Stuff up left dying patients without pain relief
EXCLUSIVE: Patients dying of cancer were being denied crucial pain medication after a crackdown on opioid prescribing backfired forcing the nation's top doctor to apologise to GPs.
Fearing a US style opioid crisis here, Chief Medical Officer Professor Brendan Murphy was last year told to identify the highest prescribing doctors and ask them to review their practice.
A year later a News Corp investigation has found not a single one of the 4,800 doctors sent the letter has been disciplined for inappropriately prescribing opioids.
Instead, Professor Murphy has been forced to apologise for the letter after doctors stopped prescribing opioids for terminally ill patients in palliative care.
Prescribing of opioids to terminally ill cancer patients is not a problem, its prescribing for other types of chronic pain that is in the spotlight but the government's crackdown did not discriminate between the two.
Palliative care and cancer doctors who received the letter feared a government review of their prescribing could see them stripped of their right to practice so they ceased prescribing pain relief for dying patients.
"You don't want to get caught up in a professional review process, even if you are innocent it's a very stressful process," said Royal Australian College of General practitioners president Dr Harry Nespolon.
In an apologetic letter published in the Royal Australian College of General Practitioners newsletter Professor Murphy told doctors: "we are certainly aware that these initial letters did cause some anxiety and distress for some GPs, and I apologise for that".
The department was not able to identify which GPs were working in palliative care or those who had a specialist pain practice or who treated cancer even though they were prescribing opioids appropriately, Professor Murphy said.
"Some recipients of the letters have raised concerns they may be sanctioned for prescribing opioid medication or that restrictions have been placed on their ability to prescribe opioids. I would like to reassure GPs and patients with these concerns that this is not the case," he said.
Dr Nespolon said when palliative care and cancer doctors rang the department to explain their prescribing instead of getting an understanding response "all they got was: 'we don't believe you'."
The RACGP met with Health Minister Greg Hunt to warn him that dying patients were being denied crucial pain relief.
A no cost solution, which was to have a different Medicare item number for opioid prescribing by a palliative care doctor, was proposed.
"The department could have done this in a more sophisticated way," Dr Nespolon said.
Pain Australia CEO Carol Bennett said her organisation had consumers contacting it to say doctors would not prescribe opioids for them.
"Some palliative care patients were not even tapered off their opioids the doctor just stopped them and it's quite dangerous to do that," she said.
Palliative Care Australia's National Clinical Adviser, Kate Reed said "outside of palliative care, the misuse and overprescribing of opioids is a serious public health issue that must be addressed".
"However, it must not be at the expense of people receiving palliative care who have a human right to access medicines to relieve suffering including opioids," she said.
A spokesman for the Department of Health said "the Government has not placed restrictions on doctors prescribing opioids".
"The department will evaluate the impact of the letters on the opioid prescribing levels in late 2019," the department said.
"No disciplinary action has been taken to date."
DOCTORS IN THE DARK WITHOUT OPIOD GUIDELINES
Opiod deaths have doubled in the last decade and Australia now has the third highest number of fatalities from the drug in the world after the US and Canada.
Today we can reveal that a key cause is that doctors are completely in the dark when it comes to prescribing the pills and get only limited training on pain in their medical degree.
Three people a day are dying from opioid-induced causes but there are no formal guidelines on how many tablets patients being discharged from hospital should be given, according to intensive care specialist Matthew Anstey.
Monash University research found 50,000 of the 1.9 million Australian patients prescribed the addictive drugs every year end up becoming long-term users.
And US research found patients needed much lower opioid amounts after surgery than doctors thought they needed.
"We are really not good at all at giving guidance to prescribers or to patients when to stop taking opioids or how to stop taking them," Dr Anstey said.
"We currently don't have good evidence about the average duration of pain following different operations, and duration of analgesia needed.
"As a result many places don't have formal guidelines on how many tablets patients being discharged from hospital should be given."
Monash University PHD candidate Samanta Lalic's research found over 1.9 million Australians started on opioid medications including panadeine forte, oxycodone and tramadol every year and 50,000 ended up using them for over 12 months.
Monash University Professor Paul Myles said in general patients who have had minor surgery should not need more than 6-8 opioid tablets and even those who have had hip replacements shouldn't need them after four weeks.
He is calling for the government to look at reducing pack sizes to force doctors to review opioid use after 10 pills in patients who have had minor surgery.
Many doctors and most patients are unaware that long term use of opioids can actually cause more pain, he said.
"Opioids induce pain sensitivity that works through the nerve pathways and the patient becomes hypersensitive," he explained.
"They think they are in pain and need more opioids."
He wants more training for doctors and says they need a set of official guidelines on prescribing opioids.
"These guidelines now exist in the US and Canada and we absolutely need them in Australia as a matter of urgency," he said.
More than three million Australians had one or more prescriptions for opioids in 2016-17.
The number of deaths in Australia involving opioids has nearly doubled in the decade to 2016, from 591 to 1119.
In 2016, the most common types of opioids responsible for deaths were prescription opioids (oxycodone, codeine and morphine), which were attributed to 550 deaths.
'YOU ARE MADE TO FEEL LESS THAN YOU ARE'
Louisa O'Neill who suffers chronic pain after 11 surgeries in 15 years had her opioid pain medication suddenly cut off earlier this year after a government crackdown on doctors overprescribing the drug.
The 48 year old mum from Mornington, in Victoria, suffers severe arthritis and has had her upper and lower jaws replaced. She has had her gall bladder and appendix removed, has had a nasal septoplasty to deal with sinus problems caused by basketball injuries and also had a caesarean.
"You walk out feeling like you are a drug addict. You are made to feel less than you are," she said of her humiliation at her treatment.
However, she said she's now been off the drugs for four months and said after the first few nights of pain "it's not too bad".
She is still worried about how she will cope without the pills if she is left in pain after a night of dancing.
Ms O'Neill's experience with opioids is not as devastating as the 18-year-old basketballer who was left in a coma after a misadventure with hospital prescribed opioids.
That case still haunts intensive care specialist Matthew Anstey.
"I still remember a patient I looked after in my last year of ICU training," he told the recent Choosing Wisely medical conference.
The young man had been playing basketball and fractured his ankle and he had an orthopaedic surgeon put a screw in the ankle and was discharged the next day with a box of oxycodone.
"Like any 18-year-old might do he went out to a party and had a misadventure with a box of tablets and some alcohol and had a respiratory arrest," Dr Anstey said.
"He came to us and left our ICU about a month later in a persistent coma which is probably the worst outcome you could have thought would happen," he said.
The fate of that young man was one of a number of factors that drove Dr Anstey to take a closer look at the way hospitals prescribe opioids to patients when they are discharged from hospital.