Rheumatologists back controversial plan to curtail GP prescribing of opioids

Rheumatologists have backed a contentious plan that would see GPs only able to prescribe strong opioids for non-cancer pain under the oversight of a specialist.

The idea to restrict prescribing of Schedule 8 (S8) opioids to specialists or authority-prescribing only is touted in a TGA consultation paper on options for a regulatory response to the use and misuse of S8 opioids in Australia, which finds osteoarthritis to be “a major driver of increases in opioid prescriptions in Australia in recent years”.

The idea sparked outcry from several doctors’ groups, who argue it will have a detrimental impact in the bush where specialists are thin on the ground.

But the Australian Rheumatology Association says the move could stop a trend in which GPs are prescribing opioids to patients with rheumatic disease.

“All of our members see people who have been given long acting potent opiates without a proper consideration of their diagnosis and that there are other ways to manage their condition which are safer and more effective,” said ARA president Dr Dave Nicholls, who stressed the ARA does not want restrictions extended to the area of cancer and palliative care.

“Recently a manual worker in his fifties had been prescribed oxycontin for more than four years by a series of general practitioners working on the assumed diagnosis of degenerative back pain. The most recent GP refused to keep prescribing it and asked for a specialist opinion on his diagnosis. The patient actually has ankylosing spondylitis.

“So now we have a problem where he has a treatable disease and a significant dependence on oxycontin and my task is going to be – and many of the members of our association do this every day – we have to undo the opiate addiction as well as treat the disease that should have been diagnosed in the first place.”

Rheumatologists across Australia were seeing cases like this every day, he said, particularly in regional areas.

“I work in a practice of five and one of our frequent points of discussion is people who have been given opiates for a treatable disease.

“There needs to be an increased awareness that inflammatory arthritis can mimic degenerative arthritis, and if in doubt asking a specialist for confirmation of the right diagnosis. The trouble is they might not think they are in doubt.”

The ARA’s submission suggests a specialist be required to review diagnosis and management within the first three months after a GP has prescribed an opioid.

This role could performed by physicians such as rheumatologists, geriatricians, rehabilitation physicians or addiction medicine specialists, Dr Nicholls said.

Several doctors groups oppose the proposal to limit GP prescribing.

The Rural Doctors Association of Australia said such a move “may have significant adverse effects” on patients living in rural and remote areas where access to specialists services are poor.

This was echoed by the AMA, which suggested requiring GPs to undertake accreditation to prescribe opioids instead.

Meanwhile, the Royal Australasian College of Physicians said the idea of limiting prescribing to certain practitioners “appears somewhat redundant” in the current environment, where there is high awareness of both the limitations and addictive potential of opioids, suggesting a “universal approach” was more appropriate.

“I am happy for our position to be at odds with others,” Dr Nicholls said.

“I accept there is a resource limitation but I don’t think we should accept (the situation) just because there is no rheumatologist or specialist available.”

He said the current authority system ascribes different codes for cancer and non-cancer pain, making it relatively simple to separate the categories in future regulatory changes.

“If the government separated those two it would alleviate some of the concerns in the community that GPs wouldn’t be able to look after people who have cancer and are dying, but would allow our platform which is that what’s really important is that you have the right diagnosis and you have explored the best treatment for that condition.”

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