Prescribing drugs of dependence in general practice

Part A - Clinical Governance Framework

Summary

Last revised: 31 Oct 2019

Introduction

Clinical governance should ensure that patient care is accessible, appropriate and responsible. Drugs of dependence have important therapeutic uses and are highly beneficial to many individuals and the clinically appropriate supply of these medicines needs to be maintained.

To ensure this, measures are required to minimise harm from inappropriate and unsanctioned use.

General practice needs to be an integral part of the solution to problematic prescription drug use in Australia.

The quality and safety of care could also be improved on a national level through:

  • consistent laws and regulatory definitions of drugs of dependence across all jurisdictions
  • an effective, real-time national prescription monitoring or surveillance program
  • state and territory health systems that support continual and coordinated care for patients with complex and/or multiple problems (eg combined substance use disorders [SUDs], chronic pain and mental illness) in conjunction with general practice • national support for the ‘medical home’ concept, ie, a patient having one general practice and preferably one general practitioner (GP) to provide ongoing care and accountable prescribing of drugs of dependence
  • adequate resourcing of systems of care within general practice for patients with SUDs.

The following sections contain summaries of the recommendations from the rest of the guide. Note that ‘should’ refers to a recommendation, ‘must’ to an obligation, ‘must not’ to a prohibition and ‘may’ for a discretionary action. General practices need to consider the recommendations in the context of their local circumstances. Implementation of recommendations should be based on relevancy and appropriateness on a practice-by-practice basis. For definitions of key terms such as dependence and tolerance, refer to Appendix A.

The quality and safety of patient care is no longer confined to the individual practitioner.

General practices have responsibilities to work collaboratively with practitioners to continuously improve care for their patients and improve quality and safety concerning prescription drugs. With respect to drugs of dependence:

  • General practices should undergo and attain accreditation according to the RACGP’s Standards for general practices (4th edition) (the Standards) and have clinical leaders with designated areas of responsibility regarding safety and quality improvement systems. Practices should:
    • support and facilitate ongoing quality assurance arrangements
    • consider appropriate monitoring systems to ensure early alert and sentinel systems are in place.
  • General practices should assist GPs in preventing prescription drug misuse by:
    • promoting and supporting GPs in using non-pharmacological interventions
    • promoting the development of competency in prescribing drugs of dependence – this may have particular relevance to registrars.
  • General practices should have systems of care that seek to maximise health outcomes and social functioning for all patients prescribed drugs of dependence while minimising drug and alcohol misuse, abuse, diversion and crime. Practices should:
    • implement strategies to ensure the occupational health and safety of GPs and other members of the practice team
    • promote multidisciplinary care for patients who use drugs of dependence
    • have agreed clinical policies regarding prescribing drugs of dependence
    • have an effective handover system that ensures safe and continuing healthcare delivery for patients
    • insist on timely, high-standard referral letters for clinical handover or shared-care arrangements from secondary care
    • consider having policies regarding risk stratification of patients to reduce clinical and occupational risks.
  • General practices should consider secondary prevention strategies that attempt to manage problematic drug use in its early stages of development before it results in significant morbidity. Practices should:
    • consider letters to the practice population to reduce benzodiazepine use
    • have agreed clinical policies regarding a standard approach/management to patients displaying drugseeking behaviour
    • facilitate GP access to information management data designed to monitor potential prescription drug abuse (eg state and territory health ministries’ drug units and Prescription Shopping Information Service [PSIS])
    • consider policies on simple benzodiazepine and opiate withdrawal regimes.
  • Selected general practices should support the organisation and coordination of services for patients with substance use disorder. These practices should:
    • support GP-based dependency programs with suitably qualified staff, organised support and ongoing quality assurance arrangements (where possible)
    • consider tertiary prevention to limit existing disease and its effects through appropriate treatment (eg opioid substitution therapy for opioid-dependent patients).

Accountable prescribing is a commitment to evidence-based practice, the use of medicines with proven effectiveness and avoidance of medicines when they do not help or when they cause harm. Prescribing must be based on a comprehensive medical assessment, a diagnosis, thoughtful consideration of the likely risks and benefits of any medication as well as alternative interventions, and a management plan derived through shared decision making.

  • GPs must prescribe within legislative frameworks and should comply with professional standards and approved clinical guidelines.
  • GPs must maintain professional boundaries when prescribing drugs of dependence.
  • GPs should maintain or improve their skills in relevant areas such as chronic pain, mental health or drugs of dependence.
  • GPs should optimise non-pharmacological interventions.
  • GPs should use universal precautions in guiding their approach to patients who require drugs of dependence.
  • GPs should inform patients that drugs of dependence should be prescribed from only one practice and preferably by only one GP, and drugs should be dispensed from one pharmacy.
  • GPs must ensure that patient records are clear, up-to-date and contain sufficient information for another practitioner to take over care.
  • GPs have the right to discontinue care of a patient who has behaved in a violent or threatening manner.
  • GPs should be prepared to utilise specialist support to manage problematic drug use in complex patients with significant issues or if the clinical situation deteriorates.
  • In the context of drug dependent patients:
    • prescribing must be based on a comprehensive medical assessment
    • GPs must seek a permit or an authority from the relevant state or territory health department when prescribing an S8 drug to a patient who is drug dependent.

Patients have the right to respectful care that promotes their dignity, privacy and safety. Patients with problematic use of prescription drugs and those who use illicit drugs have the same entitlement to respectful care.

The decision to prescribe drugs of dependence, like other aspects of clinical practice, should be made with the patient. Shared decision making brings together the GP’s clinical expertise and judgement and the patient’s values and preferences (which are informed by their beliefs and their personal circumstances such as their age, family and social relationships). Patient-focused care is not equivalent to care dictated by the patient – boundaries and clinical judgement are key components of high-quality care.

To facilitate patients (and their carers) to participate in shared decision making:

  • General practices and GPs should provide patients with information (at the appropriate level and manner) about the purpose, realistic expectations, options, and benefits and risks of any treatments.
  • GPs may wish to consider using patient information resources to help patients understand their options and the consequences of their decisions.
  • GPs should develop respectful, non-judgemental and clear responses to inappropriate requests for drugs of dependence.
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