A letter from Australia’s Chief Medical Officer about opioid prescribing is somewhat terrifying. What does it mean, asks Dr Linda Calabresi?
My first response was there must be some kind of mistake. A letter from the Chief Medical Officer informing me that I was in the top 20% of opioid prescribers in the country simply had to be wrong.
For a start I only work a few sessions a week in general practice. But no. That had been considered and pro-rata, in the period the department looked at, I had prescribed opioids at a rate higher than the majority of my colleagues.
How could this be? Had someone stolen a script pad and been supplying addicts using my details? Had I simply forgotten a little sideline business in black market opiates I set up a few years ago? (That’s a joke – I’d never forget that!)
After decades in general practice, I believe I’m pretty fierce when it comes to drugs of addiction – any drugs of addiction, not just opioids. I hardly ever initiate their use, and I am always re-evaluating whether they are needed when I re-prescribe them. What’s more I work in your average, elderly, middle-class suburban practice where Metamucil is far more commonly prescribed than morphine.
So, who was I seeing back a couple of years ago that had set off the red flag at the Health Department. What was I prescribing that now had me fearing a call from Today Tonight?
On reflection, I think at that time I had two patients, both of whom I had inherited, on regular opiates for chronic pain who I knew had to be addicted. Both of these patients I referred to the local pain clinic which swapped their opioid to physeptone.
One has since successfully weaned off her addiction (thanks to my very patient colleague – not to me or the pain clinic) and the other, a man in his early 20s with rheumatoid arthritis, disappeared after I refused to supplement the physeptone with more painkillers.
Other than that, I had a lady with fungating breast cancer, a couple of other palliative care patients, and some nursing-home residents with severe pain from arthritis or osteoporotic fractures, for whom the Norspan patches had been a Godsend.
Proportionally, I may have had more of these patients than perhaps other GPs who care more for a younger demographic, but that doesn’t mean the scripts weren’t justified. If the authorities want to come and audit my opioid script-writing, I am sure they would agree.
My initial shock and outrage has settled, but the letter certainly caused some angst, as it has no doubt done with the thousands of other GPs who will have received a similar letter. I know the MDOs have had a number of calls from upset members who feel they have been unfairly, and even incorrectly, targeted for what appears to be poor practice.
There has been no consideration of patient demographics, GP special interests, or details of the indications, drug strengths or duration of opioid use by individual patients when the authorities compiled the list of recipients of these letters.
What exactly is the Chief Medical Officer hoping to achieve by this campaign?
The Australian Bureau of Statistics has shown that prescription drugs are a major cause of drug-induced death. But, looking at the data from 2016, more people had a drug-induced death from benzodiazepines than oxycodone, and there were actually fewer deaths from oxycodone or codeine in 2016 than in 1999.1
And while deaths from other prescription synthetic narcotics (fentanyl, tramadol, pethidine) were 3.5 times greater in 2016 than in 1999, the fastest rise in terms of prescription drugs causing death has to go to the antipsychotic and other neuroleptic class (quetiapine, olanzapine, risperidone) which caused eight times more deaths over the period.
I’m not saying we should ignore opioid-prescribing. Of course not, especially in light of an increase of more than 100% in prescriptions of oxycodone between the years of 2010 and 2015. But we do need to get the problem into perspective.
And even if we accept opioid-prescribing should be targeted, are such letters to GPs, who are very often the represcribers of these medications initiated elsewhere, the best approach?
I don’t think I am Robinson Crusoe in feeling that every patient who presents to hospital in acute pain winds up being discharged on oxycodone. And while my prescribing tends to involve checking, gradually increasing, monitoring, tapering and requesting home medication reviews, specialists tend to prescribe emphatically and, in some cases, almost defiantly.
Take my delightful patient Beryl, for example. Beryl, aged 95, with now significant dementia, has finally gone into care. She’s always been anxious and the anxiety has become severe with the dementia.
In the aged-care facility, Beryl’s anxiety manifested as paranoia, restlessness, depression and aggression. Along with non-pharmaceutical approaches, we tinkered with her medications, mindful of her frailty and comorbidities. Some sertraline, a low-dose opiate patch, some lorazepam and even an unsuccessful trial of risperidone. Nothing helped.
Then disaster, she fell and broke her hip. Off to hospital. One benefit we thought was, with 24-hour nursing care and immobility, we would get the psychogeriatrician to look at the anxiety issue.
Well they did that! Without a word of a lie, my 47kg Beryl is now on desvenlafaxine, diazepam, oxycodone, sodium valproate, mirtazapine, buprenorphine, paracetamol, risperidone and, if she needs it – a little haloperidol! What’s more, her anxiety has resolved. And she’s not a zombie, but is back to being her sweet, if demented, self.
No doubt some bureaucrat at the health department will tut-tut when he sees me writing scripts for all these, but seriously what is best practice here? Maybe if I’d been more aggressive with medication earlier she would not have fractured her hip.
I do appreciate that we, as prescribers, need to be accountable. And if the purpose of this letter was to make me be even more careful when prescribing opioids, it will have worked. But it will be interesting to see, ultimately, if it changes health outcomes for patients. And we shall also see whether putting the wind up about 5000 GPs on the sole basis of number of scripts written is indeed a worthwhile exercise.
Time will tell.
Reference:
1.ABS 3303.0 -Causes of Death, Australia 2016
