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Real Time Prescription Monitoring

Bethany:
 
Good evening, everyone and thank you for joining us for tonight’s What is Real Time Prescription Monitoring and how will it support me in managing patients who are using high risk medications? Our presenters tonight are Dr Hester Wilson and Aine Heaney. Before we get started, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the lands on which we all meet tonight, and pay our respects to Elders both past and present.
 
I would now like to introduce our presenters. Aine Heaney and Dr Hester Wilson. Aine is a pharmacist by background and has worked in the UK, New Zealand and Australia. She was involved in the real time prescription monitoring program that was developed and implemented in Victoria in 2018 and 2019, and currently works as one of the subject matter experts that is designing the equivalent tool for use in New South Wales. She has a particular interest in the quality use of medicines across the continuum of care.
 
An FRACGP Hester, is also a Fellow of the Chapter of Addiction Medicine. Hester is the Chair of the RACGP Special Interest Group in Addiction. She works for South Eastern Sydney Local Health District Drug and Alcohol Service, and in general practice in Newtown, Sydney. An experienced medical educator, Hester has written widely on general practice and substance use issues and is involved in planning and facilitating the current RACGP AOD training. Hester is currently undertaking a PhD focussed on GPs and patients with chronic pain and prescription opioid use disorder.
 
Now I am going to pass you over to Hester who is going to take us through the learning outcomes.
 
 
Hester:
 
Thank you so much, Bethany and welcome to everyone tonight and Aine it is really great to have you taking part and supporting me and being the expert in this area. Real time prescription monitoring is what we are looking at tonight, and the three things that I am really hoping that you take away from this, is an understanding of how, the planning for how is going to work in New South Wales, and how you might use it in your setting. As well, thinking about how you can use RTPM to support you in managing your patients with using high risk medications and knowing where to access additional support and resources to support you in this important area.
 
Okay, I have just got to work out how I make things go forward. Yes, okay. First of all, I just want to do a quick poll with you guys, so Bethany if you could start up the poll? So two questions for this first one. I have a high level of knowledge about the real time prescription monitoring program that is rolling out in New South Wales. So if you can just click on there. And there is a second question, just in case it is not all turning up on your screen, which is, I believe the New South Wales real time prescription monitoring program will make it easier for me to manage patients taking high risk medications. So if you guys could click on your answers there. Fantastic. So there is about 27% of you that have pretty good knowledge of the real time prescription monitoring program in New South Wales, that is brilliant, but the majority of you do not. That is the reason you are here tonight, and that is the reason that we are here tonight, to actually give you more information about it. I am also interested that while there are a small group of you who are concerned about prescription monitoring and whether it will help you manage your patients, overwhelmingly, the vast majority either agree or strongly agree that it is going to make it easier to manage your patients. So that is truly brilliant. I am really, really happy with that. I am just going to close that. Great.
 
And when I work out how to make this thing move forward. Here we go. So first up, and I want you to put in the Q and A, your response, just thinking about Murray, your first thoughts as you look at this little preliminary case study of Murray, who is a 49-year-old man, new to your surgery, arrives late on Friday afternoon as a walk-in and says, Doc, I know you are busy, I will not waste much of your time, I just need my repeat script. And then he asks for an oxycodone prescription. He waves a letter in front of you from his specialist that states he is on Endone, he is on oxycodone, he is diazepam, he is on Oxazepam and he is on pregabalin. Now just getting a bit of a sense, if you can put in the Q and A there your thoughts. Heart sinks, Penelope, yes. Absolutely right. Thanks Penelope, that is a really common one. Anybody else want to add their thoughts on Murray? No. A couple of red flags. Probably a drug seeker. Thanks, James. Just waiting for a couple more people to put in their thoughts. So bottom line. Look, Murray is someone, specialist letters are often forged. Absolutely. There are some red flags here around Murray, the 49-year-old who comes in late, walks in, says I will not take your time, a specific medication, has a letter, and when you look at these, this combination of medicines is high risk. So we are going to come back to Murray a little later on to have a look at… oh sorry guys, just getting the hang of this thing. It is going forwards, how do I get it to backwards? Just technologically challenged.
 
Okay, now just moving to a little bit of data here, and I want to flag really the section that says “preliminary data” in the green. And looking at, this is drug-induced deaths by the most common drug classes over the years. There is a peak back there in the late 90s, then we saw the heroin drought that happened after that, but we have really high levels of overdose and that resulted in the National Drug Strategy and things like our medically supervised injecting centre here in Kings Cross was one of the outcomes of that. But looking now at this data, 2017 to 2018, what you can see is opioids figure really highly, but so do all depressants. The non-heroin opioids, do not forget your anti-depressants and anti-psychotics and other analgesics including the gabapentinoids that cause harm. Three out of five of drug-induced deaths ae due to opioids, and of those, three out of five of them have benzos on board as well and that is something that we really commonly see, is the multi-drug toxicity. So this is Australian data.
 
And then if we move to New South Wales, a little older and this is looking at what is happening in the New South Wales setting and drugs detected after people’s deaths in the forensic setting. Ambulance officers administer six to seven shots of naloxone per day in New South Wales. So that is your antidote, that is your emergency treatment for opioid overdose. One in one thousand emergency department presentations are due to opioids, most of it at the moment oxycodone. It is that group of people aged 35 to 44. Certainly the 25 to 34 and the 45 to 55 also are in that, but it is this group that are most commonly represented as well as people who come from the most disadvantaged and marginalised communities and low socioeconomic communities. And we have seen increasing rates of opioid-related deaths, with 5.4 deaths per hundred thousand in 2018. And if you just come to this graph once again, you can see the combination of opioids and anti-depressants, combination of buprenorphine, combination of benzodiazepines. They are the ones that have risk. I would flag in terms of opioid plus buprenorphine and methadone, yes, they are all opioids, but when they are talking about buprenorphine they are talking about people who are on opioid-agonist treatment. And the numbers are quite low, but you know, really important to look at the opioids as a risk for overdose, as a risk for harm, and when they are mixed with other central nervous system depressants, that risk is increased.
 
Okay. So why RTPM? Real time prescription monitoring. What are we trying to solve? And this is part of a national commitment to reduce harm due to medicines that are high risk. And it was first flagged in 2011 by the then Federal Government and we have seen State-based programs roll out in Tasmania and Victoria, and now we are moving through this process here in New South Wales and I know other programs are in process in other jurisdictions. So, the thing, when I am thinking about it for myself and when I talk to my colleagues, one of the difficulties, and if you think back to someone like Murray, we are thinking, is this letter forged? Is he taking these medications? When did he get his last script? What else is he taking? And it has been really difficult and I do note that somebody did talk about prescription monitoring. That was Win and Sez. That going to the Federal Prescription Shopping Hotline. But information there is limited and it is old. And it is only PBS scripts. And so we have been operating in the dark, trying to make an assessment of risk for our patients. Our current management systems, you know, they are out of date and Prescription Shopping Hotline is a good example of that. And using the technology that we have at our disposal now to really use this information more effectively and get it in real time. We will talk a little bit more about what I mean when I talk about high risk medications, and I would also flag that it is not a one size fits all. You need to take into account each patient’s unique risk factors, whether it be their comorbidities, the other things that they are doing in their lives, you know, their other medicines, other drugs that they are using. You really need to do a good assessment so that you can make a really specific and unique assessment of their risk.
 
So what makes medicine high risk? Now basically, it is central nervous system depressants. The ones that cause overdose. They are sedating. If you are too sedated you get respiratory depression, then you get respiratory arrest, and then you get a fatal or a non-fatal overdose. Now in that data we have been looking at fatal overdoses, but I do want to flag the risk for non-fatal overdoses, that these can cause ongoing disability, ongoing cognitive impairment and if somebody has had a non-fatal overdose, they are at risk of overdose. So it is a good thing to be aware of. And the medicines that we are using here are complicated by their propensity to cause dependence for people, who once they start them, find they cannot stop it. They become tolerance to the effects, they take bigger doses. They take larger doses for a longer period of time. They cannot stop when they want to and there can be aberrant behaviours around that as well. Multiple medications as we said before, multiple sedatives, multiple centrally acting sedatives, whether it be medications or non-medications for example, alcohol or GHB or other sedatives. Their comorbidities, respiratory, cardiac, you know, and also things like the renal and liver function that affect their ability to metabolise and manage the medicines and also the risk of respiratory depression. How much they are using. And this is really important. The risk is dose-dependent, and we will come back to that. The route of use, how they are using it. Are they injecting? If you are injecting a medicine, even if it is one that is meant to be used orally, you are going to get a bigger dose. You are going to have a quicker onset, it crosses that blood brain barrier more quickly, you get more sedation, more risk of overdose. And you are getting a bigger dose because it is bypassing the first pass metabolism in the liver. Lack of access to treatment. And here I am talking about access to emergency treatment. We talked about naloxone in the ambulance setting. You know, giving people access to naloxone and we will talk a little bit more about that later. But also access to treatment for their complex presentations, whether that be their mental health, their chronic pain or their drug and alcohol issues including their opioid use disorder or dependence. And the lack of knowledge, lack of knowledge that our patients who are taking these medications, high risk medications, may not realise that they are at risk. They may not know that these are the issues. And if they do, it is kind of like, well I have not had a problem so it is probably okay, it is other people. So it is really thinking about how we can work with our patients to increase their level of knowledge and understanding, and also that of their families so that their families know that there is a risk, that we can talk to them about they can support someone who they think may have overdosed. There has been a number of coroners cases that I have been involved in where people died of multi-drug toxicity basically overdose, in the same room and in the same bed, or in the same rooms as their family members, and their family members did not realise that they had overdosed. So there is a huge issue here around ensuring that people have knowledge.
 
So, High Risk Monitored Medicines List. So this is what is included in New South Wales. All your Schedule 8s. So that is your Schedule 8 opioids and benzodiazepines. All the benzodiazepines who are in the Schedule 4. All the codeine preparations and tramadol is Schedule 4. Pregabalin, quetiapine and the Z drugs. Now I should flag that there will be ongoing monitoring of medications and if there are others that are starting to turn up that are not on this list, they may be added in the future.
 
Now, Aine, I just wanted to ask for your feedback about the reason that these eight varieties have been included at this point in time. Can you speak to that just very briefly?
 
 
Aine:
 
Sure no problem. So one of the things we did was we established a really eminent expert panel and Hester was a part of that group. That group undertook really rigorous, well based on literature, looked at a number of criteria and assessed all the medicines against all of those criteria. Schedule 8s were a bit of a no-brainer. They are high risk by the very nature of the schedule that they are in, but what we looked at was things like evidence of harm, the trends of misuse and abuse, the chilling effect that might occur, so that people might not be given medicines if they are being monitored when they had a reasonable therapeutic use to have it. As you said, that substitution effect, so if people start moving away from misusing and abusing the drugs because we are monitoring them, but they move onto other substances. So you know, they shift from pregabalin to gabapentin for example, or if they shift to you know, barbiturates to get away from benzos, things like that, we do have a really robust surveillance system to be looking for those unintended consequences.
 
But we also had to find some sort of harmonisation with other states and territories. So as you said, eventually this is going to be a national system. We are not slavishly following the lists that every other jurisdiction has, there are slight deviations. But again, we do not want people to experience different things in different parts of Australia, so we are trying to keep them as consistent as possible, but also there was a new criteria of, is there a clinical utility and a doctor being aware of being on one these medicines was an important criterion. And so that is how we arrived at the list that we have arrived at.
 
 
Hester:
 
Fantastic, thank you. I just now wanted to move onto this next slide. Aine, can you speak to this one? So this is looking at, and I should say this is based on the Victorian SafeScript program. At the moment we are thinking that it is going to be called SafeScript New South Wales, is that correct?
 
 
Aine:
 
We have in principle agreement from the Commonwealth and from Victoria for that to occur. We just have not seen the signature on the dotted line but it is highly, highly likely that it will be called SafeScript New South Wales.
 
 
Hester:
 
Yes. So, the real-time aspect of it is really important. So what happens is, when the patient comes to visit one of us, when we in our software start to type in a high-risk medicine, then what happens then, Aine? Take us through the process of what happens in terms of real time prescription monitoring.
 
 
Aine:
 
There will be some technical things which we will have to caveat a little bit, but broadly speaking, if a patient presents and a doctor decides they are going to prescribe a monitored medicine, depending on how integrated your system is, it is likely that you know, your system will send information to the National Date Exchange where as a part of electronic prescribing and how all of that happens, if there is something in the SafeScript database that would be relevant to that patients and that prescription, like within seconds it will return a notification. So, if there is no information it will return a green notification, we will talk a little bit more about that. If there are perhaps records that you might want to look at it will be an amber notification. And if it is a high-risk scenario it will give you a red.
 
 
Hester:
 
Sorry, that was me.
 
 
Aine:
 
That is the theory, so that somehow you will be notified whether there is relevant information in SafeScript for you to check. So, again, your system talks to SafeScript. SafeScript talks back to your prescribing system. And equally, if there are concerns there, so if you get a red or an amber notification, you can then check that patient’s medication history. If it has generated alerts, and again we will describe for you what alerts are and what they look like, then it is up to you to make a clinical decision as to whether you want to continue with prescribing in that event or not, based on the information that you have been provided. Particularly when the patient visits the pharmacy, a similar sort of workflow will ensue, because yes, as I said equally there is an opportunity to intervene there if somehow the patient has maybe got a forged prescription or fraudulent prescription that the pharmacist is able to double check. They also have the ability to put it into the SafeScript just to see if there is anything.
 
 
Hester:
 
So one of the things I think Aine that I think is important to flag at this point is that, just because you get a notification or an alert, does not mean that you cannot prescribe. It is just giving us information that will support us in our clinical decision making. You know, so using this to help us make, you know, decisions based on more information is what it is at. But it is overseen by the Department of Health in New South Wales. What happens to that information?
 
 
Aine:
 
So we are looking at it more globally I guess rather than individual patients, prescribers or pharmacists. We will be looking for trends. We will looking at macro data. We will be looking at areas of concern because then that is where the regulator will determine how they target their interventions if you like. So, they will look at it perhaps you know in certain circumstances where there are inspections and investigations going on, at a more individual level, but as you can imagine, the regulator is more concerned with the overall safe and effective use of medicines. So we are likely to be looking at it at geographical level in terms of the way we slice and dice it, it terms of where we need to put our efforts, in terms of inappropriate medicine use.
 
 
Hester:
 
And one of the things Aine that you were saying to me is that we did want to make it as close as we could to what is happening in Victoria, and I do note that there are some slight differences in terms of the monitored medicines. But is there going to be capacity in the future for these different systems to talk to each other across state boundaries?
 
 
Aine:
 
Absolutely. So all of the real time prescription monitoring programs that are being established in jurisdictions now are all using the same Commonwealth infrastructure. So we all use the National Data Exchange which was set with the purposes of electronic transfer prescription about 10 or 12 years ago. So while at the minute we can only have the lawful provision to collect data for either patients or doctors or pharmacists that are in New South Wales, eventually there will be a data sharing arrangement brokered by the Commonwealth for all of the jurisdictions and then we will able to see the data from everywhere. So if you have people you know that are travelling, grey nomads who go around Australia, and you do not have a New South Wales address, we will be able to see that. We will be able to see you know particularly in places like border crossings, Albury-Wodonga, obviously people in New South Wales are going to want to see what happens in Victoria and vice versa. So yes, we hope in the not very distant future, it ultimately will be a national real time prescription monitoring system.
 
 
Hester:
 
Fantastic. So I am just going to move onto the next slide, which is, I love this slide. I think it is brilliant. And there are some people that are going to groan and go, oh my goodness and other people just love flow charts. When I look at it, what I am seeing is the prescriber over here that I am working on my desktop, and then information if I am starting to prescribe any high-risk medication, it will then be flagged by the real time prescription monitoring, and then it will give me information back. Now Aine, you did say before that there are some of the general practice systems that can be more integrated, and that is the Medical Director and Best Practice. But there are others that may not be able to be integrated as smoothly, but you can still access the program by having the portal open on your computer. Is that right?
 
 
Aine:
All of the big, common prescribing softwares will be covered. There are a couple of little tiny cottage industry boutique ones which are not yet fully integrated. And they will have two options. You can actually download what is called a notification client onto your desktop, a bit similar maybe to what some of the pathology companies and things do, they put a widget on your desktop so that you can both send and receive pathology requests and results. So it is a bit like that. It is a little extra piece of software that you can download. And that way you will get notifications. Or the other way, which is always available to people whether their software is integrated or not, and this is very commonly used say in the hospital setting, is you can just directly log into the portal and search for the patient. So, yes.
 
 
Hester:
 
Fantastic. I am going to move onto the next slide. So how do I get RTPM? I am here listening to this Aine, and I am thinking, that would be brilliant. How do I access it? How do I register for it?
 
 
Aine:
 
We will be absolutely saturating the areas in which this is available. I will talk to you little bit about the staged approach that we are going to do. But essentially, how your identity is validated is via the App or database, because there are only certain types of registered clinicians that will be able to access this. Broadly, that means prescribers and pharmacists. So prescribers includes things like nurse practitioners and dentists, but it would not you know, include say allied health, physiotherapists or those who do not have prescribing rights currently. So in the first instance what we will do is we ask the APHRA database to allow us to send you an email, whatever your preferred email is that is registered with APHRA. That will be an invitation to register with the system. It is just a little hyperlink that will take you to the registration portal and it then just takes about 10 minutes, because it just asks you, you know,  a couple of things about your preferences and you know, what your location is and your practice and what phone number you would like us to use to notify you. So it is a relatively seamless process, and having been involved in Victoria, none of the general practices that I dealt with found it an onerous process. And so you only have to do that once. So then you will establish a user name and a password, then thereafter when you want to log into the portal, you will enter your user name and password. It will send you a verification code, so there is two factor authentication. Because again, the privacy and security of this information as you can imagine is exquisitely sensitive and at that point, then you will be asked to set up a pin, and that pin will be valid for the rest of that day. So that is something that you do have to do every day. However should you choose to select exactly the same six digit pin every day, that is possible to do that.
 
 
Hester:
 
Fantastic. So just moving onto the next slide. Once again continuing how do I get RTPM? Tell us about how it is all going to start, and when and who, and all that kind of stuff.
 
 
Aine:
 
So we have a lead PHN region. Again, based on Victoria, we found that was a really good way to begin the roll out, so we will really intensively saturate the lead PHN region that we will testing this with for the first time, just to make sure we iron out all the kinks and all the bugs. We do not think there are any, but nonetheless, it is just good practice. So that PHN region will be going live around the end of August or beginning of September. They will do that testing for as short a period of time as we can allow, but possibly until about December and then we will chose three other PHN regions around the state and again will have a mix of metro and rural and those with their own particular challenges or opportunities. And so they will be testing in early 2022. And then I would imagine by March to June next year, it will be state-wide.
 
 
Hester:
 
Fantastic. So going on to how it would look on my screen. So Medical Director screen there. And tell us about the SafeScript warning down here, the green tick and what that means.
 
 
Aine:
 
Yes, so as in mentioned before, your system will check the RTPM database and then return a notification to you. So if there is no relevant information, and we have not actually chosen the time period but it will likely be three months or six months. If there is no relevant information for three to six months for this patient, then it will return a green notification, so it is basically saying there is no record in SafeScript. It does not mean there is nothing of concern, but it nonetheless is telling you that SafeScript is running and has checked, and has not found anything for this patient.
 
 
Hester:
 
Yes, and I think that is an important thing to mention, is that it is flagging high risk medicines that the system is aware of, but it is not fool proof. There are some, you know, you do need to also just make your assessment of the patient as well.
 
 
Aine:
 
Yes, I mean we know from the pandemic that e-prescribing has become a lot more prevalent, but the reality is there are still some paper prescriptions out there. So what we think is that about 70% of GP prescribing is happening electronically and we be captured. We think 99% of community pharmacy is happening and being captured. So even if you have written a paper prescription, it will likely end up in the system, because a community pharmacy dispenses it and it will be captured there. So we think we have got good capture, but we do know that there is still some non-conforming systems and some you know, paper prescribing going on out there which you know, would mean that the data capture is not complete.
 
 
Hester:
 
Yes. So the next one that can happen is getting this amber, which is flagging please check SafeScript. So, what does that mean when that one comes up?
 
 
Aine:
 
Yes, so again, we are still tinkering with this a bit so it is not entirely set in stone. But what it will at a minimum tell you is that there are records in that timeframe, that will be the three to six month time period that our records monitor medicines for this patient. So again, in Victoria, it is mandated that the prescriber or the pharmacist if they get an amber notification, needs to check. We have not yet done that in New South Wales, but it is just basically a signal to you saying, there might be something in this patient’s medication history that might be relevant to this new monitored medicine that you are about to prescribe.
 
 
Hester:
 
I have just had a couple of questions. One from James which is asking about patients enrolled in opioid pharmacotherapy treatment. Can you speak to the issues there?
 
 
Aine:
 
So we are exploring that. I have not landed on exactly what the solution is going to be. New South Wales is a little bit different from other jurisdictions in that we think about 50% of our OTP transactions I call them, so that is prescribing and supply, do not happen in a way that can be captured because they happen either in you know, public clinics or private clinics, or again they are not processed in community pharmacies. So we are aware and alive to that issue, and that was not a problem that other jurisdictions faced, so the vendor did not come up with a way for that to happen. So we are looking at you know, whether we can have a sort of an OTP flag for someone who is currently enrolled in OTP. But again, that is still a work in progress, we have not entirely landed on the technical solutions for that.
 
 
Hester:
 
So the really important thing is that the program is aware of the risk, we do not quite have a solution yet, but we are working on it because it is a high risk area. The next one is the red alert. What does that one mean?
 
 
Aine:
 
So the red alert means that alerts have either now, or at some time in the recent past been generated for this patient. So, high-risk scenarios, that some threshold has been met that has required a red alert to be fired, and therefore again, it would be a really good idea to go and have a check of the patient’s past.
 
 
Hester:
 
Fantastic. So once again, the difference between notifications and alerts. I am a little confused about it. It sounds like the alerts are, is that the coloured ones as compared, or tell me what the difference between notifications and alerts are.
 
 
Aine:
 
Really, really good question, and it is a bit of a mind bender that took us all a while to get our head around. So, if you can think of it like this. The notification is the little pop-up that will appear in your clinical information system. It will be quite generic. It will not tell you very much about why it is fired, other than it is green which means there is no record in SafeScript. Amber, there is probably records in SafeScript that you should look up. Red, you really, really definitely should go in and look at SafeScript. So that is a little traffic light kind of system that will appear in your Medical Director, in your Best Practice, you know, without you having to do very much. If you get those notifications, then the green one sort of appears and then fades after a few seconds. The amber and the red will stay in your clinical information system, so again we would encourage you very much to use that notification to click through and it will take you directly to that patient’s profile in SafeScript.
 
 
Hester:
 
Yes, and Aine, once you are looking and that is what we are looking at here, this little box where I cannot read any of the writing. What information will it give me? Is it going to give me details of the other prescribers? The dates? The amounts? How much information can I get from going into the portal and looking at the patient’s record?
 
 
Aine:
 
Yes, well we are really limited, so there is only a 200 character limit. We are very limited and that is why it is very generic. So as I said, it may only say there is no relevant prescriptions in SafeScript. There are relevant records in SafeScript, or there are alerts in SafeScript please check. So it will be not very prescriptive about why it has appeared. But then as you click on it, so the difference between an alert is an alert is actually only ever exists in the RTPM database, so if you want to know why you got a red notification, you will have to click through and when you go in then to the SafeScript portal, it will actually tell you, this patient is either on a high dose of opioids, or this patient is on a risky combination of medicines, or this patient is seeing you know, multiple prescribers, which is a concern.
 
 
Hester:
 
And will it give you details about the name of the prescribers or the dates? The amounts of medicine? Dose?
 
 
Aine:
 
Yes. If you can see the middle of the screen there, and I appreciate it is a bit small, but that is what the SafeScript portal looks like. So you will see the alert is that little red text banner up the top. So the alert message will tell you the detail about why it has fired. But if you see that there are sort of three little transactions underneath the patient’s details, so those are the actual details of either the prescribing or dispensing event, and you can see that it has got little red explanation marks. So again, those are the transactions that fired the alert. You can click on that, again it will exactly give you the details of why the alert was fired, and it will give you all of the details of that transaction. So if it was a prescriber, it is prescriber, it is the patient, it is the pharmacy, it is all of the details that are captured in that transaction will be there including the contact details of who the health professional was.
 
 
Hester:
 
That is fantastic. So, basically the notification is the little pop-up that comes up saying nothing on SafeScript, have a check there might be something, or red flag there is stuff you need to check. And then once you go into the portal, then you get this really detailed information, who, when, where, how much, what, which is really, really brilliant.
 
Just, oh here we go, moving it around. Oh gosh, so here we go. So we have got more information here. So we can actually see who it is, what they have prescribed and the whole detail is there with the alerts. I am aware of the time, so I might move on.
 
And these notifications once again. We have talked to these. The little green tick that says there is nothing in SafeScript, the amber alert that is saying look, there is something in there, and the red alert that is saying please check you know, to make sure that you are not going to be doing anything that is too risky for the patient.
 
What will be flagged? And there are certainly some questions coming up in the Q and A around what is going to be flagged. First of all, are private scripts going to be flagged, Aine? It is very faint.
 
 
Aine:
 
Sorry I will try again. Can you hear me?
 
 
Hester:
 
Yes.
 
 
Aine:
 
I am having a sound issue, sorry. Absolutely private prescriptions are captured.
 
 
Hester:
 
And for those ones that are written on paper prescription, either in hospital or in a general practice, how will they be flagged?
 
 
Aine:
 
So hospital transactions, can you hear me still or am I still having my problem?
 
 
Hester:
 
Yes, beautiful.
 
 
Aine:
 
So hospital transactions you know, that happen as an inpatient and even you know, the public system, not even an outpatient, will not be captured in the system, at least at this stage, although again maybe in a year or two once some of those software systems can be made conformant. But for now, hospital data is not captured. As I said, paper-based prescriptions or indeed prescriptions from private hospitals and other places will be captured, because as I said, there is almost entire, complete capture at the community pharmacy when they are dispensed, because again the driver for all the community pharmacies to be connected to the prescription exchange is both e-prescribing but also PBS claiming. So the vast majority of transactions.
 
 
Hester:
 
Fantastic. And look, and once again there are a few people asking the same question. Private scripts are monitored guys. Hearing that really clearly. Private prescriptions are monitored. And it does not matter whether you are registered for Medicare. If you are getting a prescription that is going into a practice software, or is going into software at the pharmacy level, they will be monitored.
 
I wanted to come to the three areas that really tell us who is going to be flagged and for what. The first one is multiple providers. So if a patient is seeing four or more prescribers in four or more practices, and four or more pharmacies dispensing a script, that will be a high-risk alert. So it is really important that it is four or more practices. So it could be in your practice that you have got four or more prescribers prescribing a variety of medications. That will not be flagged in the same way as if it is in four or more practices. The next one is the high-risk oral morphine equivalent dose. So a dose of 15 to 100 oral morphine equivalence is a medium risk. A dose of greater than 100 oral morphine equivalence is a high risk. And I just want to draw your attention to the little green box there which is a terrific App put together by the Faculty of Pain Medicine that helps you with your opioid equivalence. Now if we are looking at oxycodone for example, it is stronger than morphine, so you know, if you are giving someone 75 mg of oxycodone it is around about 100 mg of morphine. So what the Opioid App can do is look through all through all the different opioids that a person might be using and give you the oral morphine equivalent. And what they have on that App, is once you get into the 50 to 100, it turns orange, and when you go above 100 it turns red. So what we are doing in RTPM is consistent with that.
 
The other one is multiple medications, and I flagged that at the beginning of the session, that there is a real issue in terms of multi-drug toxicity and multi-drug use that increases harm. And for these ones, it is the last 90 days will flag a high-risk alert for those combinations. Now, Aine one thing that I wanted to check around this is, so we have got quetiapine and pregabalin for example in there. But they will not be flagged as a high risk alert. Can you tell us a little bit more about that?
 
 
Aine:
 
Yes. So again, in part for consistency with other jurisdictions at the moment, we are adopting what many of the other states have done. So again, it is a sort of consistent experience for people. But over time that will definitely evolve and mature. So one of the examples, the alerts that we are still developing, are for example if a patient is on a benzodiazepine and reaches a threshold of an oral morphine equivalence that seems a bit harmful and they are on quetiapine and pregabalin, so that may well generate an alert. It does not today, but it is something we are working really hard with the vendor to develop.
 
 
Hester:
 
So at the moment, Aine, will that be flagged as there is something in SafeScript, take a look?
 
 
Aine:
 
It would appear as an amber to say that there are records. Yes.
 
 
Hester:
 
Fantastic.
 
 
Aine:
 
There are a lot of records about other medicines, but at the same time this is equally to your point Hester about do not rely on the alerts to tell you about all risky scenarios. Because what we did not want to do was design them that they are so frequent that everyone gets alert fatigue and then everyone ignores them. So it is about just finding that right balance. So at the minute, it is firing on the really, really high risk scenarios, but there can be plenty of you know, other risks for monitored medicines and people being on them. So it is always a good idea to check the medication history.
 
 
Hester:
 
Fantastic, fantastic. Now I wanted to move onto the next section, which is looking at some case scenarios and how RTPM might be used in those case scenarios. So please, if there are questions, you guys as asking some great questions in the chat and I am keeping an eye on them, so please keep asking those. What I wanted to do now is go to another poll. Bethany, if you could just run the poll and what I am interested in here is whether you feel like you have the skills to manage patients who are flagged by the real time prescription monitoring program, and if you know where to get support for yourself and for your patients who are flagged in the system. So if you guys can just fill that in for us, that would be brilliant. Okay. So we have got 28% who feel that they may not have the skills, but the majority of you feel that you have the skills. That is totally, totally brilliant. Knowing where to get support. There is slightly higher disagreement with that one and we will be covering that, so that is totally brilliant. Thank you so much, everybody.
 
So let us go back and have a look. So what I have focussed on here is, new patients, patients that belong to you and inherited patients, but also the other option is reviewing a patient for your colleague is part of the PBS yearly conditions, you know when somebody has been on medications, opioids, for a year then having that review, that this is a really nice time perhaps to be thinking about how RTPM could assist you with that. And it is really important to let your patient know that you are checking. That you are checking this real time prescription monitoring, SafeScript. It is to ensure that I am not going to cause you harm, that I am ensuring that I can give you the best possible care. Understand that this process can be very distressing for patients. Patients can have an experience that they are not believed, that they are being judged or discriminated against, and it is not uncommon we see this in the literature, and I have seen this anecdotally as well, that they feel like I am being treated like a drug addict. And also, that it is distressing for us as said at the beginning, it is heart sink, it is tricky, you do not want to do it, you do not want to go there. There could be difficult conversations. So do take that into account. This shift is important and having those conversations in a way that supports both us and our patients to move towards solutions and minimising harm and working together is really important. So think about the language that you use. We do want you to consider the consequences of risky prescribing, but also the consequences of not prescribing. So really do think about what might happen if I do not support this patient, and in no way am I suggesting that you prescribe in a risky or unsafe way, but really thinking about how you can actually assist that person. And for us as GPs, we do not have to solve everything now. We have the luxury of time. We have longitudinal relationships with patients. And so over time, we can start to work with patients to improve their medication use, their chronic pain, and their overall health outcomes.
 
So, let us go back to, if I can get this moving, Murray. So he is our 49-year-old, arrives late Friday afternoon, I know you are busy Doc, I will not take up much of your time, I just want my repeat script for oxycodone 50 mg twice a day. So first up, we know from that dose, so he is on 100 mg oxycodone which is around about 120, 130 morphine, that he will turn up, he will trigger real time prescription monitoring. We know he will get a red alert because of the dose. And just remember that risk is related to dose. It is possible, that he might also be flagged, we might get a notification that he is using multiple high-risk medications. We do not know from this history at the moment. And it is also possible that he is attending a number of practices, getting scripts from a number of prescribers and also a number of pharmacies are involved. So with someone like Murray, it is true, it can feel like he is that heart sink patient. Oh, and here we go. This is the rest of his medications. So he is also on a fentanyl patch. He is also on diazepam. He is also on Oxazepam and pregabalin. So he would have multiple red alerts potentially because he has multiple high-risk medications as well as that high dose, and it is possible that he would be seeing you know, the multiple practices. So Aine, can I just check with this one, because he is on both the fentanyl and the long-acting opioids, he would get two red alerts?
 
 
Aine:
 
You would probably actually get three.
 
 
Hester:
 
Three?
 
 
Aine:
 
Yes. Because he will get the high oral morphine equivalent because of the Endone and the oxycodone and OxyContin that he is on. Because he is on slow release OxyContin and he is on fentanyl, that is an alert. And because he is on fentanyl and a benzodiazepine, that is an alert. So, I think there will be red flags aplenty.
 
 
Hester:
 
Risky, risky. Absolutely. And, oh sorry I just wanted to say just one more thing about Murray. Look it really is a clinical decision that all of us would need to make when we are faced with a Murray. And certainly what the real time prescription monitoring can tell us is, you know what Murray, you had these scripts yesterday, and I cannot give you any more. Or it could be that it is clear from what you can see from the additional information that you have got, that there is a legitimate need for a prescription, but you have got to think about how do you do this, and how do you do this safely with Murray? And we will talk more about things like staged supply, providing Nyxoid or naloxone for the reversal of opioid overdose, supervised dosing, getting other people involved. But I just want to send that message that it may be very appropriate to say Murray, I am terribly sorry, I cannot give you a script today because I am concerned for your risk and you have had these medications very recently. But I would also encourage you to express your concern that it is very likely that you are not getting your healthcare needs met and you are not functioning as well as you possibly could. I would really like to help you. You are at risk of real harm. I would like to support you to actually do this differently, and if you want to come back and see me, even if I do not give you a script I am very happy to support you, I will do what I know and believe to be safe. So you are letting them know that you are not going to do unsafe prescribing but that you also really do want to assist them to ensure that they can decrease the level of harm and risk that they are at and improve their health and wellbeing.
 
So while I was thinking about how to respond I broke this down into four parts, and because I can only remember three plus one. So the first one is the conversation. Talking about the risk of harm, talking about how you can improve outcomes for them, how you can improve their quality of life. And setting boundaries around what you can and cannot do. As I said before, being careful around the language that you use. Seek advice, seek support. There will be a telephone support service for advice connected with RTPM. Health Pathways, all our local PHN Health Pathways and LHD Pathways are developing pathways to assist with this. I do not think they are up for all of the pathways, it is different for different jurisdictions. But do check that out, it is a really amazing online tool that can assist us. Get a second opinion from one of your colleagues in your practice. If you choose to manage the person, once again, engaging them so that they understand, so that they have the information that they need. And the reality is, if you are going to change, if it is an entrenched behaviour, they have been taking these medications for a long time, it is a long term collaborative commitment by yourself, by the patient, by the pharmacists and other services involved. And certainly what I hear from consumers is that there is a huge amount of fear about changing their medications, and to hear you say, I am here for the long haul, I am here to support you, these are the boundaries of what I can and cannot do, but I am here for you to support you through this, I know it is difficult and I know thing will improve, is just an incredible support for patients. One prescriber, one pharmacy, frequent reviews. Staged supply or supervised pharmacy dosing, so you are limiting the amount of medication that people take away with them, or they are actually having their dose observed. And also the pharmacist can observe, are they sedated, is it safe to provide this medication? Urine drug screens. Once again, for me that is around a collaborative approach that is just making sure that what we are doing is safe. Prescribing naloxone or Nyxoid the intranasal Nyxoid, very easy to use, available on the PBS. If somebody is injecting, supporting them around accessing safe injecting advice and the medically supervised injecting centre to reduce their risk of harm.
 
Setting goals. And I am much more interested in people’s function that I am in their pain. So things like the PBI, the Brief Pain Inventory can be really useful. It has measures of pain but it also has measures of activity and function. Your weaning plan. Thinking about in some people whether opioid substitution treatment or opioid agonist treatment, methadone, buprenorphine, really is appropriate for this person. Looking at the self-management and the non-medication options that are so core to helping people manage chronic pain and anxiety. And really important that you have a practice-wide approach so that everybody in your practice is on the same page. You might have case discussions, you might be managing them collaboratively in the practice, particularly as part timers, to make sure that you are all on the same page around what you are wanting to achieve and support the patient to do.
 
Look at other options. Involve their families. Look at non-medical or social prescribing which includes things like exercise and hydrotherapy and physiotherapy. And of course, refer for specialist opinion or collaborative management from allied health from your pain and addiction services as needed.
 
Now we are going to run out of time, but I really just wanted to quickly look at someone like Janet, who is a 44-year-old woman who is a patient of a retired colleague. And she comes in and say, oh Dr XX has prescribed oxycodone for me for years. And you look in the notes and you see she is prescribed oxycodone 30 mg bd, commenced in the emergency department after extensive superficial abdominal burns three years ago. Now, first thing to my mind is why is she still on it now? You know, really if there was superficial abdominal burns, they should be okay now. But she is attending regularly for prescriptions and it sounds like maybe nobody has had that conversation with her. There are no other prescribed medications. She has a past history of post-natal depression. She is a non-drinker, non-smoker and there are no other health issues. She would get an amber alert. On the basis of this risky dose. Unless she is actually attending a whole heap of other doctors, which in this case study, Janet is not. She is coming to one practice. She is not on multiple high risk medications and she is not attending other places. But this can be a tricky conversation with Janet, because she has been on this medication long term. And so once again, for us it is really thinking through how do we have the conversation seeking advice to support us with our decision making. Looking at how we can work collaboratively with the patient, and really my focus here would be a slow wean over time to get her off it completely. Always looking at the lowest possible dose for the least length of time. And supporting her with other options.
 
New patient, Cheng. A 38-year-old woman. I have recently moved into the area and I tell you, I am getting pretty desperate as I need a prescription and other doctors will not assist me. Now this is a woman that has severe migraines that last seven to 10 days most months. And she takes up to six Panadeine Forte tablets a day during an attack, and with this medication, she functions. She can get to work. She can make dinner for the kids. She can do all the things she needs to do. She happens to be a single mother with three children. And she has found that the triptans help, but not all the time. Blood pressure meds, the anti-convulsants and the anti-depressants have not helped. There are no other risk factors there. But one of her concerns is that she goes to a doctor and says, look I need this for my migraines, there is a good history of migraines, but doctors say sorry, I cannot help you. This would be a green notification. So once again, you get that little tick saying on the basis of what we have here, this is low-risk. Six Panadeine Fortes, 180 mg of codeine is pretty low-risk. It is around about I think 27 or 35 or something like that of oral morphine equivalent. Varies by individual because metabolism across to morphine is very individual. But she is not taking multiple high-risk medications. She is not seeing a whole heap of prescribers. So once again, for someone like that, I do not like Panadeine Forte particularly, it is not one of my favourites, but you know, really this woman is low risk and I would want to look at her around what else can we do to support the migraines. There are some new treatments coming out, I want to limit the Panadeine as much as I can, but you know, really looking at what would I do for that person.
 
I am going to move on because I am aware of the time. Just coming to Abdul. Once again, this person has Targin. He is taking some of those other medications. There will be an alert. But once again, he is only seeing you. He is not seeing multiple prescribers. And once again, going through the same thing, I want to if I can possibly, to reduce the amount of tablets that he is having. There is some risk there, but it is an amber notification.
 
 
Aine:
 
And just Hester, just for clarification there, so he gets an amber notification because he is on monitored medicines not an amber alert.
 
 
Hester:
 
Oh, amber notification. Thank you, thank you, thank you. And coming to Joe. So, he is the same. It looks the same, but what is happening here is that he is getting medicines from other doctors. So you know, looking once again at what might happen there. Sorry, I am aware that we have got three minutes left and so I am going to move on.
 
Once again, coming back to what is available, and we have mentioned this briefly. Health Pathways. The dedicated telephone advice service which will be available. There is going to be some e-learning modules through NPS MedicineWise. There is going to be more sessions like this through the RACGP. They are going to be multidisciplinary as well with the pharmacist, with Pain Australia, which is a consumer organisation and also the New South Wales Users and AIDS Association which is a consumer organisation for people who use drugs. There is going to be lots of information out there. We are working really hard to ensure that the support that you need and the information that you need is going to be available.
 
I am going to finish up just very quickly, just flagging once again the role of Nyxoid, this intranasal naloxone. The role of staged supply of medicines, getting the patient to go to the pharmacy, you know, frequently, whether it be daily, every three days, every week, to really just help them to control how they use the medications. Supervised dosing when they take it in front of the pharmacist. Do not forget a group of people, not everyone, but a group of people, that they can develop prescription opioid use disorder and you think about the evidence based treatments. Methadone and buprenorphine. All of us can start people on Suboxone, the buprenorphine and naloxone combination and we can have up to 30 people, 20 on Suboxone and 10 on methadone, and we also have a new injection which is a depot buprenorphine, either Sublocade or Buvidal, which you can do monthly injections. So there are really fabulous evidence based treatments for this, so do think about that, because a group of patients that you will see would greatly benefit from that. Psychological support, helping people to manage their approach to their lives, to their pain, to their mental health, and working in teams. You do not need to do this on your own. Do it with your colleagues. Do it with your allied health colleagues. Do it with a specialist colleague. Do it with your pharmacist.
 
So that is it. Record time. We have got one minute left. And there have not been many more questions. There is just one here from Chumal. Injecting OxyContin if fentanyl is never saved. I am not sure what you mean by that, but certainly OxyContin and fentanyl are high-risk medicines, so they are monitored medicines so they would be flagged.
 
Aine, just as we are finishing, any quick last words?
 
 
Aine:
 
No, just to that, I agree. Injecting OxyContin and fentanyl is never safe, which is what I think they intended. What we are hoping is that this system, it may not stop that practice, but it should stop a lot of the diversion of prescription medicines into the illicit market is what we are hoping.
 
 
Hester:
 
Absolutely. Absolutely. Aine, I just want to thank you so much for your expertise and keeping me on track, and look, this is a really great system and I look forward to the roll out around New South Wales.
 
 
Aine:
 
As do we. It has been great, thanks for the opportunity.
 
 
Bethany:
 
And I just wanted to jump in and thank both of you, thank you Hester and Aine for your presentation this evening. And thank you to everybody online, thank you for all your input and your questions that have come through as well. Have a lovely rest of your evening, everybody.
 
 
Aine:
 
Thanks, all.
 
 

Other RACGP online events

Originally recorded:

23 June 2021

This webinar will provide GPs with information about the real time prescription monitoring system being implemented in NSW and how it is intended to be used within the clinical workflow for patients who use drugs of dependence.

Learning outcomes

  1. Demonstrate an understanding of what the Real Time Prescription Monitoring system is and how it will be incorporated into clinical workflow
  2. Demonstrate an awareness of current best practice clinical guidance for managing patients using drugs of dependence
  3. Know where to access additional resources to improve knowledge and expertise for managing patients using drugs of dependence.
This event attracts 2 CPD points

This event attracts 2 CPD points

Presenter

Dr Hester Wilson
(FRACGP, FAChAM)

Dr Hester Wilson is a GP, addiction specialist and Chair of the RACGP’s Specific Interests Addiction Medicine network. Hester has many years’ experience working with people with addiction issues in both general practice and specialist settings. She also works in a public Drug and Alcohol Service in South East Sydney Local Health District. She is a Conjoint Lecturer and PhD candidate, School of Public Health and Community Medicine, University of New South Wales, NSW.

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