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• W2137677144 abstract "In recent years, there has been considerable interest in the misuse of pharmaceutical drugs, resulting in part from the large increases in mortality from prescription opioids seen in the USA 1. In Australia, there have been dramatic increases in opioid prescribing 2, 3, and coarse estimates of pharmaceutical opioid-dependent people have been in the order of 150 000 people, comparable with the number of heroin users at the peak of the heroin market in the late 1990s 4. In response to concerns around unsanctioned or inappropriate prescription drug use, many countries have introduced prescription drug monitoring programs (PMP) 5. Depending on how monitoring is implemented, there is a range of potential benefits of PMPs, including alerting prescribers and dispensers to medication history and interaction potential, and making available information on medications recently dispensed. Such information can assist health professionals in determining if medication is prescribed by multiple doctors and/or dispensed at greater frequency or in larger amounts than may be medically necessary. A plan for implementing an electronic PMP in Australia was announced in 2012 6, expanding an existing system that was piloted in Tasmania. Issues relating to the implementation of this plan are currently under consideration. When the system is eventually introduced nationally, health professionals such as prescribers and pharmacists may be headed into uncharted territory, with access to medication history information not previously available and a need to make decisions based on this information. The practical question of how regulators and practitioners could make best use of this information needs to be addressed, in addition to the consideration of how this new ability to identify prescription drug-related issues will impact on health services, including those services that provide drug treatment. Several key questions need to be considered in the implementation process for prescription drug monitoring: The proposed Australian PMP will monitor only Schedule 8 controlled drugs, including stronger opioids such as Oxycodone morphine and fentanyl, and the benzodiazepines flunitrazepam and alprazolam. The system will not monitor weaker opioids such as tramadol, codeine–paracetamol combinations and the majority of benzodiazepines despite these also being important contributors to morbidity and mortality 7-10. The range of drugs covered is a crucial part of any PMP, and the range proposed for Australia does not cover the full range of pharmaceutical drugs with known significant non-medical use and harms. Any PMP implementation in Australia needs to support good clinical practice, in line with consensus guidelines for pain management. Simple triggers such as the receipt of opioid prescriptions from more than one prescriber or receipt of concurrent opioid and Schedule 8 benzodiazepine prescriptions from different practitioners may not be not sufficient as they could result in false positives, which can unnecessarily stigmatise patients who are using medications appropriately. There is the potential for ‘flags’ to be set that specify clinical requirements for regulatory approval, which could include prescribing medications beyond a particular period, above a particular dose or if the patient has particular characteristics (co-morbid psychological disorder, history of substance dependence, etc). Expert input is required to reach an agreement on what these ‘flags’ might be in order to maximise the usefulness of a PMP. While introducing a PMP represents an enormous opportunity for improving clinical care, it raises the questions of (i) whether there is sufficient person power in the regulatory body to be able to respond in a timely manner to these requirements and (ii) of the ability to access review from specialists in a timely manner. These two issues were able to be managed in the Tasmanian pilot scheme. However, upscaling the Tasmanian system to NSW alone would result in 90 000 applications per year, an unmanageable number for both the current regulatory and addiction medicine workforces. Further, the Tasmanian experience showed emergent problems with consumer complaints, where in some cases the decision was not clearly communicated to those affected the most (i.e. those prescribed the medications being monitored) 11. The proposed PMP identifies medications at the point of dispensing, meaning that pharmacists will have a key role to play. Pharmacists have already identified that responding to addiction, mental health and opioid supply issues is an area in which they feel challenged and hesitant to intervene 12-14. Evaluations of existing PMPs have demonstrated that when provided with adverse dispensing records, prescribers are likely to refer patients on 15, and pharmacists often inform consumers that medication is ‘out-of-stock’, when confronted with problematic pharmaceutical use 14, 16. The US experience suggests that pharmacists may be less likely to communicate information directly to consumers when they have information from electronic PMPs 15. These findings suggest action is required to provide pharmacists with the skills to communicate with patients who are ‘flagged’ in PMPs. Early engagement of professional pharmacy groups, in addition to other key stakeholders, may identify opportunities for better infrastructure and skills to support pharmacists in talking to patients about the difficult subjects of addiction and mental health, which would have benefits that would be more far-reaching than the implementation of a PMP 17. Increasing the capacity in primary care to respond to alcohol- and drug-related problems is desirable and recommended 18, independent of the introduction of a PMP. The implementation of a PMP may provide an important formal mechanism to identify, and respond to, prescription drug-related problems. A key factor in realising this opportunity will be providing the support and training for primary care clinicians in this regard. Current treatment pathways for those dependent on prescription medications people are not well defined, with few services currently sufficiently equipped to manage the common presentation of concurrent addiction and pain. Chronic pain and addiction are both complex clinical areas, with limited evidence available to inform clinicians of the best approaches to treating these conditions concurrently 19. There is no doubt that (i) chronic pain is a considerable health issue, and (ii) increased use of opioids has been associated with increased mortality and morbidity 20. The implementation of PMP may bring much-needed attention to these important issues. Further, the referral pathways to specialist services need to be established while ensuring primary, secondary and tertiary services have the capacity for the potentially large number of patients that may be identified by a PMP. Many community and specialist drug treatment services already operate at capacity and/or have substantial waiting lists. Well-known geographic challenges to treatment exist in regional and rural areas, locations in which pharmaceutical use is known to be most problematic 21. The Tasmanian experience suggests that one likely approach to manage patients may involve increased use of community pharmacy programs to dispense medications in smaller amounts, known as ‘staged supply’, though the limited funding for these programs may need to be expanded to meet the demand 22. PMPs have long been recommended to reduce harms related to pharmaceuticals and, although further evaluation is required, may also produce real benefits in improved quality and safety of clinical practice. While there is still time for the practical aspects of implementation to be considered, a formal mechanism for consultations with those with addiction and chronic pain expertise, alongside representatives from primary health-care professional bodies, is required. This could include a roundtable with representatives from key organisations, such as the AMA, pharmacy professional groups and treatment providers involved. Furthermore, in addition to the logistical and infrastructure costs of implementing the PMP, thought must be given to the resources needed for up-skilling the health care professionals who will be responding where concerns are identified. Finally, establishing clear clinical treatment models for those with concurrent pain and substance use disorder is essential. Even if the introduction of a national PMP is delayed, addressing these issues should remain priorities, in light of the increasing morbidity and mortality associated with prescription opioids. While both pharmacy and medical professional groups appear to be supportive of the introduction of a PMP 25, 26, the best outcome will be if a plan is made now to address these important issues with significant input from the professionals who will be most impacted by any PMP. SN is supported by a National Health and Medical Research Council Research Fellowship (#1013803). The National Drug and Alcohol Research Centre at the University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund. SN and RB are investigators on untied educational grants from Reckitt-Benckiser. RB is an investigators on an untied educational grant from Mundipharma." @default.
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• W2137677144 title "Implementing real-time prescription drug monitoring: Are we ready?" @default.
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