Extent of prescribed opioids and related harms in Tasmania

6. Extent of prescribed opioids and related harms in Tasmania

It is important to consider the issues associated with OTC CACCs within the broader context of opioid related harms. The use of OTC CACCs is a common pathway to opioid dependency.

As a result of their ease of access they are misused by people who are opioid dependent, often taking amounts far in excess of the recommend maximum dosage.  (17)

Tasmania has the highest rate of opioid prescribing of any state or territory in Australia. According to the Australian Atlas on Healthcare Variation, 73 641 opioid prescriptions were dispensed per 100 000 people for Tasmania compared to the Australian rate of 55 126 in 2013-14 (aged-standardised rates).

The local areas of Central Highlands, South East Coast, Brighton, and Hobart - North West were among the 10 local areas with the highest rates of opioid prescribing nationally.

Key factors associated with higher rates of opioid prescribing in local areas across Australia include lower socioeconomic status and regional areas (compared with major cities or remote areas). (26)

Pharmacists and medical practitioners in Tasmania are recognising an increasing number of people who are misusing opioids, especially codeine.

The total number of circulars issued by the Tasmanian Department of Health and Human Services Pharmaceutical Services Branch (PSB) regarding people identified by pharmacists or medical practitioners seeking drugs which are subject to misuse more than doubled between 2013 and 2016.

The overall proportion of circulars relating to CACCs also doubled between 2013 and 2016. In 2016 more 200 circulars where issued regarding people seeking drugs which are subject to misuse with around half of these involving codeine.

While the rate of opioid prescribing is high for Tasmania, there has been a recent reduction in the average Oral Morphine Equivalent Daily Dose (OMEDD) of 60 per cent between 2004 and 2015 with respect to the prescribing of opioids for chronic pain patients.

National Schedule 8 reporting data obtained from the Commonwealth supports this data and indicates for the past five years Tasmania has fallen from well above to below the national average OMEDD in grams per 1 000 people for the six most commonly used Schedule 8 opioid analgesics. (27)

There is a significant burden on Tasmania hospitals associated with harms related to prescribed opioids. The number of hospitalisations a year to Tasmanian hospitals with an opioid related diagnosis has steadily increased from 29 admissions in 2011 to 61 admissions in 2015.

This is likely to be very conservative given the limitations of case finding, clinical recognitions and coding related issues. During this period 66 per cent of admissions related to codeine, morphine or oxycodone. (28)

National Coronial Information System data shows that national codeine-related deaths more than doubled between 2000 and 2009, during which the consumption of codeine increased significantly.

For every two opioid related deaths due to strong opioids (Schedule 8), there was one codeine related death. While most codeine related deaths involved multiple drug toxicity, OTC sources of codeine is recognised as a contributing factor to many deaths. (29)

Prescribed opioids contribute to many preventable deaths per year in Tasmania. Between 2005 and 2009, before the implementation of the Drugs and Poisons Information System Online Remote Access (DORA) real time reporting system, an average of 25 deaths per year in Tasmania were related to prescribed opioids.

After the implementation of real time reporting, the number of deaths in Tasmania related to prescribed opioids reduced by a third to an average of 17 deaths a year between 2010 and 2014 (27).

The technology used in Tasmania to monitor Schedule 8 dispensing events has been supported by a collaborative clinical-regulatory approach between PSB, addiction specialists, general practitioners and pain medicine specialists.

The National Drug and Alcohol Research Centre (NDRAC) Review of Opioid Prescribing in Tasmania Report (2012) recognises many of the key system-level drivers of opioid prescribing and related harms in Tasmania.

This report provided 61 recommendations to address this issue. Since the report was released, many of these recommendations have been implemented across the health system in Tasmania. (30)

7. Overview of opioid regulation in Tasmania

The Tasmanian Poisons Act 1971 (Act) provides a legal basis for protecting clinical and public safety in relation to the handling of drugs and poisons.

The value of this legislation in supporting good clinical practice is often under-estimated, and sometimes criticised as unnecessary red tape.

The Commonwealth’s Poisons Standard consists of decisions regarding the classification of medicines and poisons into Schedules for inclusion in the relevant legislation of the States and Territories.

It provides the framework for uniform scheduling of substances and uniform labelling and packaging requirements throughout Australia. The Poisons Standard is the legal title of the Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP).

The SUSMP is adopted by reference in Tasmania. Further information can be found at www.tga.gov.au/scheduling-basics. Of particular interest to healthcare are Schedules 2 (Pharmacy Only), Schedule 3 (Pharmacist Only Medicine), Schedule 4 (Prescription Only Medicine) and Schedule 8 (Controlled Drug).

Schedule 8 substances are of particular public health interest. These substances have tight controls within clearly defined clinical boundaries as they are substances of such danger to health as to warrant strong regulation of sale, supply and use.

Examples of these substances include oxycodone, morphine, fentanyl, buprenorphine. Codeine is a Schedule 8 substance when not in combination with other Scheduled substances.

Long term prescribing (more than two months) of Schedule 8 drugs such as strong opioid analgesics requires an authority in Tasmania, issued in accordance with specific provisions within the Act. There are some substances and instances where authority is required before prescribing.

A small team of DHHS pharmacists are appointed as delegates for the purposes of administering the Act and issuing authorities to prescribe. In order for an authority to be issued, a doctor must provide sufficient information demonstrating the proposed Schedule 8 prescription regimen meets quality and safety standards.

While the focus quite understandably is on the safety of the regimen, in Tasmania processes for the regulation of medicines which are subject to misuse has evolved into a broader set of metrics and joined up clinical-regulatory processes that are focussed on best (evidence based) clinical practice, particularly in the clinical management of persistent non-malignant pain and concurrent opioid dependence.

Following receipt of an application, if the delegate identifies a particular patient is at higher than standard risk, they will seek the advice of a consultant medical officer.

Those patients demonstrating particularly complex pain conditions and high risk behaviours concerning their prescribed and/or non-prescribed drug use or management are referred to an expert advisory panel consisting of a pain medicine specialist, addiction medicine specialist, general practitioner and one or more of the delegates.

This panel scrutinises available, relevant clinical information and provide advice to the delegate.

The pain specialist(s) focus on whether the current or proposed medication regimen is likely to be effective in treating this patient’s pain in the context of current best practice and where feasible, considering what might be appropriate in the context of a broader multimodal, multidisciplinary treatment framework.

The addiction medicine specialist focuses on whether this regimen is likely to be safe and appropriate in the context of any evidence of concurrent drug dependence and associated clinical and/or public health risk.

The GP focuses on practical matters eg will the applying GP be able to be safely manage the proposed regimen in the primary health care setting.

A recommendation may be made for further specialist assessment in order to map out a best practice treatment approach.

This real time information is made possible by Tasmania’s leading edge work in developing DAPIS (its Drugs and Poisons Information System), available to all medical practitioners and pharmacists in Tasmania through a light version known as ‘DORA’.

DAPIS and DORA formed the basis for the development of a National Electronic Recording and Reporting Controlled Drugs (ERRCD) System which the Commonwealth Government has made available to all states and territories with a view to establishing a nationwide real-time reporting of controlled drugs system.

8. Implications for Tasmania

The rescheduling of codeine will result in significant public health benefits in Tasmania.

Key tasks for the CRIG will be to identify the implications (challenges and benefits) of codeine rescheduling for individuals and the healthcare system, and to develop actions to maximise the short, medium and long term public health benefits.

The following questions will help members with these tasks:

  1. What are the challenges resulting   from the rescheduling of codeine for individuals using OTC CACCs?
  2. What are the benefits resulting   from the rescheduling of codeine for individuals using OTC CACCs?
  3. What are the challenges resulting   from the rescheduling of codeine for pharmacists and GPs to provide safe and   effective care for individuals who use OTC CACCs?
  4. What do pharmacists and   GPs need to provide safe and effective care for individuals who use OTC CACCs?
  5. Do   other health professionals such as medical specialists, allied health   professionals and dentists need support to provide safe and effective care   for individuals who use OTC CACCs?
  6. How   we will know if we have been successful?