Focus on chemical restraint, not prescribing rights

Responses by pharmacy organisations to the Royal Commission into Aged Care interim report are not based on evidence, argues Dr Juanita Breen

At the end of October the Royal Commission into Aged Care and Safety released its interim report. Although the Commissioners warned that they wouldn’t be making any recommendations, they named three areas that needed immediate action. One was to address the issue of chemical restraint, including through the upcoming 7thCommunity Pharmacy agreement.

I think it’s important to define the term chemical restraint. According to the Federal Government, chemical restraint “involves the use of medication to influence a person’s behaviour, other than medication prescribed for a diagnosed mental disorder or a physical condition”.

With 86% of aged care residents currently diagnosed with a mental health or behavioural condition, it’s difficult to determine whether a medication is used to treat a person’s symptoms or to control their behaviour. It may well be both.

Rather than fixating on whether a medication is being used to restrain, I believe it’s far more constructive to ensure that psychotropics are used appropriately. That is, in accordance with professional guidelines and after non-drug strategies have been unsuccessfully trialled.

When prescribed, effectiveness and adverse effects should be monitored, and these agents should be prescribed for the shortest period required.

However, with rates of psychotropic prescribing exceeding 65%, the average duration of antipsychotic use above two years and 40% of residents charted for benzodiazepines (either regularly, ‘prn’ or both), I think it’s safe to say appropriateness of use is a major issue.

It didn’t take long for our pharmacy organisations to respond to the Commission interim report.

The PSA said the recommendations illustrated the need for enhanced medication safety standards in aged care – and for pharmacists to have prescribing rights.

The SHPA said the report supported their ‘pharmacists in aged care’ stance.

Of the three pharmacy peak bodies, the Pharmacy Guild was the only one to stay on topic, emphasising that “the Community Pharmacy Agreement should have a pivotal role in addressing the particular problem of the significant over-reliance on chemical restraint in aged care”.

Yet, in rare agreement with the PSA, they also recommended pharmacists be provided with prescribing rights.

My big question is: how will granting pharmacists prescribing rights address chemical restraint?

There is no evidence that granting prescribing rights to pharmacists, or nurse practitioners for that matter, will reduce reliance on chemical restraint.

Pharmacist prescribing was not mentioned anywhere in the interim report. It appears the Commission’s findings are being used by the various pharmacy organisations to pitch their own agendas.

Yet, they have also selectively ignored some major points.

The report’s main suggestion was that the Pharmacy Guild and PSA should review the effectiveness of the current RMMR program by:

  1. Removing two-yearly caps;
  2. Allowing residents receiving respite and transitional care to have RMMRs;
  3. Enhancing the quality of reviews, including by auditing; and
  4. Ensuring that pharmacists can monitor whether their recommendations are implemented.

It needs to be stressed that the poor quality of psychotropic prescribing has occurred while the current RMMR and QUM program has been in force.

Psychotropic use was problematic even before the RMMR caps were introduced and the QUM program diminished.

These programs, in their present and previous forms, do not address over-reliance on chemical restraint.

Research conducted at the University of Sydney showed that of all recommendations made in RMMR reports, those regarding central nervous system medications had the lowest uptake (less than 50%).

When I interviewed aged care pharmacists about reducing antipsychotics and benzodiazepines, they said they were met with marked resistance from staff when these suggestions were made.

Many claimed they stopped making these recommendations altogether.

In my experience, I would also argue that the quality of RMMRs can be inconsistent – and don’t get me started on QUM service quality. This is what the Royal Commission suggests we rectify.

Yet the problem of psychotropic use in aged care is more complex than just increasing and improving the quality of the current RMMR and QUM provision.

It requires complex solutions and an understanding of the forces influencing psychotropic prescribing.

The consistent finding is that interventions incorporating nursing and staff education improve psychotropic prescribing, which points to the key practitioner group influencing their use.

Since the interim report’s main recommendation was addressing chemical restraint, it is surprising that an evidence-based intervention, the ‘RedUSe’ (Reducing use of sedatives) project, which was supported by the Pharmacy Guild in their Royal Commission submission and by the PSA from 2013-2016, has not been mentioned as a key solution.

I led the research for this project, results of which were published in the MJA.

RedUSe demonstrated that pharmacists have a key role to play in educating aged care staff about psychotropic use.

The program employed community pharmacy-provided psychotropic audits to good effect. RedUSe also showed the impact of nurse involvement in a targeted sedative review process.

Importantly, the RedUSe QUM strategies were delivered by both accredited and non-accredited pharmacists. RedUSe reduced psychotropic use in 40% of residents taking these agents.

Although I support pharmacist prescribing, there is no evidence to support this strategy to reduce chemical restraint.

It will also take several years to implement and it’s hard to ignore the marked resistance from our medical colleagues.

The Royal Commission recommended prompt action on this issue. The majority of RedUSe strategies can be embedded now as part of the current QUM program.

It just needs the support and leadership of our pharmacist body representatives.

Dr Juanita Breen (previously Westbury) is a pharmacist and senior lecturer at the Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania.

She gave evidence to the Royal Commission into Aged Care and Safety in May 2019.

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