A national real-time prescription monitoring system must happen as a priority, says Anthony Tassone

The need for a real time prescription monitoring system to prevent avoidable overdose deaths from pharmaceutical medicines is not disputed but it’s worth questioning why the TGA did not build this in as a fundamental flow-on from the up-scheduling of codeine recommendation.

In a consultation on the use of prescription opioids for pain, the TGA initially listed on its webpage options including; “consider whether the highest dose products should remain on the market, or be restricted to specialist/authority prescribing” and “potentially include controls of prescribing for… particular classes of medical practitioners”.

In other words, potentially influence the prescribing of opioids in the first place at the practitioner level. However when this was reported in the media, with the usual outrage from doctors’ groups, we saw a quick retort with the TGA posting on its website:  “The story today (27 January 2018) that suggests GPs may not be able to prescribe high dose opioids under a review being done by the TGA is totally incorrect. The medicines’ regulator is not proposing and will not be stopping GPs from prescribing high dose opioids. As part of the discussion paper the TGA has issued on the use and misuse of opioids, there is an option about the level of training for potentially dangerous drugs which is being discussed in consultation with the AMA, the RACGP and other appropriate bodies.”

That’s not to say the proposed option is the right way forward, but it seemed unusual that the TGA appeared to rule out an option in its own consultation following the first instalment of media coverage.

Furthermore, why would there not be an option that included consideration of a real time prescription monitoring system covering a sufficient scope of substances to minimise harm?

We simply need to get “real with real time monitoring” and ensure it is central to all our decision-making on scheduling, and medicines policies and approvals.

Data shows that in Australia lives lost from prescribed pharmaceuticals is greater than deaths from illicit drugs and the road toll. The Australian Bureau of Statistics reports there were 1,808 drug induced deaths registered in 2016. This is the highest number of drug deaths in 20 years, and is similar to the number recorded in the late 1990s, when a steep increase in opioid use, specifically heroin, led to deaths peaking at 1,740 in 1999. 

The ABS said an individual dying from a drug-induced death in Australia in 2016 was most likely misusing prescription drugs such as benzodiazepines or oxycodone in a polypharmacy setting. The death was most likely to be an accident. 

The Federal Government has acknowledged the need for monitoring and last year announced $16 million would be given to the States and Territories towards the funding of real time monitoring at the State and Territory level.  To date what we have seen is Tasmania lead the charge with the introduction of a system and Victoria well advanced in the development of its own system to be introduced by the end of the year.

However, we need to know what the other States and Territories are doing.  The $16 million in funding is public money and the Australian public needs to know when a system will be implemented in each and every jurisdiction for the sake of community and public health.

But we also need consistency and already we are seeing issues. Tasmania’s DORA system monitors Schedule 8 medicines and has just commenced monitoring codeine but the oversight of a broader range of substances is needed in an effective and sustainable national solution.  DORA is commendable and is already having an impact on saving lives, however it may not be scaleable to larger jurisdictions and nationally as it relies on health department staff (human intervention) contacting a pharmacy at the point of dispensing.

Victoria’s approach – SafeScript – is different and will monitor Schedule 8 medicines; quetiapine, benzodiazepines , ‘z-class’ drugs (zopiclone and zolpidem) which are also major contributors to overdose related deaths. Codeine will be included at a later stage to allow clinicians time to adjust to the rescheduling of over-the-counter codeine products to prescription only.

The SafeScript system is based on more contemporary technology that will source data from Prescription Exchange Services (PES) technology that is already in use in the vast majority of pharmacies and medical centres to facilitate electronic transfer of prescriptions.

With this approach, along with using modern cloud based architecture means the Victorian SafeScript system will be scalable to an increasing volume of prescriptions.  By comparison, significant redevelopment work would have been necessary before the Commonwealth software could have supported Victoria’s prescription software, let alone at a national level. 

Most importantly, SafeScript will be designed around clinicians’ needs and will offer a better user experience and cause minimal disruption to clinical workflow.  Clinicians will receive pop-up notifications from their desktops within seconds after a prescription has been issued or dispensed which will prompt clinicians if a review of the records in SafeScript is necessary.  The notification will also provide a direct link to the patient’s record.  The Commonwealth software does not provide these workflow features for clinicians.

The Victorian SafeScript system will be mandatory for use by prescribers and pharmacists (with some exceptions in certain instances) – whilst the Tasmanian DORA system is currently non-mandatory for use.

While it would be Victoria’s preference for SafeScript to be adopted by all jurisdictions as part of a nationally consistent system, should other jurisdictions decide to use the Commonwealth software or any other software for real-time prescription monitoring, SafeScript is designed to accommodate and share data from other databases so a national data sharing arrangement can still be achieved.

Sadly a national approach is still lacking. Doctors’ groups have stated that codeine up-scheduling is about ‘patient safety’ but the siloed upscheduling decision means that the Guild’s national MedsASSIST monitoring has ceased so there has been no real time monitoring of codeine on mainland Australia since 31st January 2018. 

In the interests of patient safety, we hope and expect that doctor’s groups would advocate strongly and loudly for the urgent implementation of a mandatory real time prescription monitoring system in all jurisdictions.

The current system of drug addiction treatment and support programs are already facing capacity challenges, with an expected and unpredictable level of increased demand to come. 

This was highlighted in a recent opinion piece in Fairfax media by Sam Biondo, executive officer of the Victorian Alcohol and Drug Association, who wrote: “More also needs to be done regarding referrals from primary health vis-a-vis doctors and allied services, as currently less than 1 per cent of all alcohol and drug treatment referrals are made from general practice. Should the level of referrals to existing treatment services increase rapidly, the impact would be felt and with considerable disruption and potentially extensive waiting times.”

The pharmacy profession is committed to acting in the best interests of patient safety in collaboration with other health professionals.  The conversation is far from over with the up-scheduling of codeine. 

Disclaimer and declarationAfter a competitive tender process Fred IT Group Pty Ltd was awarded the contract to deliver the SafeScript real time prescription monitoring system for the Victorian government. The Pharmacy Guild (Victoria Branch) are shareholders in Fred IT Group.

Anthony is a member of the Victorian Department of Health and Human Services Real Time Prescription Monitoring External Advisory Group.