the consult, I now utilise it as part of the discussion: just checking your medications again. And just turn around and check SafeScript so that patients become comfortable that this is part of their care plan.
LW: So it's part of their care plan regardless of whether they're using opiates or benzos or other drugs. Because it gives you a quick summary of what they've been taking and how often they're having it dispensed which is just useful in itself. Also I guess for those GPs who are feeling they may not have done this sort of work as much as others, there are GP clinical advisors available who have been trained in mental health conditions, addiction and pain. And they're a great resource as well especially if you can't get that referral to a pain specialist immediately and that's often the case so we really encourage people to use those people.
MH: I think most of the pain services do have a process for telephone advice or offer early access if there is a patient who really needs early input then there should be no barriers to that.
LW: One of the issues that GPs raise is the problem of opiate analgesics commenced in hospital, perhaps someone’s had some surgery, with no clear indication of the clinical intention for ongoing use. So Anthony you often will see this as I guess first port of call and pharmacy out-of-hours prescriptions or coming from emergency departments. What's your advice to pharmacists in how they look at that situation and how they counsel the patient?
AT: Well I think like any scenario involving considering dispensing a prescription for patients, we have to put the patient first, their interests, their safety and the appropriateness and use your clinical skills to do so. It can be a challenge if you aren't able to contact a prescriber given certain circumstances but this is not a new issue either. We have been having to work through these scenarios before but pharmacists are really well trained and have the expertise to be able to you know make that assessment. And also the importance as we spoke about earlier, that referral to a general practitioner in a timely manner to review what may have occurred in hospital and review their pain and circumstances.
LW: So referral back to their GP as soon as possible. And Malcolm in that situation, I mean GPs don't have a lot of information immediately often either, although discharge summaries are finding their way more rapidly to the general practice. What would you say?
MH: I think this is a focus for the hospitals as we move towards greater integration of electronic systems that there will be improvements in our communication and that's really what it is about, clinical handover. And it's not always evident on a document like a discharge summary, so having a telephone number or a way to follow-up in person through conversation is also a focus to improve that handover. Particularly if there's patients who have been discharged after significant injury or significant operations on an opioid. The emphasis at the hospital's sites are to improve that communication, one, but also have a plan so that we're not dispensing maximal doses on PBS, that we're organising a clinical appointment for the patients for their wounds to be checked, for the trajectory of their pain experience to be of improvement. And then to have pathways, sort of sub-acute or transitional or acute pathways back to the hospital if patients are not following the expected trajectory of recovery. That trajectory should be in the order of you know within six weeks. If we know that people are still taking opioids six weeks after a hospital admission or an acute onset of pain, then they're putting themselves in a higher risk group for longer-term use of both opioids but also longer-term complexities of their pain or other complications. So it's worth reviewing their whole clinical state at that time and the requirements. It may be that the opioid could be rotated to a potentially safer opioid with a different mode of action namely buprenorphine or tapentadol. Because it's that time that the sensitisation component becomes a greater feature of the pain event. So if pain is persisting it's generally less opiate responsive at that time and we need to be re-evaluating our management plan.
LW: And in this situation the GP, the hospital doctor and the pharmacists all have access to the same information in SafeScript so hopefully less fragmentation of care, better coordination and better safety for the patient.
MH: Correct and looking at both dose and type of opioid and then how it's being utilised with other non-opioid strategies. Which might include physical strategies, psychological strategies but also the the non-opioid analgesics regimes.
LW: So we can reduce the fragmentation of care and we can really normalise the way we use SafeScript within a practice. So we know in a pharmacy, Anthony you feel that that's something you could be doing on a regular basis with your patients?
AT: Well I think Malcolm made an excellent point before around SafeScript being part of establishing and putting together a care plan for management for patients and as you said it's normalising what we're doing for patients. It is a real-time prescription monitoring tool but it's not being only used to identify an issue, it's being more proactive and helping manage patients so that's what's really important about it as well. And I think it’s fantastic that it’s going to be mandatory here in Victoria from April 2020 because that means we get as complete a picture as possible. And my message to other jurisdictions that are considering real-time monitoring is that mandatory is really important because as we’ve mentioned earlier, more people die from prescription medicine overdose than the road toll. I mean, would we tolerate as a society that you only need to use seatbelts in Victoria but not other states? No, we would acknowledge and say: no this is a risk to the public, these are some measures that can help reduce avoidable deaths and this is what we’re going to do for the best thing for patients in a harm minimisation sense.
LW: Primary care is the one place in the medical system where holistic care is offered. Complex patients using opioid analgesics are amongst the most vulnerable and they need consistent, quality, coordinated care from all their health professionals. Setting and managing expectations, managing the need for escalating doses, reducing fragmentation of care and monitoring patient safety are part of that quality care. And it requires a team effort. SafeScript will help us with that. It is the new indispensable tool for safely managing patients who need opioid analgesia.
More information and resources to support your management of chronic pain can be found in the SafeScript online training modules and your local PHN SafeScript health pathways. The SafeScript GP Clinical Advisory Service is a fantastic peer-to-peer advice service to GPs managing patients with complex pain, addiction or mental health disorders and they can be contacted on 1800 812 804. For more information, go to the Victorian Health website www.health.vic.gov.au/safescript.
Thank you for listening today and thanks to our guests, Malcolm Hogg, Anthony Tassone and Julian Rait.
The next podcast will look in more detail at the challenges of managing a patient with both chronic pain and a mental health condition. I hope you can join me.
The take-home message from today’s podcast is that patients with chronic pain need a patient-centred approach to care that weighs up potential benefits and harms. For most patients, their general practice and community pharmacy form the bedrock of that care and SafeScript is our new tool to provide the very safest care for all patients. Have a great day.
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