“We know doctors haven’t done really well setting boundaries in this area.”

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With rising numbers of people hooked on prescription opioids, pharmacists are crucial to flagging overprescribing and reducing dependency harms, says GP

A workshop on responding to dependency at the Pharmacy Connect conference has highlighted the role of pharmacists in tackling rising levels of opioid addiction.

Held at Sydney’s Hilton Hotel on Friday 1 September and hosted by the Pharmacy Guild, the workshop featured some top experts in the addiction space.

“It’s important to hear from doctors so we know how to make the program run better,” said community pharmacist and event facilitator Angelo Pricolo.

“Ultimately it’s triangle a of treatment: the doctor, the patient and the pharmacist.”

Suzanne Nielsen.
Dr Suzanne Nielsen.

Dr Suzanne Nielsen, from the National Drug & Alcohol Research Centre, said opioid prescribing in Australia has increased in the past 25 years, with accompanying increases in use and harms associated with opioid use.

“Unfortunately the pattern is that opioid overdose deaths continue to rise. There are two prescription deaths to every one heroin death.”

For example, Dr Nielsen said that of oxycodone deaths, 53% were related to prescribed drugs, compared to a minority with a history of injecting (27%).

And she said medical practitioners have seen a trebling of treatment entrants for codeine and oxycodone in the past decade.

“Even when codeine is a prescription drug, it’s still going to be a problem. One in four (24%) of those using opioids in the community meet the criteria for addiction.”

“We have a treatment gap. There are almost three quarters of a million who meet the criteria [for dependency],” said Dr Nielsen.

“However not everyone who is dependent is going to want treatment.”

Dr Marianne Jauncey, Medical Director of the Sydney Medically Supervised Injecting Centre, said pharmacists are crucial in treating overdose.

“Opiate overdose is killing more Australians every year – it’s up to about two a day. This is more prescription opiate overdoses than heroin,” said Dr Jauncey.

“We have a safe and effective antidote in naloxone,” she said, with a reminder that the medication is available OTC.

“Pharmacists are absolutely uniquely placed and a crucial part of the puzzle in order to scale this up across the country… to help reduce the number of people dying for accidental opiate overdose and ultimately save lives,” said Dr Jauncey.

“People who abuse prescription medication don’t think they are at risk of an overdose, they think that’s the domain of ‘drug users’. So there’s also a need for community education around this.”

Dr Hester Wilson, an addiction medicine specialist based in Sydney, said GPs are also seeing more and more people who are dependent on both OTC or prescribed opioid pharmaceuticals.

She pointed out the importance of the GP-pharmacist relationship regarding medication errors.

“I love when a pharmacist calls me and tells me, ‘I think you might have made a mistake with this script’. I think, ‘thank God you noticed it!’ It’s so important that we keep talking to each other.

“What I tell my GP colleagues is: ‘This relationship with the pharmacist is so important because they see your patient much more often than you do’,” said Dr Wilson.

“I can’t tell you how important you guys are to us and to our patients. That relationship and the quality of that relationship is so important.”

Dr Hester Wilson
Dr Hester Wilson, Addiction Specialist

Pharmacists are particularly crucial when it comes to overprescribing of medications.

“A lot of times, if someone flags that a doctor is overprescribing it’s a pharmacist,” said Dr Wilson.

“We know doctors have been really bad at overprescribing e.g. antibiotics, we haven’t done really well in this area with boundaries. And it’s the same with all pharmaceuticals. There are pain patients coming in, and these are pharmaceuticals that can cause anyone to become dependent.

“Right now, you have a bunch of people in palliative care not being prescribed painkillers because the doctors are worried about opioids, but then you have this whole group of people with chronic pain that are getting prescribed bucketloads.”

Dr Nielsen agreed with Dr Wilson.

“It’s important when preparing for rescheduling, don’t assume that GPs know what to do, or that patients know where to get help. They might not be particularly confident about what to do,” said Dr Nielsen.

“Prescription opioid dependent people are a growing and potentially undertreated population,” she said.

“We need to change the way we treat this issue and I think pharmacy is a key part of that.”

Tips from Dr Hester Wilson:

  • Many GPs don’t know about staged supply – so tell them about it.
  • If you’re concerned about a doctor overprescribing, report it to PSU.
  • If a script is really unsafe and the GP refuses to change it, don’t dispense it.
  • Think about reducing the cost of take-away pharmacotherapy.
  • Reduce stigma in the pharmacy. For example, if yours is a pharmacy where a person who comes in for methadone is asked to step aside until all other patients have come through first. “This is a medicine like any other. It’s not okay. This is a group of people that have been strongly stigmatised and it really affects them. So change those structures.”

Tips from Dr Suzanne Nielsen:

  • Appearance is not related to dependence. How do we know which patients are at risk? 4As: analgesia, activity, aberrant behaviours, adverse effects.
  • If people are still reporting 9 or 10 on the pain scale despite being on high doses of opioids, this is probably a sign that this person doesn’t need more opioids, they may have a dependency problem.
  • Management of mental health comorbidities is important. It’s not common for people to develop codeine dependence without something else going on at that time (they are usually experiencing high levels of psychological distress). If that’s not addressed, treatment might not be effective.

Tips from Dr Marianne Jauncey:

  • In about 10 to 15 minutes, you can train people to recognise and respond to overdose.
  • There is no abuse potential for naloxone.

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