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SafeScript NSW – One year since the statewide launch

SafeScript NSW: One year since the state-wide launch
 
Jovi:
 
So good evening everyone, and welcome to tonight's webinar, SafeScript New South Wales - one year since the state-wide launch. I am Jovi, your host for this evening. And before we get started, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online.
 
I would like to introduce to you our panel for this evening. Firstly, we have our facilitator, Dr Hester Wilson. Hester is a GP, Addiction Specialist and Chair of RACGP Special Interest Addiction Medicine. Hester has many years’ experience working with people with addiction issues in both general practise and specialist settings. She the Lead Clinician of the GP Liaison in Alcohol and Drugs project in South East Sydney Local Health District. She is also a conjoint lecturer and PhD candidate School of Public Health and Community Medicine in University of New South Wales.
 
On our panel tonight, we have Dr Gunjan Singh. Gunjan completed her postgraduate medicine with Monash University, an obtained her FARCGP in 2020. She believes in empowering her patients with education and fostering a team mentality towards health issues by involving her patients throughout. Gunjan has a strong interest in building wellbeing for patients with a holistic and total approach to patients, their family and our wider community.
 
Scott Walters is and experienced pharmacist, having worked across the acute and primary healthcare sectors both in Australia and overseas. As both a pharmacy provider and University of Sydney pharmacy tutor, he has mentored many students through their early pharmacy careers. Scott is now focused on expanding the future of healthcare through integration of services across the primary and secondary healthcare networks via his role in the PHN with the ultimate goal of delivering patient centred care.
 
On our consumer panel for tonight, we have Kim Allgood. Kim is the President of CRPS Awareness, which is the Purple Bucket Foundation. Kim has been working in the not for profit sector for over three decades and is the President of the registered health promotion charity, having also served at executive levels in a number of community organisations. So welcome everyone this evening.
 
I will just go over the learning objectives for tonight. So by the end of this online CPD activity you should be able to utilise the SafeScript New South Wales system to analyse and interpret the patient's history to inform best practise patient outcomes, recommend when to seek advice or make referrals when required, demonstrate how to use functionality that will be introduced in SafeScript New South Wales in 2023, and demonstrate an awareness and understanding of authorities to prescribe or supply particular medicines in New South Wales, including the introduction of new application forms.
 
I will pass you over to our facilitator, Dr Hester Wilson.
 
 
Hester:
 
Thanks, Jovi. Thank you so much, and welcome to everybody this evening and welcome to our wonderful panel. The first thing that we wanted to do see if I can get my, okay, is to have a poll. So just the first poll, have you used, very simple, have you used SafeScript New South Wales before? So just a yes or a no. Hopefully there is nobody out there that does not know, but you know, please, just to give us a bit of a sense of for everybody that is coming out there tonight, what are we looking at?
 
 
Jovi:
 
Give it another 10 seconds.
 
 
Hester:
 
I think we might have just about everybody. I think that might be 100% there, if my maths is right.  And so we have got about two thirds who have used it and two thirds who have not. Well that is totally brilliant. It is really great that there are people coming along tonight who have not used it. Hopefully by the end of it you will be signing up and have a better understanding of when it is going to be useful for you. So that is really brilliant. I am going to move now onto the second poll. And this is for those who have used it, and maybe if you have not, if there are reasons why, the biggest challenge. So it is just one, you have got to choose one that is your biggest. I do understand there may be multiple reasons, but please choose your biggest challenge, so that we have got an idea. And there are more, further down. Nice to see there is a percentage of people that have got no concerns or challenges. And no one so far is concerned about lack of support or education, and no concerns over privacy.
 
How we going, Jovi, with the numbers?
 
 
Jovi:
 
Yes, we have got 100% answered. So I will just share results.
 
 
Hester:
 
Yes. Yes. So, what we are seeing is that for 25%, there is some issues with logging in. So we can go over that this evening. Integration with clinical software, data accuracy, slowness of the system, knowing what to do in response to an alert. Hopefully we will be able to give you a really good basis on how to manage that. Conversations with patients taking monitored medicine, absolutely acknowledge that that can be tricky, but once again, hopefully by the end of tonight you will feel more comfortable. There are three people who said because of other issues and almost, one fifth said no challenges or concerns. That is really fantastic. So I am going to move on from there.
 
So first of all a bit of background, and this probably is directed at the one third of you who have not used the system. A real time prescription monitoring system. So it is around giving you access to real time information around the medications that your patients are accessing through you and through other providers, and both prescribers and pharmacists, whoops, sorry, I do not know why that went forward. Jovi, can we just move that back? Does not seem to want to go back for me.
 
 
Jovi:
 
Sorry, just one second.
 
 
Hester:
 
Yes. I honestly did not touch it, it just moved on sorry. But both pharmacists and prescribers have access to patients’ prescriptions for specific high risk medications such as opioids and benzodiazepines amongst some of the others. And this information is collected when it is put through your systems if you are using an electronic prescribing system and also through the pharmacy systems that are used when they dispense. If a prescription is handwritten, it will not turn up until it is actually dispensed through the pharmacy system. The other really important thing that people often ask, this includes private scripts as well as PBS. So you are going to get all the scripts turning up there. The only way that they could slip through it is if it was a handwritten script and it happened to go to one of the very few pharmacies and it is kind of, I think it is around 99% of pharmacies now in New South Wales that are using the software that goes straight into the system. So it would be very, very uncommon for someone to slip through. And we do have integrated clinical software that integrates well into Best Practice and Medical Director. And now maybe the people who are saying, look, I am having problems with the interface, it might be that you are using a different software system. And that will come up when you prescribe, it will come up and flag it. So even in your software as you are using, it will come up and flag it. The other way that you can do it if you are not using a software where it integrates, or there are reasons why you are not integrating it, is you can do it directly through the SafeScript portal, and that is pretty easy to use as well.
 
The whole idea of it is, it gives us real information that helps us to make safer decisions so that we do know what our patients are using, so that we can look at what is going on and make sure that what we do is safe. It does not tell us what to do and we as prescribers and pharmacists as dispensers know our patients well and we may have very good reasons why something that comes up and is flagged in the system, it is appropriate to prescribe. But what it does, is if it comes up, it is a moment to reflect and think, oh, is there something that I need to think about here? Is there something I have forgotten, or is there something going on that I did not know about? And I would really encourage you, you know, if an alert comes up, do record it and do, if you are going to continue to prescribe, do actually put in your clinical reasoning around why you are continuing to do that prescribing. The other thing is that there is lots of good support at the time on the website and for the training and this webinar tonight that can give you some ideas around how you might respond to that. Okay. I do not think I can change slides anymore, Jovi.
 
And just flagging, there is more information that Siva has just put down there on SafeScript.health.nsw.edu and there is a lot of really good information there. The other thing I should flag for those of you that are not aware of it, is that there is a 24/7 phone line so that if you have got any issues, you can actually ring and ask for advice as well. So we are going to move on to the panel discussion because we want this to be the majority, of the… Did we miss a page there? Sorry. No, we are in the right place. Okay. Sorry, something just flashed up. So we want to spend the majority of the time looking at a clinical case and talking through with myself and Gunjan and Scott and Kim around how we can respond to that.
 
Okay. So next slide. I will see if I can move it. No. Okay, here we go. Here is the case study. This is what we want to look at. So Janet is a 44-year-old. She is a patient of a retired colleague in your practice, so you have not seen her before. You are seeing her for the first time, but you have access to her records. And when you open it up, so she is coming in asking for more medication, there is a red alert that says, look, there is a high dose oral morphine equivalent dose, daily dose, that has come up. When you look at what she is prescribed, she is prescribed oxycodone 40 milligrams twice a day, Endone 10 milligrams twice a day, and that is been for at least the last six months. She initially commenced on a lower dose in an emergency department after extensive superficial abdominal burns three years ago. So really painful, really appropriate to be started on opioids. However, she stayed on the opioids since that time. She was started on the lower dose and what we have seen over time is that that dose has crept up. She has been attending the same practice and the same pharmacy regularly. And when you look in the system, she is not accessing medications from other prescribers. It is all come from your colleague and it is all picked up from the one pharmacy. There is no other prescribed medications. She does have a history of postnatal depression. She is a non-drinker, non-smoker and is pretty fit and well. So I wanted to come to our panel, and guys if you want to turn your cameras on and come and join me. First of all, I want to come to Scott as the pharmacist. Just thinking about if you had been sent this script and it came up in your pharmacy software, what would be your approach?
 
 
Scott:
 
Yes, look, thanks Hester. I think in this particular scenario we do have an advantage in the sense that this patient attends the same practice and pharmacy regularly. So, we know this particular patient. I would be using that as an opportunity to open up the conversation about the pain management and how that is going and how are you finding the management of your pain, general mobility, acknowledging that over time we have noticed a bit of an increase in dosage since you were first prescribed the medication. How do you find managing the side effects? How do you fit taking the medication into the routine of your daily life? There are options available in how we can manage the pain through a number of means of which medication is one such way, but that can also be carried out in conversation with your GP as part of a combined case conference conversation, for example. I think what is important too is carrying out this conversation in a secure private manner, not across the pharmacy floor or in front of other patients there as well. And making it really clear that this is not a conversation about stopping supply or withholding the medication in any way. But it is a discussion about how to best manage the pain of this particular patient and improve their quality of life moving forward. So for me it is all about the approach in how you can manage these particular scenarios and I personally do not consider it as policing, but I consider it a tool to help guide a conversation with the patient.
 
 
Hester:
 
That is fantastic. So if you saw this, would you be calling the GP? Let's imagine for a moment that it is Gunjan. Would you be giving her a call about this? Or how would you approach it?
 
 
Scott:
 
So for me that would follow up off the back of the conversation with the patient. I start there with the story around this, you know, what particular vibe or story am I getting from that particular patient? Does this all add up? Is this reasonable at this point in time? Has there been some sort of complication that has added to the potential pain management of this patient, which would make this seem reasonable at this particular point, then absolutely I would be comfortable in going ahead with this. However, if I felt that there was more that I could gain from this, more that could be added to the story to the value of the patient, that is when I would be giving Gunjan a call. And you know, particularly if we are all in the local area and we know one another, that is of real great value in building that healthcare neighbourhood approach and just giving Gunjan a quick call and saying look, I have noticed this, what were your thoughts on it? And she might be able to provide me with some insight that I was not aware of that might help guide the conversation. Or equally she could say, oh yes, I actually did not notice this particular thing, or actually now that you mention it, I was considering that at the time as well. I am glad you picked that up. It could go in a number of directions. So it really depends on a series of points of contact and information that is provided for me.
 
 
Hester:
 
Yes. Look Scott, I think it is, you know, certainly my point of view as a GP. I love my pharmacy colleagues because sometimes they pick up things that I miss, and I love the call from the pharmacist saying, hey Hester just wanted to check, you know.
 
 
Scott:
 
It is a team based care approach isn't it?
 
 
Hester:
 
Yes, exactly. Though I do hear some of my pharmacy colleagues saying doctors do not listen to me, or they do not take my calls or what would you have to say about that?
 
 
Scott:
 
Look I think in any profession in any line of work you have, and any person has bad days as well, in how things might be interpreted or spoken to. So I do not think that is reflective of any profession really. I think that just might be a particular incident, and overall that does not really phase me in the approach that I take. Because if you are coming from a place of genuine concern about the patient’s care and you have taken the due steps and I am saying hey Gunjan I have had this, I have noticed this history, I have spoken to this patient and this is why I am calling, I think that is a pretty reasonable approach that you know, most could not really deny why that call was made.
 
 
Hester:
 
Thanks, Scott. Gunjan, coming to you, first of all, I am sure that if Scott rang you, you would not ignore him.
 
 
Gunjan:
 
No.
 
 
Hester:
 
I just wanted to step back for a moment and let's pretend for the moment that Scott has not seen this prescription and has not given you the call, but you are in this situation where you are seeing Janet for the first time. And you are looking at this script and you open up the computer and you are looking at it and up comes that red alert, what would be your response?
 
 
Gunjan:
 
Yes, I think this case study actually is right up my alley because I have been in this exact situation in the past, and I think the approach that I had decided, you really kind of have to prepare yourself, I feel, especially if you are taking on, you know, patients from another doctor that might have been there 20-30 years and you know, the comfort level that this patient will have with that GP, there is a real loss there sometimes. There is a real grieving process of a retiring GP. So I take a moment to look at the history, go back, look at all the system notes and you know, how often the prescription has been made. And it is also really lovely to see that, you know, she has got the one practitioner, one practice, one pharmacy. So I take a bit of a step back approach and think, okay how would I feel if I was in this situation? So when I bring the patient in, I introduce myself and I say I do recognise that, you know, your doctor has retired. I am just looking through the file. I am familiarising myself with your history. Can you give me a bit more information on what is going on? Let's paint a picture here. And that I think gives the patient an opportunity sort of to give us their perspective on how things went, how things are, how, you know, they would like things to be. And that gives me a better understanding on where am I trying to take this patient, what should be the focus. And the first appointment, I mean, I could imagine the lady is probably a bit anxious seeing me in the first place. I would have taken a really gentle and sensitive approach. I think empathy will get you far and beyond.
 
And I totally, totally agree with Scott. This multidisciplinary approach is supremely useful. So even when the patient has left, if I have got questions or I am not sure, often I will call the pharmacy and say, hey, just wondering, I saw so-and-so, when was the last time you saw her? How did she look? You know, were things okay? This is what I came across today and what do you think? And I think just taking sort of a gentle approach with the patient step by step.
 
 
Hester:
 
So with this dose, which is 100 milligrams of oxycodone a day.
 
 
Gunjan:
 
Yes.
 
 
Hester:
 
It has been flagged up as high dose oral morphine equivalent dose. So that is probably an oral morphine equivalent dose of about what, 135, something like that?
 
 
Gunjan:
 
Yes, and on the SafeScript system, it probably would come up as a red alert.
 
 
Hester:
 
It has come up as a red.
 
 
Gunjan:
 
Yes, it is not going to be an amber, it is going to be red. And I think practitioners really have to, you know, it is just as scary for a GP. There is a red alert on your system. You might think, oh, what have I done? Am I going to get in trouble? I have been prescribing this medication. And then same for the patient, they are probably thinking, you know, what is this? I have not been doing anything wrong. I have been getting my script from the doctor. And so I really try and again go back to that team approach. I will often turn my screen and show the patient exactly what I am clicking through. I would like to keep it really transparent because there is a bit of a secretiveness when it comes to SafeScript. And to be very honest, I do not think patients have got enough education. I think Kim will speak to this as well, where consumers do not seem to understand it is not their fault. I do not think we have gotten into that zone of really educating the patients as well on what is SafeScript. To some people, it is almost like, you know, in the US where they can look into your files and they know where you are going and what you are doing. It is very secretive. So I try to break that barrier down. I will turn the screen. I will show them, look, this is what the system looks like. All it is doing is telling me, hey, Gunjan, just be careful, these are some higher doses that you are playing with. Talk to your patient about it. And then I will talk to the patient and say, so, did you know that, you know, this is a bit of a higher dose? How do you feel about that? And a lot of the times patients turn around and go, oh, I was not aware. I know that my pain is not being controlled, and every time I have told Dr X what she suggested, oh, hey, maybe we try a bigger dose. But perhaps they have not delved into the deeper conversations on what does that mean, tolerance, you know, abuse, all of that sort of stuff. And you have to do it so sensitively.
 
 
Hester:
 
Yes, yes, yes.
 
 
Gunjan:
 
But if you ask me what I, and I do not know if this is coming up later, but as a first time doctor seeing this patient and the other GPs should be confident in knowing that yes, it is a red alert, but you are the clinician. So if you can justify why this patient needs to have their medication and it is at this dose for this time, for this script, then I would have actually gone ahead and done that and then made follow up plans on what do we do from here. Let's make an appointment. Let's get a long appointment. Let's discuss what does this mean.
 
 
Hester:
 
Yes. So, Gunjan, what you are saying is red does not mean stop. Red means think about it.
 
 
Gunjan:
 
Yes.
 
 
Hester:
 
Have a conversation. Really, it is an opportunity as Scott said, to re-evaluate and to look at what is going to be best for Janet. I will come back to you, but I wanted to go to Kim. Kim, in a way, you are the most important person in this webinar tonight because it is so important for us as practitioners not to forget the consumer or the patient’s experience and I would love you to give your sense of first of all, how do you think Janet might be feeling, what might be going on for her and what would be most helpful for Janet in this, what could be a quite tricky conversation?
 
 
Kim:
 
I believe in this situation from what I have been told, somebody is going to a new doctor once their doctor has retired, they would be frightened, they would be expecting the new doctor to be ready to be taking their medicine off them, they would be on guard, they would be defensive, the walls would be up and they would be ready for a fight. So it would be a very, very frightening situation for them. So, yes, a red alert coming up would just make it more frightening. So yes. And as Gunjan said, the education about SafeScript for the consumer is not really there. So having doctors explain the way that it works is what they need, because I am still hearing this do not punish pain stuff that is going around and that is not what SafeScript is about. It is not about punishing the pain patient, it is about helping the pain patient, so the education is required. So having doctors explain it to them is a much safer way of going.
 
 
Hester:
 
And Kim, just thinking, what for you are the important factors that doctors need to explain to patients? What do we need to be aware of to make sure that we are getting all the information patients need?
 
 
Kim:
 
I was thinking about this today. It is a little bit like smoking. A long, long time ago people were told that smoking was great, and now we know that it is not. We used to be told that this pain medicine will help you, and now we know that it is only good for a short period of time and then it starts to do damage. So we need to change the way we talk about how long we can be on it for. So maybe we just need to change the way we communicate about pain medication. So it is not good for you, it is damaging your body. So maybe if we can explain pain medication in that sort of way. I am not sure. I do not know how to do it.
 
 
Hester:
 
Yes. Because Kim, it is one of the confusing things I think for someone like Janet, who is you know, coming to the one doctor, doing exactly as the doctor has told her, you know, and may not even know what the medication actually is, to suddenly then be told well we are going to stop it. It is like well, what have I done wrong? Why has this changed all of a sudden? You know, so yes, so it is a tricky one. Coming back to you, Gunjan. How might you explain that?
 
 
Gunjan:
 
I try to gauge what the patient’s understanding is first, and I have seen all manner of people, I am sure we all have patients that you are right, do not even know that it is morphine. So they might know it as a brand name, they do not know that there is morphine in it. And all the way up to the patients that are very well aware of what it is but are having difficulties coming off the medication and maybe need extra support. But I do try to explain it really simply, and exactly as Kim said, it is such a, I really actually really like that analogy, where we have come to know more, and what we know is that temporarily for acute pain these medications work really well. But overtime, what happens is that you end up needing more and more of the medication for it to do the same job. What it does also do is interfere with other things. Now if you have got things like depression, if you have got, you know, other medications that you are on, it is going to interfere with those things. So ultimately what we want to do is actually deal with the problem, not mask the problem with the pain reliever. So I try to sort of shift the focus, if you will, back on the problem away from pain so much, and say where did this pain come from, what should we do about that? Who can we enlist to help us? You know, have you ever seen a pain specialist? That sort of thing. So then I am not just talking about the pain all the time or the medication, but I am very clear in explaining that we need to come up with a plan. Let's come up with a plan together. Even if we come down by, you know, 2 milligrams, 5 milligrams, you know, every fortnight. Let's come up with a plan together and see how you are going. And there is a lot of support required. There is a lot of follow up required to make sure that if you are going to make changes, you empower the patient with enough information and enough support, and you do your regular follow up so that they are not going into withdrawal and other things.
 
 
Hester:
 
 Yes. So, Gunjan, I just wanted to come back. She was started on oxycodone in the emergency department three years ago for superficial abdominal burns. Why is she on the medication now?
 
 
Hester:
 
Yes. Which is also a little bit strange, isn't it? Yes. And that is where the story becomes so important. And it is really important not to assume that the ED has done the wrong thing, or the retired GP has done the wrong thing, or the patients done the wrong thing. I think it is very important to start on a blank slate and say, you tell me the story. I am here to help you. But I also want to be honest with you and tell you that these things in the long term, really are not very good. So let's work on this together.
 
 
Hester:
 
Kim, you have got to unmute yourself.
 
 
Kim:
 
I was just thinking though, where you said about the superficial abdominal burns three years ago, Janet has also got a prior history of postnatal depression, so we need to look at that story.
 
 
Hester:
 
Exactly, exactly. We need to understand more about it because I look at that and I think, the superficial burns have healed, what is going on, that Janet is still on oxycodone? Is there more to this story? Is there other chronic pain? Or is, as you say, are there more complex life issues, for example, the depression, anxiety, what is going on?
 
 
Kim:
 
The pain might be in the abdominal area, but it might be a much, much deeper pain than pain painkillers can fix.
 
 
Hester:
 
Well, and also I mean I am aware that you are part of the Complex Regional Pain Syndrome Awareness.
 
 
Kim:
 
Oh I am not thinking that.
 
 
Hester:
 
You are not thinking of that? No?
 
 
Kim:
 
No, not at all. No, far from it. I am thinking more along the lines of a mental health issue. The postnatal depression and beyond that. 
 
 
Hester:
 
And certainly chronic pain is a very complex human experience. It is not a simple thing. Scott, I just wondered if you had any thoughts about this?
 
 
Scott:
 
Yes, look, I was just thinking too and reflecting on Gunjan's comments around, you know, wanting to direct the conversation about the story behind this and be a bit less about the pain and less about the medication. Because particularly if patients might be aware of SafeScript or had an experience that was a negative one with it in the past, they might have associate a red flag or something to that effect with stopping of their medication or, you know, some sort of negative approach to their pain management. I try and frame in these particular scenarios with the patients that there is a red flag, that is the flag for me that I need to have a closer conversation with you and take some time out to have a conversation with you about how you are managing everything, not just this particular pain or this particular medication, how are you managing everything in your life of late, that forms that picture. So it is a flag for me to say, hey Scott, take some time out to talk to this patient in more detail. So again, taking it away from being about them, something that they may have done or not done in order to end up with this flag, but it is about flagging me to be able to sit down and have a conversation with you.
 
 
Hester:
 
I think the other thing for me, Scott, it is around flagging, it is the medication itself. You know, as Kim was saying in the past we thought it was going to be really helpful, but what we know now is that it is limited in its help when you have been on it for a period of time, and it can cause problems of its own. And so we need to understand how the medication might be affecting you, how it might be as Kim says, be affecting your mood and whether we have got the best possible management for you, for your health and your wellbeing.
 
 
Scott:
 
That is exactly right.
 
 
Hester:
Sorry, Scott.
 
 
Scott:
 
No, I was just going to say that is the point too when you assess how far they are along the road with that as well, are they absolutely not up for that today? This is you know, not entertaining that particular theory, in which case, you know, you can try with them again next time and approach that. And other times you work a little bit or you work a little bit the next time, and they are willing to open up to other options, you know, other potential forms of treatment, a conversation with their doctor, et cetera and so on and so forth. So it is about measuring that level of hesitancy versus willingness to be able to change as well. And I think that SafeScript is like an enabler at that point to be able to give you the opportunity to have that conversation.
 
 
Hester:
 
Absolutely. And I think coming back to what Kim was saying, that if people are very fearful or scared, how much information are they going to take in on that first consult?
 
 
Gunjan:
 
Exactly.
 
 
Hester:
 
It is not, you know, you have got to think how well does your brain work?
 
 
Gunjan:
 
I think you have to play the chess pieces really well. You have to focus on the appointment to first gain that trust and rapport, because if you do not have that, I mean this patient can go away and probably find somebody else to prescribe. You know, realistically she probably can. But having that really sensitive approach and focusing away from just, you know, oh, why are you on this and making it all about the patient, I think letting the pain and the pain meds be the beast, which is the truth, and the patient, the sufferer, the victim in this, I think is a gentler approach.
 
 
Hester:
 
So what you want to have is that conversation just saying, look our understanding of this has changed. You are on a dose that is more risky. And what are the risks? How would you explain the risks, Gunjan, to a patient on this dose?
 
 
Gunjan:
 
Well at a dose this high, I mean even simple changes such as a common cold infection, things can really affect the way that your body has used these medications. In certain situations the medications can be absorbed to a higher level. They can cause even coma in some patients. And that is the thing, I mean I am assuming this is not going to be done in the first appointment, because that is really going to freak the patient out. But I think giving some written information rather than giving them a whole bunch of scary things that can happen with this medication is very important. And using SafeScript for the fact that it is called SafeScript, talking about this combination that you are on, the worry is that there are interactions happening that can be really detrimental to you. Let me print something out so you can have a bit of a read. Let's get you back in here and then we can talk about it a bit further. But I do not think it is helpful to say, you know, this can happen to you and this can happen to you. I am not sure about, yes, doing it that way.
 
 
Hester:
 
I guess the only thing I would say though, I mean, and when we look at Janet, she is young, she is a non-drinker, non-smoker, and no other health issues. Really the only thing we have got there is that postnatal depression which is important, you know, and you are absolutely right if she has got a chest infection that does increase her risk of respiratory depression. But as the dose goes up so does your risk of respiratory depression. But she does not have the other health issues that increase her risk. So it is really important that we are starting to gently make that assessment of the individual's risk. Do they have cardiovascular issues? Do they have respiratory issues, do they drink a lot of alcohol? Are they on other sedating medications? What are the other things that will increase the risk? Please. Sorry, I interrupted you.
 
 
Gunjan:
 
No, you are right, absolutely. And you know, I mean, I know it says postnatal depression there, but some patients are still on antidepressants and it is labelled as postnatal depression. So it is very important to think about that and whether there is an antidepressant involved in that whole mix. Are there sleeping tablets involved? There is stuff you can get off the pharmacy. Doxylamine, I believe is one. You know, you can mix that in, patients can get temazepam and things as well. So that is something to look up, which you can see on SafeScript who has prescribed what. And it is not so you can say, hey look, you know what is here? It is more if it comes up, I often go, oh, when was the last time you used this? You know, has that helped you? And it is more a curiosity. It comes out of curiosity where I am not sure, you are educating me about this whole scenario. It works a lot better. And I think patients are more open to that than to hear about the negative side effects of these types of drugs. I mean, she might even be constipated. You know, like even something as simple as bloating and constipated for a 44-year-old woman. I mean I do not know if she is nearing menopause, is there mood and sleep problems going on? Then on top of that, she is on this medication as well. So there is a whole myriad of things that you could talk about. But yes, take a holistic approach as they say.
 
 
Hester:
 
Yes, I mean, certainly we do not know much about her. We do not know if she is working. We do not know if she is got kids. We do not know, you know, has it become clear that the medication is affecting the quality of her relationships? You know, so her ability to be in relationship perhaps with a partner or husband, and to care for kids. You know, like what is going on for her that we do not know about. I did want just Gunjan, if it was a higher dose or if there were other medications that meant that the risk was higher. So at this dose you are saying look, I would be comfortable, we are going to have that conversation, we are going to spend a bit of time. If that is a higher and your concern about risk was higher.
 
 
Gunjan:
 
Your clinical intuitive bell is going.
 
 
Hester:
 
What would you do differently?
 
 
Gunjan:
 
Okay, so that is where SafeScript is so versatile. If your red alert comes up there, I forget what the actual wording is, but you can click on it and it will actually give you where things were prescribed, who dispensed them, when was the last time, how much. And I would have a look at that. And if I am thinking that this conversation is not going as swimmingly as I would hope, I would say, hey, can I get you to take a seat outside? I am just going to look through my system a little bit. I cannot find a few things. I will talk to my receptionist. I will bring you back in a couple of minutes if that is alright. Or I will make some excuse and I will make myself go outside the door and I will find another computer in the practice and I will figure out a way to kind of print it off and have a look in a different room. But there is many ways in which you can actually see what else the patient is on. And there might be times where you find that the story, the history, the patient is giving is not really matching up. And in those situations you do need to be prepared to say I am uncomfortable today to prescribe you these very high doses because of XY Z reasons that we have explained. In my situation, and I do not know this is right or wrong, but I often will also suggest that I am happy to give you five tablet. I will prescribe you four or five tablets, you know, whatever I can deem is a safe amount which is not going to send them to hospital and is not going to send them into sort of, you know, a whirlwind frenzy. And I will make them an appointment with myself before the end of those five tablets or six tablets what have you, so that they have security that we are going to come back to this topic and we are going to figure out what to do. But it is not appropriate I think often to just say, I cannot do anything for you. See you later. It depends. I mean there are drug seeking behaviours and be really honest. I mean, I have worked in a lot of different practices in a lot of really low socioeconomic areas as well, typically associated with the higher OxyContin uses and things like that, but generally by and large, people are trying to do the right thing. By and large people want to be heard and for someone to take the time and say, hey, I am really worried, what is going on here? Let's have a conversation. To take the time to say, did you know that this is actually pretty high? Are you experiencing this and this? And they go, yes, well actually, you know, I have not had a conversation with anyone, but I have been really feeling awful, you know, and I do not know what to do. So it might just be a conversation to start with, but I try my best not to push people off. I do not like that concept of see you later.
 
 
Hester:
 
And look, I think you know, that there is stuff out there about people doctor shopping and there are a tiny percentage of people who actually their business is doctor shopping, you know, and they get the medications and then they sell them on.
 
 
Gunjan:
 
 A very small percentage.
 
 
Hester:
 
Yes, but the vast majority of people who have, you know, there may be very good reasons why they are seeing different doctors. They may have a number of specialists in the picture. Or it may be that they have really complex, tricky issues, you know, of physical health and mental health and they are just doing their best to try and manage it. So really, you know, I love your approach, where you are saying this is people seeking help and I want to assist them. I wanted to just flag the idea of supervised dosing or staged supply. Scott or Gunjan, who wants to speak to that one quickly?
 
 
Scott:
 
Oh, look, I am happy to jump in a little bit on that because I was going to reflect on Gunjan's comments earlier about, you know, prescribing five tablets in order to give the patient something to be able to get them through, but to be able to restart that conversation quickly. The same applies for me in pharmacy as well. If I was really concerned, was not able to get in touch with the GP after hours in those particular scenarios late on a Friday night, those are the particular scenarios where if I did not know the patient and was concerned, I would give them a few days’ supply, getting them through to the Monday, saying this is where we need to speak to your doctor again. I would put a call through on the Monday morning to restart that conversation. But that was just following on from Gunjan's earlier comments.  
 
In regards to staged supply, I think that is a fantastic way to build that real team based approach. I have great relationships with my local GPs in managing patients really well on staged supply. It builds a great rapport. I must say from a pharmacist and patient perspective, it gives you a good understanding of their progress, how they are managing on their dosing as well, and a real trust is developed within the healthcare team. And you are able to give really comprehensive information back to the GP. We are able to say yes, this patient is really, I do not like the word compliant, but regularly attends, collects their medication on time, within the recommended dosing range, you know, even simple things like, they are paying on time or if for whatever reason they are not able to, they arrange an alternative method in which to collect the medication. So I think it delivers a lot of periphery and supportive information about the patient's general lifestyle, wellbeing and management of their issues that I find really helpful in managing their pain control.
 
 
Hester:
 
So when we are talking about stage supply, can I just get you just to describe quickly what we mean? Just so that everybody is on the same page.
 
 
Scott:
 
Yes, sure. So that might mean having a box of medication of which there is an arrangement made between the patient, the GP and the pharmacist to supply a couple of days medication at a time, for example. So it might be supplying three days of medication at a time, which the patient comes in regularly every three days to collect that new three days of medication. It is a joint agreement, which I think is the really important thing there between the patient, the GP and the pharmacy. And it just allows that regular supply of medication that they are not going to miss out, but there is also reduced risk of any sort of abuse, loss of medication, so on and so forth.
 
 
Hester:
 
I think it is also useful for some people who find that it is hard to manage a month’s worth of medication that they kind of get to the end of the month and they are running out. So it helps them to kind of manage that. And I think you are so right, the importance of the therapeutic alliance and the collaborative relationship as part of that. We do have a question here from Puya who says, the patient comes in and says I have lost my script and SafeScript is red. What do you do?
 
 
Gunjan:
 
So from a GP perspective, same sort of situation, it is come up as red. You can, once you play around with it, you will be able to see that you can actually click on a button that can give you a history of that patient’s prescriptions prescribed and dispensed. And if it is red but you know the patient, or you can see the history of the patient and you know they are getting scripts say every fortnight, what it might be saying to you, hey just be aware that this is a high dose and in some cases they might already have an authority prescription letter from New South Wales Health, they may not. It might be a conversation starter. But you can still prescribe that medication if you feel that clinically, contextually, it is relevant.
 
 
Hester:
 
But it may be once again where you might do staged supply because it may well be that that person is homeless, or has insecure housing, or it is difficult for them.
 
 
Gunjan:
 
Or they are new to you.
 
 
Hester:
 
Yes. But once again I think you have really got to do that assessment. So if you look on there and you see the person is accessing lots of medications from elsewhere and they are saying I have lost a script, give me another one. It may well be that the right answer there is to say I am really sorry, I can’t, or I am going to send the script to the pharmacy and you are going to need to see them daily. Potentially. Kim, I just wanted to get your feedback on those ideas.
 
 
Kim:
 
When it comes to the lost script, it is a hard one, and I agree with the maybe seeing the pharmacist daily. I have a big problem with the lost script that is collecting medications and building them up. So, yes, I understand people lose scripts. I know that happens. But I also know that people like to collect medications if they have other plans. So yes, see a pharmacist for controlled supply is a great idea in those situations. So I know it sounds judgmental, but I work in the suicide prevention space. So yes, it would be one.
 
 
Hester:
 
It is about risk, isn't it? It is really about risk.
 
 
Kim:
 
Absolutely.
 
 
Hester:
 
And if we are talking about people hoarding scripts, you know, it may well be that it is because they have suicidal ideation, or it may be because they are worried that their scripts are going to be taken away from them. So the other really important part I think is really flagging to that patient, I am your GP, I am in this for the long haul, and I will do what is safe and let's work on this together. We do need to move on. There is a question here, if red flag shows, the patient denies she has seen another doctor for an opioid prescription, is it possible to have system errors or is the patient lying to me? Gunjan no system is perfect. How would you respond to this? You are thinking, it is there in black and white and the person saying, no, that is not what happened. How would you manage that?
 
 
Gunjan:
 
Look, that is a really tricky one and I am very open when it comes to that sort of thing. I am just going to print the whole thing out and say this is what I can see. You know, as you can see on this there are multiple medications, da da da, and it is not safe for me to do this. And I will also often say that this is my, you know, this is just as much my credibility as for yourself, if they are combative. It is unlikely that there are going to be medications on there that patients have not actually gotten in their hands. So I do not think it is worth arguing with that type of patient, I think the document speaks for itself and it is very official. It has got all the important bits on there, the headings and everything, the medications and name of even the pharmacists that dispensed it. So I think that kind of ends the conversation there.
 
 
Hester:
 
Gunjan, I have to say it is not a perfect system. But I do not think it means that you just say, oh well, maybe the system is wrong, I will give it to you anyway. I have got a situation where, and it was a patient I knew well, who had quite complex health issues. She said, oh look, I got a couple of days of diazepam from my dentist and when we looked it up on SafeScript, it looked like she been given 50, and she went, no, I only got two. Okay, I rang the dentist and asked, and I rang the pharmacy and asked, and the dentist said no, I only ever give two and the pharmacy looked at their records went oh my goodness, we have made a mistake, it was only two. You know, so I think it is unlikely it would happen, but really it depends on your relationship with your patient as well, but you know, if there is something happening there, then there may be a good reason, but you know, it does not mean just doing what is easiest, but it does mean kind of you know, looking at it a bit closer.
 
 
Gunjan:
 
Sometimes you need to know how to get out of sticky spots. So just having a bit of an idea on, you know, it can get a little uncomfortable and so even just again doing that staged approach can get you out of those sticky spots sometimes.
 
Hester:
 
 Exactly, exactly. Okay. So there is a few questions there, but we have kind of, Chowdhury, we have kind of answered that first one, and we might come back to the second one from the anonymous attendee if we have time. I am just aware of the time. We are going to move on now from the case study and just talk briefly about the resources. So up in the chat have been the links through to the web page, but just remember that there are patient brochures, there is clinician guides, there is lots of information there. So please do go and take a look at it.
 
The other thing is that there is the resources on the website that we have seen, the quick reference guides and fact sheets, how to register for those of you who are finding it a bit tricky. Personally I work in different situations so some of them it is already in the integrated software, and for the others I use the portal, and I find both of them, now that I have been using them a bit really quite easy to use. I really encourage you to spend that bit of time getting yourself registered. It only takes about five minutes, and then make sure that it is, if it can integrate into your software in your practice, go for that, that is super easy. Or using the portal is pretty easy as well. So there is a lot of information there just to help you with that.
 
Additional support as I said before the clinic advice line, they have got specialist pain and addiction and medicine specialists that can actually assist you and give you feedback. Health Pathways also has information in your local Health Pathways PHN.
 
This is just a quick thing because sometimes it can be a bit tricky when people think about authority, that there is the PBS Authority which is a federal thing, but there is also a New South Wales Authority, so that if you are seeing someone who is on a medication, it is a high risk medication and they are a person who is using drugs of dependence so that they actually have a dependency, They do need to get an authority. If they are a non-drug dependent person, they are prescribed high risk medications and it is going to continue for more than two months, you do need to get an authority. Now there are specific medications that you need an authority for in New South Wales, and others that you do not. But if you have somebody that is drug dependent already and you know the most use common thing would be somebody that is drug-dependent already, and the most common thing would be somebody who is on methadone or buprenorphine for their opioid use disorder, you do need to apply for an authority. And for others it is after two months. So just really wanted you to be clear that those two authorities can be a bit tricky and you may well be applying for both.
 
The other thing is that there are new authority forms that will be becoming available and an online authority management system. So, these are new and the forms are much better than the old forms. So, I really encourage you, and they are PDF on the website so you can fill them in, download them send them in, do what you need to do and they are much better than the old form. So I really encourage you to go and take a look at them.
 
The other thing is that the Therapeutics Goods Act for Medicines and Poisons is being updated and they are anticipating that this will be ready to go by the end of next year. And so it is really once again, they have been rethinking through it to make it more contemporary, to make it more responsive to issues that we are facing today. Now if you want to have a look at it and you want to be involved in the development and look at the draft, there is public consultation going on in the second half of this year. So if this is not your area and it is an important area, you know, please get involved in giving feedback around the changes to the Act.
 
So I wanted to come back. We have now got six minutes left. I wanted my panellists to come back on online and I wanted you to give you all cameras and yes, back on. Scott, you are first up. So I will ask you, just your take home messages for the participants tonight, the GPs attending tonight.
 
 
Scott:
 
Look for me, I think it is that SafeScript is a tool. It is not a piece of technology that decides the final decree on what happens with your patient. You know your patient best. And it is a tool to open up a conversation and for keeping the patient at the centre of the conversation and the best outcomes for them. I think you cannot go wrong.
 
 
Hester:
 
Great. And Gunjan, for you?
 
 
Gunjan:
 
Same thing. I think again, I will say that SafeScript is a tool and it is to be used to empower yourself and empowering the patient. Look at it in terms of not just your education but also theirs and in a team based approach I think is the best way forward.
 
 
Hester:
 
Fantastic and Kim?
 
 
Kim:
 
Well, rather than echo the other two, I will just say please use it as a tool to empower your consumers. The patients need to know what it is all about. I am hearing that they are not understanding. They want to understand, the majority of the people I speak to want to get off their opioids. Lots and lots of people who I have spoken to have come off their opioids, but they just feel like they are being punished. They do not want to be punished. They want to be helped. So, yes.
 
 
Hester:
 
Thank you so much Kim, because really it is around us as GPs, the fabulous thing for us is that we can see people over the long term, and being there for the long term for people, for these long term conditions. It is so important that we are working together to have the best possible management of their conditions to make their lives as, you know, as positive and liveable and as wonderful as possible.
 
 
Kim:
 
The one thing that patients need to understand more than anything, is if the opioid is what they need at the moment, then they are allowed to have it. If it is not the best thing for them, explain to them what is. But if it is what they need, then that is what they need. This is what they are not understanding. Do not take it away from me. It is the only thing that works. So that is what they are frightened of.
 
 
Hester:
 
Yes, fantastic. And I guess the other thing just thinking of Janet, once again coming back to, you know, we really need to be clear what the diagnosis is, what is actually going on here, what is really driving this. And a really important diagnosis not to forget is, has somebody developed an opioid use disorder or an opioid dependency because of the opioids that have been prescribed? Really important not to forget that. In New South Wales all doctors can diagnose this and can treat it with the relevant New South Wales authority with buprenorphine, either the sublingual or the injectable form. So I really encourage you to think about that as an option. There is good training online for that and there is also your local drug and alcohol services, as well as this this information line we mentioned before to help you make that diagnosis and help people. The really great thing about opioid treatment for opioid dependence or use disorder, is that it really works, and people do much better, of it is appropriate. And not everybody that has pain who is on opioids actually does have that diagnosis. But do think about it.
 
We have got a couple of minutes left and we have got somebody that is talking about, and Gunjan, this is probably one for you. How do you manage a patient who is taking Oxazepam 30 milligrams a day, using it for five years, how to do dose reduction scheme? What are your thoughts on that one?
 
 
Gunjan:
 
A lot of education. Oxazepam, I actually called the psychiatry line, I remember one time which is which is another very useful tool for a GP, because I was concerned this patient was taking it for sleep reasons. It is coming up again, what is the root cause problem, what are you actually using it for? Some of these patients have been on it for 20 years and they have no idea what it is actually doing because they do not know what a benzodiazepine is. So really going back to basics and explaining, and you would do very, very small incremental changes and sometimes I do, I mean, I do not know what tablets that comes in, but sometimes I even might give like a 20 milligram and a 10 milligram. Cut the 10 milligram in half and then you have got 20, you know, the 35 milligrams or whatever, and, you know, make up a routine for them which gets them involved as well in wanting to come down. But it is going to be a lot of education, finding out what the concerns of the patient are.
 
 
Hester:
 
Yes. So really it is around working together again.
 
 
Gunjan:
 
Absolutely.
 
 
Hester:
 
It is not actually a big dose, but it is understanding what is its benefit, what is the reason for it? How is it really helping? Long term benzodiazepines, there is no clinical reason for it. But once again it is working together collaboratively. The last thing before we finish from Chowdhury was, if a death happens with overdosing on an S8, would you be responsible medicolegally? Now Gunjan, I suggest that that might be, you know, you saying, look I would continue to prescribe. What are your thoughts on that one? In 20 seconds.
 
 
Gunjan:
 
Oh, yes. Are you legally responsible? It depends. How much did you give them? You know, did they have a mental health history? Did they express any suicidal thoughts? I believe everybody would have some responsibility involved and it would have to be looked at very carefully. And this is why you have SafeScript to look at. You know, what other things they are on and what does their own and how to bring that approach with your team.
 
 
Hester:
 
Yes, exactly. And what this points to is the need to do a very good comprehensive assessment, really document what you are doing so that there is clinical reasoning behind what you are doing. Do look at things like cutting the dose down, you know, really looking at the actual risk of the person, staged supplies, supervised dosing. And the other thing of course is naloxone. And that is a whole other area, but it is a spray that goes in the nose that if you are worried that somebody may be at risk of an overdose, that you can prescribe as well. It is a really good flag to them that this is not safe but it is also lifesaving.
 
I am going to finish it there because we are now 8:31. Scott, Kim, Gunjan, I wish I could have another hour chatting to you guys. It is been so fantastic. To our audience, you know, coming along to this and all your fabulous questions, thank you so much.
 
 
Kim:
 
Thank you.
 
 
Scott:
 
Thank you.
 
 
Jovi:
 
Thanks, Hester. So that is all we have time for this evening. So just a reminder that this is a CPD accredited activity and to be eligible for the CPD hour, you must complete the survey following this webinar. I will be sending through the copy of the slides to your emails tomorrow morning. I would also like to thank all our presenters and everyone that has joined us online. I do hope you have enjoyed tonight's presentation. Good night everyone.

Other RACGP online events

Originally recorded:

8 May 2023

The webinar will provide an update on SafeScript NSW, the state’s real time prescription monitoring system.

You will hear from health practitioners who have been using the system and learn about new functionality coming in 2023 that will allow prescribers to submit authority applications online to prescribe a controlled drug.

Learning outcomes

  1. Engage with the SafeScript NSW system to analyse and interpret the patient’s history to inform best practice patient outcomes
  2. Demonstrate an understanding of how to seek advice or make referrals when required
  3. Demonstrate an awareness of new functionality that will be introduced to SafeScript NSW in 2023
  4. Demonstrate an awareness and understanding of authorities to prescribe or supply particular medicines in NSW including the introduction of new application forms.

Facilitator

Dr Hester Wilson
FAChAM, Chair RACGP Specific Interests Addiction Medicine

Dr Hester Wilson is a GP, addiction specialist and Chair of RACGP Specific Interests Addiction Medicine. Hester has many years’ experience working with people with addiction issues in both general practice and specialist settings and the lead clinician in the GP liaison in alcohol and other drugs (GLAD) project 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.

Speakers

Dr Gunjan Singh
Principal Doctor, Crestwood Family Practice

Gunjan completed post-graduate medicine with Monash University and attained Fellowship of the Royal Australian College of General Practitioners (RACGP) in 2020. She believes in empowering her patients with education and fostering a team mentality toward health issues by involving her patients throughout. Gunjan has a strong interest in building wellbeing for her patients with a holistic and total approach to patients, their family and our wider community.

Scott Walters
Pharmacist, Pharmacy Tutor (USYD)

Scott is an experienced pharmacist having worked across the acute and primary healthcare sectors both in Australia and overseas. As both a pharmacy proprietor and USYD Pharmacy Tutor, he has mentored many students through their early pharmacy careers. Scott is now focussed on expanding the future of healthcare through integration of services across the primary and secondary healthcare networks via his role in the PHN, with the ultimate goal of delivering patient centred care.

Kim Allgood
Founder, CRPS Awareness - The Purple Bucket Foundation

Kim has been working in the not-for-profit sector for over three decades; she is presently the CEO of a registered health promotion charity, having also served at executive levels on a number of community organisations.

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