Real-time prescription monitoring

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It only takes a cursory knowledge of celebrity gossip to realise that prescription medicine dependence can result in real harms. But it's far easier and far more common than you might think. At the moment in Australia, more people are dying due to the use of prescription pain and sedative medications than on our roads. Real-time prescription monitoring has been heralded as part of the solution, but what is it really and what does it look like in real life?

I'm Dr David Liew, your host for this episode. It's medication prevention dependence month and today I'm speaking to Peter Boyles, who is the chief pharmacist for the Tasmanian Department of Health and we'll be discussing the editorial on real-time prescription monitoring and the Tasmanian experience. Peter, welcome to the program.

Thanks David, it's a pleasure to have this chat.

Tell me a little bit about what a real-time prescription monitoring service is and why we need one?

Real-time prescription monitoring is a useful tool that provides the right people with the right information at the right time. So it allows medical practitioners and pharmacists, when making decisions either to prescribe medication or supply them, to be able to see in a timely manner the medication history for those relevant substances. So, whether or not somebody's been treated for opioid substance use disorder in the past, and in Tasmania specifically, whether or not a medical practitioner has had reason to either declare that patient to be drug dependent or to be a drug seeker.

Most of real-time reporting is focused on Schedule 8s, but we're also now introducing high-risk Schedule 4 drugs such as benzodiazepines into that mix and gabapentinoids.

So really what we're targeting here are the patients who go to multiple different clinicians to get prescriptions, multiple different pharmacies to get prescriptions, is that who we're targeting here?

On one hand, yes. And for want of a better phrase, it's sort of the low-hanging fruit. Tasmania, since implementation of our real-time prescription monitoring system DORA, we don't have a problem with long-term doctor shopping anymore. We have the occasional patient that will try to present to multiple practices or attempt to get their medication dispensed well ahead of time. But they're not long-term issues anymore, they're brought to the attention of the prescribers, either through their self-assessment by looking the patient up on DORA or on the occasion that that hasn't occurred, when pharmacists, when in the Pharmaceutical Services Branch in the Department reach out to the health professionals involved in that care to draw their attention to that patient.

Right. Okay. This kind of situation seems to make up a large proportion of prescription medicine related deaths, really? You've written in your article about the Victorian coronial experience?

Yeah, so in fact very few opioid-related deaths are due to doctor-shopping events. Most of it is due to either diverted medication that's been prescribed, so diverted to a patient that wasn't the intended recipient or through the injudicious use of the opioids for that specific patient. So, the doctor shopping is absolutely part of the harms that we're seeing with pharmaceutical opioids but it's far from the overwhelming majority of the problem.

Okay. And so how does the prescription monitoring service, what piece of the puzzle does this help to address in amongst the problems that we do have?

It takes the blindfold off the prescriber and the pharmacist. Doesn't give them the full clinical picture but it does give them a fighting chance to have some idea about the level of risk that they're dealing with with that specific patient.

Okay. So let's just talk through this, because I think a lot of people might have heard about this in the lay media and probably seems like a very good thing from the outset. But, can you talk us through how a clinician might go about using this?

So a patient presents, overtly requesting a prescription of opioid and let's say the GP has not met this patient before and they do not have a sense that they've got sufficient clinical information to be able to make a decision. They can, within a matter of seconds, interrogate the DORA database and get the information that they need to either satisfy themselves that the prescription of an opioid is reasonable, or conversely, form the opinion that perhaps opioids aren't appropriate for that patient.

So, there's nothing really that sits in the substitute to this at the moment, is there? I mean, there's obviously the PBS prescription shopper program, but that covers a different mandate really, doesn't it?

Yeah, the PBS prescription shopper is sort of, by design, actually not going to be that useful to most people at the coal face. The thresholds they've got for a notifying prescriber is that somebody's seeing too many prescribers is way above where we would see harm. So, it only takes a patient going to multiple doctors for there to potentially be harm and as I circle back to my previous comment, overwhelmingly the harms are around... we're seeing our patients that are actually presenting to a single practice, not multiple practices anyway. So, diverting drugs that have been provided by a single practice or misusing themselves or just simply overusing them.

Right. So, thinking through this now, once you've got this incredible information in a matter of seconds, what happens from there and where do you think the strengths and the weaknesses are in terms of the program itself?

So, that's sort of the guts of what I'd like to talk about. Because it is only a tool. If we don't invest in the skill, knowledge and confidence of the health professionals that are using that tool, I'm actually quite fearful as a nation we're going to be a bit underwhelmed with real-time prescription monitoring, because patients requesting these agents are frequently quite challenging for general practitioners and pharmacists and they're quite challenging for addiction specialists and pain specialists as well. So, this is a tool to give you some objective information that's relevant to the management of the patient, but it doesn't tell you what to do. You still need to make a clinical assessment and you still frequently need to make a decision that perhaps the patient in front of you is not going to be very happy with.

So real-time prescription monitoring doesn't make difficult conversations with patients any easier necessarily.

So, what I'm hearing is that this is a first step in trying to identify and then address a problem in any given patient. Would that be fair to say?

Yeah. It is. And the approach we've taken in Tasmania is to provide clinical regulatory support to our prescribers and our pharmacists in these situations so that we are providing an accessible service for them to be able to seek advice on the management of a patient, and it also is underpinned by the process we have in Tasmania and many of the Australian jurisdictions where prescribers of these medications need to seek a state authority. So to be able to be legally authorised to prescribe these medications. So we are very keen for people to pay attention to the quality assurance processes that Tasmania uses in this space. We're delighted with real-time prescription monitoring as a tool, but we think in the absence of these quality assurance processes, we're actually potentially setting clinicians up to fail because we're giving them information that might tell them there's a problem, but not giving them the resources and the confidence to be able to actually address that problem in a meaningful way.

Okay. So, let's talk about the Tasmanian experience. This is been something that Tasmania has been working on since 2009, so there's ten years' worth of understanding in terms of how this has evolved. What was the impetus for this to happen, for Tasmania to innovate in this way and how something like DORA has evolved over that time?

So, it's really been incremental changes to our approach to minimising the risk of harm. Real-time reporting is clearly a high-profile part of our response but a lot of the effort we've placed into addressing these harms has been around engaging appropriate specialist resources through pain and through addiction and through general practice to have a clinician-led multi-disciplinary approach to both identifying patients at high risk of harm or who are receiving suboptimal care and actually addressing that care and providing support to the treating team to move to a safer evidence-based, more efficacious treatment pathway.

And so, in amongst all the steps that you've been taking, with real-time prescription monitoring as one part of the overall response, what's happened to Tasmania in the face of an increasing threat from harm?

So, in the last 10 to 15 years, Australia has seen more than doubling of pharmaceutical opioid poisoning deaths. In that same period of time we've seen a modest reduction of, I think off the top of my head, around 20%. So, we're still seeing in Tasmania around the low 20s each year for a population of half a million people, so around 20 Tasmanians each year that are dying from prescription opioid poisoning. It's still absolutely unacceptable but we do note that that's occurring on a background across the country of a huge increase in these deaths.

So, how do you think that the Tasmanian experience is different to the international experience? What do you think the strengths have been of the Tasmanian experience that have made it work well?

I think David, we haven't just relied on our clinicians accessing the information that real-time prescription monitoring can supply to them. What we've done, is provided accessible support so that they are able to use that information but also seek advice about safe management, safe and effective management, I think it's worth stating because a lot of real-time prescription monitoring and the focus on the regulation of opioid prescribing is around minimising the harms. But I make the claim that our quality assurance process doesn't just minimise harms around opioid use, it also is geared to maximising therapeutic benefits through chronic pain management. So, sometimes a patient who might be receiving modest or even high doses of opioids that aren't proving to be effective, either through patient self-report or the treating team noting that they've got treatment failure, many times we're seeing with those patients that they're actually failing to engage in other evidence-based treatment modalities for their chronic pain.

So, one of the advantages of our system is that we do have the ability to nudge, support, cajole, and request that those patients engage meaningfully in other treatment modalities that are actually safer and more effective than the opioids in the first place.

It's never really enough to just say, "Well, this patient is on opioids, opioids don't work in this situation, we should just scrap the opioids." We need to offer solutions for these patients for the pain that they're experiencing. That's really what it comes down to, doesn't it?

Absolutely. Yeah.

So, where do you think the Tasmanian system is going from here?

So, we've focused in Tasmania on opioids and other Schedule 8 drugs like the stimulants. We're now turning our attention to Schedule 4 opioids and also looking at benzodiazepines, z-drugs, gabapentanoids. So other drugs of a high misuse potential, regardless of whether or not they're in Schedule 8. We approved the concept of a clinician-led clinical regulatory approach to quality assurance in this space. What we've learned is that we can, in a cost-effective manner, make a difference at a population level, we just need the will and the support of all of our stakeholders in this space and that's the medical fraternity, the pharmacy fraternity and governments to endorse this as a process and accept that they have the capacity to provide that support out to clinicians at the coal face.

Because I guess, I think, we all know this is a relatively cheap intervention compared to a lot of other interventions that occur.

Yeah David, sorry, it is cheap and regardless of the cost, the simple reality is, we do not have sufficient pain specialists and addiction specialists in Australia to provide face-to-face review of patients.

But just to bring you back to this, a lot of it does require a level of good will from the front-line clinician as well, doesn't it? How can we better support our clinicians at that particular moment in time?

The first step I think is having a much larger focus on the training and the mentoring that our clinicians need in this space. So too frequently we hear of patients that are actually, I suppose, riding roughshod over the clinician and dictating what care they're going to be receiving and really putting clinicians in a very difficult position where they actually don't feel empowered to assert their clinical authority over what's going to be happening with respect to the patient's treatment.

Patients suffering from chronic pain are generally not the quick, easy patients that get you back on schedule for your appointments. They've got, generally, a significant number of co-morbidities outside of their chronic pain condition and by definition they're in chronic pain so they are generally very concerned about the management of that pain and not necessarily particularly willing to accept that everything is being done that can be done for them. And that's not to suggest that any of us would feel any different when suffering from chronic pain. It's the nature of what makes it such a difficult condition to treat.

So, hopefully, with improved training and improved support, real-time prescription monitoring can really be part of the overall solution to turning it around nationwide, it sounds like?

Real-time prescription monitoring absolutely is an essential tool for turning that around.

Peter, thanks so very much for joining us on the podcast today.

My pleasure.

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The views of the hosts and guests in this podcast are their own and may not represent Australian Prescriber or NPS MedicineWise. I'm David Liew, and thanks once again for joining us on the Australian Prescriber podcast.