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Video: Codeine up-scheduling workshop, Panel question and answer session

Codeine up-scheduling workshop, Melbourne, 28 November 2017

16 January 2018

For further information about changes to medicines containing codeine, see the Codeine information hub.

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Presentation

  • Panel members: Dr Matthew Frei, Dr Malcolm Hogg, Adj Prof John Skerritt, Pene Wood
  • Presented at: TGA workshop: Codeine up-scheduling, 28 November 2017

Transcript

Codeine up-scheduling workshop: Panel Q&A session

Dr Matthew Frei, Dr Malcolm Hogg, Adj Prof John Skerritt, Pene Wood

TGA workshop: Codeine up-scheduling, 28 November 2017

I'm going to, I know time's marching on, and so what I'm going to do is ask the speakers just to come up to these four hot seats and we'll take any general questions or whatever and we'll see how we go. And if it's five minutes, that's fine. If it's 15 minutes, that's fine and so on. So, I'll just ask people to pop up.

Are there any risks with going cold turkey off your Nurofen Plus with codeine Extra?

I'm just thinking of people who may not want to go divulge that they've been doing it and they want to do it on their own – withdraw.

[Inaudible]

Is there a risk?

It's very unpleasant.  As doctors and clinicians, we don't want to put people through unpleasantness, but it's not life-threatening unless you're a baby, or unless you precipitate withdrawal. With naltrexone, people have been known to vomit and have diarrhoea so badly they become dehydrated and get renal failure. But you know, it's not life-threatening and plenty of people do it every day--- but people relapse.

Do you use Clonidine to assist with that?

Yes, the thing is Suboxone is such a well-tolerated effective drug that Clonidine has gone a bit out of fashion, but some people don't want to be on an opioid, even a partial agonist. So, we use Clonidine. It tends to make people fall over and so, we tend to use it in our inpatient residential detox settings but for years, it was the gold standard for managing withdrawals.

So, someone on a low dose of codeine, can you go to low dose buprenorphine or do you have to do a low heroin dose?

My experience is just the drug doesn't matter and the dose of the drug if you're dependent doesn't matter too much. So yes, you can use heroin dose. You use the dose that manages symptoms. And sometimes people are heroine dependent, simply manage on quite a low dose of Suboxone, and people who are mediocre on Codeine need quite a high dose.

Matt, can I ask…[Inaudible]

So, the problem is, the trouble is those rates of relapse are of concern because they're it's mainly data that's collected from heroin users, and heroin user relapsers tend to die. And with codeine off the market, it's hard to relapse to that opioid of choice, and if you did, I don't think the risk of dying is as high as injecting a huge bowl of heroin.

Look, I want to put this in perspective. I have people come and they say, I take 15 a day of Nurofen Plus.

Those patients …cold turkey…won't kill you. I guess the problem is with those people who take 50 a day. At what level would you say this was a concerning addiction? [Inaudible] …I don't want to go cold turkey …[Inaudible] But the issue is that the patient needs to agree to follow the protocol. So, my question is, which message should we really worry about, and which ones can we say, look if you don't take anything that's fine and I'm going to feel well. And also, my other question is I'm sure people are going to come and say, can I just have some Valium? Can I just take a bit of Valium until I get over my addiction? And they're going to be very difficult to get off the Valium. So, they're not people I'm wanting to put on Valium in any situation. I mean, obviously these people are detoxing from alcohol and we're monitoring them very closely. For those types of initiatives, sometimes that's quite appropriate, but I think I'm worried about those transient people walking in who will be the patients who are going to give us lots of grief, very demanding and difficult patients harass us and that's what [Inaudible].

I think it's difficult to say what the cut-off level for treatment is. So, I've had calls at DACUS when people say. I'm taking eight Panadeine a day. I've got a patient who's taking eight Panadeine a day. What dose of Suboxone should I put them on? To me if somebody's taking the therapeutic dose range of codeine, then they probably don't need a pharmacotherapy, I mean, they'd be more comfortable. They wouldn't be symptomatic if they did. I think you're making somebody more dependent than they are. So, it's difficult to say a cut-off point. Then somebody comes instead and says I've got symptoms and I'm finding myself drinking too much or seeking other opioids manage my symptoms, and they're taking above the daily dose of codeine in terms of ….it seems like a high dose because the daily dose of codeine…Panadeine and Nurofen Plus So, if they've got symptoms, and the dose seems significant, then I think using Suboxone is justified. But it's hard to say a cut-off dose. That's something you can bring DACAS about and I think there's every reason to look at this. It's a very reasonable question. The codeine they've been taking, is that an indication for pharmacotherapy.

The second question, the opioid withdrawal is time limited, a bit like alcohol withdrawal. So, you can use benzodiazepines but like alcohol withdrawal, you're really contain it to a very short time. And there's not much evidence that they do any good by the way.

Can I just say the underlying reason why they might have developed dependency in the first place is that they might be managing…[Inaudible]

This is more to the patient …I'm desperate. I'm taking all these tablets every day and now I've got none. What am I going to do? The issue is not wanting to say …[Inaudible] …But I'm worried more about these patients who don't and you don't quite know. …[Inaudible] Can you give me enough to tide me over? And they end up getting more.

The real-time irony is that you might get those same people turning up on your doorstep saying seeing as my regular doctors has refused to prescribe narcotics to me, can you do it?

…[Inaudible] That's fine. I don't think there's any problem about saying 'no'. But it's when you don't know the whole story of addiction. And when they say, I take 15 of these day, you can't just tell them to go home. Which is why it's a great question. People do say, sorry but I'm not going to prescribe these for you. …[Inaudible] They're not going to die, they're not going to make our patients die …[Inaudible] reassure us about.

Can I answer the question? Perhaps taper the dosage a little bit and pulling out all the other stops.

I suppose it's my experience that most GPs know their patients. If you don't know your patient, if you don't have that background, then I would be concerned about taking that patient on. You can give them 24 hours, I've got six minutes whatever they're willing to pay you. Then you say, I want you to come back tomorrow, in three days' time, in seven days' time, I'm going to engage you in that process I'll give you 24 hours if need be and bring the dose down. I use Clonidine to treat their anxiety and withdrawal, and in that week period, I've got the nurse chasing up who's their past GP, ring the GP, find out the story. And if they're not on the ball, they'll soon move on and you'll be off the hook.

But if they're saying, yes, I'm legit, I've been in the community self-treating myself, that's your opportunity to engage the patient and take a proper history, I'm going to look into your anxiety, stress, physiological aspect. What is true pain?

A lot of these people have got pain…[Inaudible] …they get injured so, they do have pain and addiction and anxiety, and you need to handle them and manage them in that process. So that's my experience with good GPs. My problem is, I've got my allocation of time and they are regularly booked up, engaging with them, engaging someone else to do it for you, that you can get them off the substance. I personally don't have a big problem giving opioids, prescription opioids to someone who's got both pain and addiction issues, but you're going to take a risk …[Inaudible] two-day pickups in the pharmacy etc.

I think doctors want to help but they only have six minutes to do it in a GP consultation. I think this condition didn't happen overnight, it's not going to kill them. It's very reasonable but for somebody that you don't know well, you have to take your time with it. It's not a medical emergency.

…[Inaudible] I'm Tom Mackenzie, a Monash 1974 medical graduate, and I've had many years in general practice at the coalface. I put that I was coming to this meeting to my colleagues …[Inaudible] and they've got a box of these things they say I should bring up. So, don't blame me, blame them. But thank you, Matthew, for that stuff on Suboxone, that's been very, very helpful.  Some of the things that they've said is, look it's all evidence-based medicine these days. We need the evidence for why we do things. But what happened to an evidence-based policy? I know that KPMG are good, but if I was going to test a medical truth, I wouldn't ask KPMG, I'd ask a few people what they think.

And that's what we've done with this policy.

I disagree. What KPMG did was look at the economic impacts. The decision had absolutely nothing to do with running of the numbers.  The decision was about benefits and harms.

What I'd like to see, well what my colleagues would like to see, instead of bringing this in for all of Australia where it's going to impact on the whole of Australia, why not take a little host community, like King Island, where you've got 1500 people, one pharmacy, one general practice, and you produce it there and see what impact it has, and then we have some real evidence. We are worried about the fact that we may not be inundated in terms of numbers of patients but these are going to be hard consultations. That's what we're worried about. It's going to really impact on the rural GP in a major way. We get 25 – 50-year-old males coming in, wanting …[Inaudible] They can be very intimidating in a one on one consultation. So, we're a little bit worried about that …[Inaudible] and it becomes a bit of a black market item. So, that's why my colleagues have suggested, why didn't we bring it in a small are which is closed and see how it goes.

Actually, just to answer that question. I'll give a bureaucratic answer. Actually, there was very little power to be able to take a little part of Australia like Tasmania or King Island have a different method of scheduling information just for that little island. So, there wasn't the legal power to do that on a small island, but I guess I do want to take issue with the comment that came about …[Inaudible] They had absolutely no impact on the decisions. … On evidence of morbidity and mortality, there was evidence of benefit…or lack of evidence of benefit and we've seen the numbers you needed to treat. From the 95% confidence intervals, it is not significantly different, paracetamol alone versus paracetamol and codeine. So, it was a drug that had very little efficacy with the majority of people and significant evidence of morbidity and mortality. That was what went out to the view of the committee, and remember, I mentioned there were two separate committees three times, and the committees were unanimous in their view. It was quite unusual. Normally, you get two thirds one way, one third the other way And, both rural and city based GPs, specialists, pharmacists, health policy makers.

Look, there were two other little comments to make. And that was we find that our patients would not go along to the accident emergency department at the hospital. They just get dulled out …[Inaudible] And that's a problem. And the other problem
is and Malcolm is the exception here but in the earlier days of pain clinics, not so bad more recently, we found referring patients to pain clinics, all it was doing was, they were just getting prescribed opioids.  This isn't Malcom's way …but I just make those comments.

…not consulted, only one session a fortnight at Caulfield and that clinic is the get people off the opioids clinic.

I'll be a bit more pragmatic because we deal with a lot of low socio-economic and … are actually optimize or minimize the harm optimize the benefit. And so the pragmatic view is we just want to get the top doses down and get them managed and support their community care. the ….concept I hear and in reflection, there's a reason those patients have got to that point and that's why I go back to my model of, who is the person? They've normally got some developmental aspect of trauma or  stress or how they've managed and coped, and it's just how long have you got to weed that out?   And I see a lot of … from surgery and other things and opioid prescribing when clearly, they should have an underlying stress level that has led them to be either addicted or psychiatrically unwell, or surgically operated… on either opioid over the counter or cannabis… use cannabis for anxiety and not for euphoria, to manage their anxiety and their sleep disorder So, do you as a GP, typical six-minute consultation, have the energy to say I want to … and that's very difficult unless you know them. And it's not just the GP that needs to do it, I think. It needs to be society educating the school kids about resilience and having processes in that place in that period. It's not just going to be up to a GP treating a 50-year-old on high dose opioids.  That's my perspective. That's based on 20 years of seeing this sort of character.

I'm a psychologist at Watson Health in Sunshine North. I grew up in the Latrobe Valley, and we work predominately with disadvantaged population. And I guess my comment is how much psychology is played into managing pain? There really needs a bigger investment into psychological services which I don't see happening despite constant lobbying. One thing I did want to highlight to the rural, remote practitioners is that there is telehealth available for psychological services, but you point out, Malcolm, that the gap, that it's not enough to cover the cost of practice, and our clients can't afford the gap. And the rely on medication to cope.

And this is partly where you've got to use all your other staff and be innovative in your model of care, and know that you're not giving rolled gold care, but you're getting three or four psychology sessions with nurse practitioner giving the extra education and support program. Yes, it's difficult anyone on a back we notice there's some

Any more questions? One up the back.

A very similar question actually. You mentioned that there was some real-time monitoring mentioned in one of the slides. How much [inaudible]

So, the system in Victoria will be mandatory. It will be captured…. at the dispensing level because 95% of dispensing is now electronic whereas only about 75-80% of restrictions are electronic. The goal will be to link into the electronic systems so it will happen automatically and you will just get a thing to say this person is registered, this is what their last restriction was.

A question then.

Are you not aware that as pharmacists, we've been doing this for quite a while now and why has that not been emphasised a lot more that we were going to control this problem? Because we're finding that they're coming at the back end of a situation where we were already trying to perform a duty to do what we could at a community level, but it seems like it's almost being ignored, whereas now it's being used or trumped up as one of the things that the government is actually trying to get through. Now, we have [Inaudible] …we've also been controlling it for the last years for codeine as well. We believe we were in the forefront in trying to monitor and actually give some good feedback and data which could have been much more useful than what they're going to do now.

So, the pharmacy guild that ran the program for codeine approach every state government. For it to have become mandatory, it would have been the decision of the individual state or territory governments because they regulate the pharmacists, not the commonwealth. Not one of the state and territory governments agreed to make this mandatory and so from a penetration… it was about 70%of pharmacies were using it Australia wide. In some regions, it was 30% and in some regions, it was 80%, but it was 70% Australia wide. There was significant evidence that it was getting no money. People who wanted to buy multiple packets of codeine, where they could go, and there was certain… of names I won't mention who were notorious for not having a system. And it was a bit like having a sign saying, well here's a map of Victoria to travel on these highways where there's never a speed camera or a breathalyser so do what you want. 30% of the roads. And so that problem led to the fact that it didn't really seem to manage the codeine issue because unlike project stop, the pseudoephedrine one, which was done for law enforcement, not one of the states and territories agreed to make it mandatory.

My question is…[Inaudible]

The recent government said no.

In Victoria, the Victorian government initiated a mandatory system it's not here yet. It's 12 months away. And that's prescription only so it's not going to cover over the counter but eventually it will cover as codeine goes to S4, it will be captured on this system as it's going to do S8 as well as S4.

Can I make another comment about ….[Inaudible] Some were using it, some weren't. So, some were recording it, ticking the box, and not necessarily doing anything with that information. I know sometimes when I looked up patients, they were getting it multiple times, every day, on and on, and there was no comment about what the pharmacist had done to manage that pain. There were no comments about whether they'd been referrals and other things, so it wasn't actually being utilised to its best advantage anyway. It was tick the box…oh yes, I'll give you another lot. Whereas it should have been used more like, [Inaudible] And it was also really hard on the pharmacies to have a conversation and have a two-minute consult. We've got ten people deep… where's my scripts...I need help here. And you're trying to have a conversation with someone about their drug dependency issue. Sometimes, it's not an entirely private area. That can be an issue as well.

Just to take one further from the point earlier. I said this won't just be what's happened electronically, the option there is for GPs to look it up. If you've got a patient dependent on codeine, you can look them up on the system and you will have access, which is where the doctor shopping hotline fell down, and a lot of other programs fell down, and the Tasmanian project fell down as well because it wasn't mandatory. And people went around it and there's no flow on effect. GPs were never empowered to say, I can use this tool to change my prescribing practice and engage the patient with managing their day or with their opioid addiction.

It is designed to be used in a clinic and not [Inaudible]

A quick question. A patient will come into a pharmacy for codeine. So where does the patient go, the one that doesn't have a regular doctor. They've been using it for a long time for their headaches, for their migraine or their back pain, and then if they go to a doctor like she said before. They're not prepared to treat this person that they have no history of and then things get hand balled over and over. Like, where in the pharmacy can we recommend them to? Because there's a pain clinic but they need a referral and things like that, but quite often, they'll struggle to find a GP that will help them. And in the pharmacy, we'll get that agro, 'give me this' or whatever it is. So, what do we do? What's the best advice?

[Inaudible] Whereabouts do you live?

[Inaudible] And also, there’s been some drug and alcohol funding for different services.

[Inaudible]…on the PHN. It's a little bit like an alcohol and drug service but it's actually more specific with… and dependence. So, it's designed to make patients feel a little more comfortable.

[Inaudible]…creation for people that potentially maybe dependent or potentially to prevent them from becoming dependent. Different areas have different services. I might be about contacting your local … and see what services are available they offer in your area.

….we're going to have health pathways for addiction psychiatry and pain and that those pathways are going to be accessed by both pharmacists and GPs. And they'll be region specific and reasonably consistent.

And to be able to refer to.

Then the government are going to have to respond because in Sunshine, you might say, well I'll send them to Western. I'm getting nowhere. Then the government will be monitoring this and say, well, we need to withdraw the services from sunshine if they can't do it. We're going to take some of those patients and refer them to another service on their behalf.

[Inaudible] They can always find a doctor. They might have to travel and come to another suburb, but if they want a doctor who is experienced in this area, they can usually get an appointment within 24 hours.

In 2014, I believe, Medicare funded Michael Nicholas to run a series of trainings for general practitioners … practitioners and nurse practitioners across Australia. And they were aimed at equipping practitioners to be able to manage pain patients locally. The philosophy being that patients be treated in their local environment and referred to pain clinics and pain specialists as a second line measure. we also have a situation where We also have the situation where we have the Master of Pain Medicine with a parallel program Master of Science and Pain Management running out of Sydney University. We have the Masters in Pain Management or something similar running out of the University of South Australia There's the online program in the University of Otago which Bonnie Lennox Thompson coordinates. Is there anything that can be done to increase referrals for people have gone through those programs because it seems there are resources out there in the community that are skilled in managing pain, chronic pain presentations from a social perspective. Practitioners who do regularly spend, not 15 minutes with their patients, but an hour, an hour and a half in some cases. And it seems that those processes, they're diversity practitioners, working in partnership with people like yourself and might be able to help.

Yes, and that's what I suppose the model was about, facilitating greater service delivery within the community level, empowering the local communities to provide that. Many did that a bit better because they identified what was important in that area: Like hepatology, pain, whatever and they had funding for all those programs. That's now been dropped away a bit more, now back to GPs to empower themselves to say this is a clinical issue. GP champions will be part of the monitoring system. There will be champions placed in most of the networks. There'll be pathways through the networks, facilitated, and then as I mentioned, there's all these resources. Some of it's going to have to be through… so, I'm going to go and spend my … to do better pain management. I can spend five thousand to do a masters. It's not going to come via a funding grant. …

That's what I'm saying. There are resources around to set people up.  I think it was you put the resource up for the college… is it RACGP? no, pain management.

My concern is what I'm hearing, I've seen patients, it's easy for me not to prescribe. I can put up a sign there, we do not describe opioids in this practice.  Great. Can't see chronic pain patients. Fantastic. So, it's easier to say no as a GP than really to engage with them. And that's my worry when I hear you talk. That's my concern.is

Is there a conversation that needs to happen between this group and the NDIS because the potential pathways for the NDIS to fund other services for these types of patients because their patients are not working, and a lot of the patients that I see, some of them are kind of disability patients.

That's a good point. I've never pursued it and I'm not sure if we are recognized like a pain program, transport through a pain program …it is potentially possible.

Just two points on that. Firstly, your earlier comment with regards to enabling and providing the resources onto the GPs….provide resources like other pain management. A lot of the funding and the support that the government is providing to those groups is to actually provide that education and that information to provide that support in regards to where else can they go.  And some of the other stuff that you mentioned with regards to resources. Regards the NDIS, one of the things the department is considering is how do we coordinate, how do we get the right groups involved in this? So, I'll take that back and we'll look at how we can engage…I'll talk to you after this.

Also, some of the regions are looking to, they've got funding and they're looking into the ECO project, which was done in the USA, and bring that over to the regional areas near Victoria, addiction and then hopefully pain. And that's about an online system where you just have cases and experts and upskill GPs. And that's a bit of a short version, but that's something they're looking to bring into regional areas as well.

Well, at one stage, I thought everyone was going to peter out at 8:30. It's after 9:00 so I will try to bring things to a halt. I just want to on behalf of the Department of Health, I just want to thank Pene and Malcolm and Matthew for contributing your evening. We've just been so lucky to draw on your significant experience and expertise in the area, and many of you who came along tonight have also shared pretty well. If there are questions or issues follow-up, Avi. Can we reuse the same RSVP address that we used if anyone has particular questions or colleagues have texted in or emailed in questions or issues and so forth, or if you have suggestions. Hey, you guys have forgotten all about this idea. So if you could use the same RSVP address, we'll will pick up on that. I mean, clearly it's not an online consulting service but there might be…even though we have spent ever since this decision was made, we've spent the last almost 12 months working very closely with who we believe are some the best consumer groups, GP groups, specialist groups, nurses and pharmacy groups, I'm sure that there's things that none of us in our collective wisdom have remembered. So, please don't hesitate to come forward with ideas, suggestions and resources. You know, we don't have to reinvent the wheel and as the point's been made, pointing people to the resources.

So look, on behalf of the department, I just wanted to thank you for coming along. This isn't a brainwashing program, it's a program of communication, education and perhaps using this as a catalyst to focus our attention on some of the other areas such as stronger opioids, and the issue of how do we manage pain in the community when it's an increasing issue. I mean, some people have said we've actually got a pain epidemic, not an opioid epidemic, and while that could be debated for most of the night, it's a point worth reflecting on. So, thanks again for coming in, for your time in the evening.