First, do no harm
By Dr Brea Kunstler*, Research Fellow
Your mother slipped on some icy concrete last week and fell, fracturing her arm in two places. You hated seeing her in pain and you were very pleased when her GP promptly referred her to an orthopaedic surgeon who booked her in for surgery and gave her some pain medication. You were especially pleased to know that her GP gave her a couple of repeats for the medication the surgeon prescribed, just in case she needed them. Poor mum.
Now let’s talk about the opioid epidemic.
An opioid is a strong medication that is often prescribed by surgeons and GPs to treat intense and often acute/immediate pain, like that experienced when you fracture your arm and require surgery. Some examples include Endone, Oxycodone, Morphine and Fentanyl.
These drugs are addictive. These drugs are often prescribed in excess (e.g. several script repeats provided to someone who already has enough medication to cover the acute pain period) and these drugs can kill if used inappropriately.
That medication your mum was prescribed was Endone. Endone is a commonly prescribed opioid, so common that I can recognise the packet from meters away on my patients’ kitchen benches, right next to the box of Panadeine Forte.
The repeats your GP gave her will keep her going for another two months, well after the acute pain period is over. During those two months, your mum will have her surgery and will receive another prescription for another opioid, Tramadol, and will be asked to wear a patch to cover her baseline pain, called a Norspan patch (you guessed it! Another opioid). Suddenly your mum has a drug shop of opioids in the top draw of her bedside table.
Your mum is at risk of becoming addicted to opioids and being one of the many adults in Australia who accidentally overdose on prescription medications.
This is over-prescription. This is inappropriate prescribing by health care professionals, albeit unintentional.
This needs to stop. But how do we stop it? How do we support health care professionals to avoid and prevent inappropriate prescribing?
Regulators and clinical educators might assume that educating health care professionals on the dangers of inappropriately prescribing a variety of different medications (e.g. opioids, antibiotics, anti-inflammatories etc.) will stop them doing it.
Our recently-published evidence and practice review suggests that educational outreach programs might successfully reduce inappropriate prescribing of various medications by a range of health care professionals. But, importantly, there is little evidence out there suggesting that educational outreach will work specifically to reduce the number of health care professionals inappropriately prescribing opioids.
Sigh! Right when we need this kind of evidence.
Sadder still, we have little review-level evidence to tell us if educational outreach will work to change the prescribing behaviour of GPs specifically. This is concerning as the GP is the health care professional who will be seeing your mum in the long term and who is now responsible for supporting her to stop using the opioids that she has become so accustomed to using.
Did I say accustomed? I meant addicted. Let’s not sugar coat the issue.
We have a problem and we need solutions … and more research.
*Dr Breanne Kunstler, Associate Professor Peter Bragge and Ms Alyse Lennox recently published their rapid evidence and practice review called ‘Changing prescribing behaviours with educational outreach: An overview of evidence and practice’ in BMC Medical Education.