‘Caught up in the middle’

GPs are complaining that they have been “left in the dark” about changes to prescription opioid prescribing, saying prescribers and patients were caught unaware

Recent changes to the PBS, reducing opioid pack sizes and removing the options of repeats for the treatment of non-chronic pain, took effect from 1 June 2020.

Also taking effect from 1 June were changes to certain opioid product listing codes: Paracetamol 500mg + codeine 30mg tablets continue to be available under PBS item code (1215Y) for the treatment of pain, with new arrangements in addition to new item codes; and the previous PBS item code (8785J) for paracetamol 500mg + codeine 30mg tablet products no longer exists on the PBS or within pharmacy dispensing software.

The changes were made following concerns about the number of deaths and hospitalisations which could be attributed to prescription opioids.

The Royal Australian College of General Practitioners now says that while it welcomes the changes, “crucial information on what medicines were affected was not adequately communicated to GPs ahead of time”.

Some GPs were unable to prescribe the new smaller pack sizes through their usual clinical software until an update was rolled out days after the regulations came into effect.

A detailed listing of the changes to opioid medications only became available on the PBS website on Tuesday 2nd June. The Therapeutic Good Administration issued a press release to publicise the changes the same day.

Chair of the RACGP’s Expert Committee on Quality Care Professor Mark Morgan said the poor communication had caused unnecessary grief for GPs and their patients.

“Many GPs were caught unaware of the changes until half way through the process of prescribing. GPs and clinic staff had to call the PBS Authority Prescription phone line for information,” he said.

“Some GPs had to hand-write authority prescriptions while waiting for clinic software updates.

“Vulnerable and stigmatised patients who were using opioids for non-cancer pain and happened to be trying to get medication were caught up in the middle and faced unnecessary upset.

“Changes to the PBS to change prescribing need to go hand in hand with a comprehensive communication strategy. These changes should have been rolled out with supporting education and publicity for GPs and pharmacists well ahead of the day they were due to come into effect, and ensuring clinical software vendors’ updates were ready to go.

“The communication needs to be nuanced, rather than demonising opioids. Over the last decade there has been a seismic shift in our understanding of the pros and cons of using opioids for non-cancer pain.

“We are now much more aware that for most, but not all patients, taking opioids long term makes precious little difference to their pain and wellbeing.”

Chair of the RACGP Addiction Medicine network Dr Hester Wilson said that limiting a patient’s access to opioids is a step towards combatting the associated harms but it’s not a silver bullet

“We should also be more proactive in helping patients with alcohol and other drug problems. One way to make a big difference would be increasing access to naloxone for patients who need it, and to their loved ones – this drug can temporarily reverse an opioid overdose and saves lives but not enough people know about it. 

“Another important issue is improving access to Medication Assisted Treatment of Opioid Dependence; (methadone and buprenorphine).  This highly evidence based treatment improves health and wellbeing outcomes and is particularly effective for people who have developed an opioid use disorder through the use of prescription opioids for chronic pain.”

Just before the changes took effect, Clinical Pharmacy Lecturer at La Trobe University, Pene Wood told the AJP that they represented a good opportunity for pharmacists to talk with patients and “talk about why we need to change them off”.

The change creates awareness that these medicines aren’t designed to be used long-term, but in the short term for acute pain. If we’re only giving you 10, then after five days you shouldn’t need them any more.

“It also encourages people to go back to the doctor and seek feedback about the problem.”

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