‘We have overprescribed oxycodone, codeine’ says AMA chief

The health sector needs a “fundamental re-education” around the use of analgesics in chronic pain, says AMA president Dr Michael Gannon

And doctors have been over-prescribing opioids over recent years, he admits.

Following the release of the AIHW’s report on the misuse of pharmaceutical drugs, Dr Gannon spoke to 2GB’s Mark Levy, who asked him whether making low-dose codeine prescription-only would solve the problem.

“Doesn’t this research show that making something prescription only won’t actually fix the problem?” asked Mr Levy.

“And when you look at codeine addiction, it exists in just 0.011% of the population. Surely you can’t punish the other 99% of the population. There must be better ways.”

Mr Gannon replied that Australia needs a fundamental re-education across the medical profession as well as the community, “that drugs that are designed for acute pain have no role in chronic pain”.

“So, whether you’re talking codeine, phosphate, four milligram tablets or 30 milligram tablets, that is not a useful drug for chronic pain syndromes,” Dr Gannon said.

“We need to get these people in to see experts in pain medicine, experts in addiction medicine. They’re two areas where we need to see more resources going, and we need to see that change.

“We’ve got a problem with opioid abuse, and that is across the board, whether you’re talking about people who start off with over-the-counter codeine, the higher doses prescribed by my colleagues, or whether you’re talking about illicit use of fentanyl, oxycodone, or heroin.”

Dr Gannon said that the Pharmacy Guild’s MedsASSIST program did not have the reach or coverage required to combat the problem.

“Doctors have a responsibility,” he said.

“We have overprescribed oxycodone, codeine, other powerful opioids in recent years, but part of what’s involved is getting our patients to a greater understanding of the fact that these are not the answer, beyond short-term use of pain relief, for example, after surgery.”

The Pharmacy Guild of Australia also responded to the AIHW report, saying it highlights an urgent need for real time monitoring.

Its national president, George Tambassis, highlighted that the report showed a 24% spike in prescriptions for opioids between 2010-11 and 2014-15. This rise was underpinned by a 60% increase in prescriptions for oxycodone.

“Demonstrably there is a need for mandatory national real-time recording of medicines which are subject to abuse and dependence or cause harm,” he said.

“Such a real time recording system must operate across pharmacies and doctors’ surgeries to be effective.

“Greater vigilance and better exchanges of information among health professionals is also clearly needed.”

He said that as MedsASSIST will become redundant from 1 February, the lack of a national system in place to monitor scripts for codeine remains a significant concern.

He also said that the Guild was worried about the lack of post-hospital reconciliation of medicines use.

“Simply giving patients a big bag of medicines when they leave hospital is just not appropriate and the transition from hospital to home or care is where much of medication misuse can arise,” he said.

“Building community pharmacies into this transition is essential. Pharmacists are the medicines experts and community pharmacies are easily accessible to help patients manage their medicines when they leave hospital rather than leaving them to self-manage.

“A structured transition plan with community pharmacists at its core can help prevent a problem from occurring rather than leaving it till the patient becomes a statistic in reports like this latest one from AIHW.”

In its pre-Budget submission the SHPA also highlighted the gap between hospital and community care for high-risk patients, and called for the development and funding of a new care model to help them. People using opioids to treat chronic pain would be among several key targets for such a service, SHPA says.

“Research from Queensland Health presented at Medicines Management 2017 demonstrated that some issues prevalent at the transitions of care include misunderstanding of reducing analgesic dose plans, as well as the absence or delay of handover to the patient’s GP for pain management,” the submission states.

“Medication reviews after discharge from hospital improve the understanding of dosing schedules, so patients can successfully wean off opioids completely or reduce their dosage, therefore reducing the incidence of developing dependence.”

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  1. Jarrod McMaugh

    “Doesn’t this research show that making something prescription only won’t actually fix the problem?” asked Mr Levy.

    Gees that question seems familiar.

  2. Peter Gerald Smith

    Codeine is now off the shelf at my chemist. I now have to make another visit to my doctor to get some panadeine. Im suffering from an L5 nerve compression and I am having a cortisone injection Friday. Thanks very much for this additional hinderance. All for the sake of a tiny percentage of the population.

    • Jarrod McMaugh

      Actually Peter the pain you describe has always required a prescription to treat with codeine.

      If you have been able to purchase it previously with that description of your pain, you have highlighted why the schedule change needed to occur, as this shows that the pharmacists you have visited haven’t abided by the legislation.

      If you haven’t described your pain this way, you have highlighted why there is a need for real-time access to data on usage to allow for an informed decision by the pharmacist in assessing appropriateness of supply.

      • Peter Gerald Smith

        I know about restrictions on oxycodone when I have to take Endone. But Panadeine extra has been available in the past from the pharmacist. What was the legislation before? I’ve had neck and back surgery before so I am used to pain. I use physio, mindfulness, meditation, arnica and woodlock and vitamin c to help. I used to take panadeine only when necessary. Its only in the past few days when the voltaren and panadeine havent helped that we did the Ct scan. My physio cant issue the prescription so it has to be the gp. We already know what the problem is so why involve the gp. Why cant the pharmacist record the usage of codeine.

        • Jarrod McMaugh

          Codeine without prescription is only for acute pain.

          The legislation doesn’t allow for treatment of the type of pain you describe with codeine unless prescribed.

          As you stated in your post, you didn’t seek treatment until the OTC options didn’t work. How much time could you have saved if you had been assessed earlier?

          • Peter Gerald Smith

            Thanks jarrod for answering my question. I’m in agreement that what we need is a complete solution, not piecemeal policy that will cause more disruption in the short term. Until then its extra ibruprofen or an expensive visit to the doctor whenever ongoing chronic pain becomes acute.

          • amanda cronin

            You could say his pain is now acute as is not always this severe. I take the legislation to mean only to give for short term use and those needing regular pain relief see a gp. Many people have acute need for pain relief for a chronic condition.

      • M M

        Jarrod, normally we don’t agree on many things however,your response this time is great. Thumbs up!

  3. amanda cronin

    I worry about the patients who have been on long term pain relief with opiates who are faced with GP’s who refuse the prescribe them at all.
    Some patients have been on high doses for decades for example have their GP retire and are left without a doctor. Making people with chronic pain go “cold turkey” is not helpful and any dose reduction should be planned.
    Often people are told to get all these meds from the pain clinic disregarding the fact it is a 15 month wait, often the have been through all this in the past and it is not meant to regular prescribing.
    I appreciate the difficult position GZp’s are in with new patients but I pity those with genuine chronic pain and medication that effectively manages it treated like drug seekers and addicts.
    I think a relationship needs to be built over a few visits to broach other treatment strategies and possible dose reductions and getting ones head around the issue warranted before changing chronic medication.
    I also worry about how long term codeine addicts will be managed- some have severe issues and need support, addiction treatment and care while others have genuine underlying health conditions causing pain such as lupus and RA that have been missed. The right GP here can be a blessing.

  4. Russell Smith

    So then folks 0.011% of the population is now the threshold for not just the anti-codeine self important holier than thou nannyists – altruistically looking after everyone else – sorry – mostly getting paid for doing it but absolutely NOT having any personal responsibility for the real outcome. Try the reality of seeing a doctor, any doctor, in rural NSW or QLD in pain on demand – oh – what about a pain clinic – where, what pain clinic? When – how long – how far, how much travel time and cost?

    Get effing real – your self importance is a blight on your profession, a profession already blighted by its own misplaced self importance.

    Anyone game to compare the 0.011% against the death/harm rate from other legitimately prescribed medication, whether Benzos, other S4’s S8’s or would that reduce one’s self-importance and influence too much?

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