Presenting for prescription is the 2nd most common reason for encounter in General Practice.
As a new GP Registrar you will inevitably be tested out by the local drug seeking community to see if they can get their medications from you. Whilst you can approach this empathetically, your eventual ‘no’ may still feel ‘Mean,’ but as Taylor Swift will say- ‘Shake it off’- check out this video parody to remind you why:
I wanted to start this post by highlighting the best prescribing is sometimes NO prescribing at all. This goes for drugs of dependence but also a whole range of medications.
In fact, Choosing Wisely has PPIs, antihypertensives, and statins in mind, as well as benzodiazepines.
After NO prescribing, is DE-prescribing. Yes, the most useful thing you can learn is how not to write scripts and how to stop writing scripts. Especially in the elderly, who have increased drug-related adverse events, hospitalisations and mortality with increased medication.
Deprescribing is a really important skill to learn, but remains a new concept as evidenced by the fact its the only word that spell check doesn’t recognise in this entire article.
Ok, so step number 1- consider if your patient actually needs this prescription. The World Health Organisation has developed a Guide to Good Prescribing. If you still decide yes, you want to prescribe a medication for this patient, then there are a few more things you need to know.
If you are completely new to the PBS in private practice, you must go to the Medicare site and complete their online learning modules ‘PBS for new health professionals’ and ‘Prescribing in private practice’. This will give you an overview of the things you must include on your prescriptions, which ones you need to handwrite, what authority and streamlined authority are, and PBS safety net information. regulations 22 and 24, and prescriber bag supplies.
Now its likely you will at some stage prescribe some medications in the top ten lists. Did you notice that the Choosing Wisely medications (statins, antihypertensives and PPIs) make up 50-90% of those lists? As well as Australian Prescriber, the NPS website is another good source of information. If you can get your hands on eTG (Therapeutic Guidelines), the AMH (Australian Medicines Handbook), and/or Paediatric Pharmacopoeia– they are also often useful resources.
Ok ok, I know you still have TayTay stuck in your head, and you want to know more about prescribing S8’s and other controlled medications.
Its really important to know the legislation for prescribing in YOUR State or Territory. Like Advanced Care Directives, motor vehicle insurance, worker’s compensation, drivers licence medicals, and many other important areas of your work, it is different in different parts of Australia. You think that sounds silly? So did someone else, so they wrote an article on it for the MJA this year:
But that’s how it is for now, so here are some other places to find some tips:
Prescribing an addictive medication can be necessary at times, and there are many people in the community who use them for various indications at various doses for various lengths of time quite appropriately. There is a big responsibility for you to decide whether or not it is appropriate to prescribe this medication to this person under these circumstances. The Opioid risk website has some additional tools to aid with your assessment of appropriateness.
So whilst there might initially be some ‘Bad Blood’ between you and your patient who didn’t get exactly what they wanted, its best that you don’t have to think ‘Should’ve said no.’
REMINDER: Don’t forget to comment with any other tips or resources you use- this resource is ‘Ours,’ not ‘Mine.’
Acknowledgement: This part of a series of posts that will address the 30 most common reasons for encounter in General Practice, based on a series of A4 handouts created by Tropical Medical Training.
Are you exam ready?
Multiple Choice Questions:
Q1. Jack is a 82 year old man who presents for his annual check up. He has been on several medications ‘for many years’. Jack is a fit and well gentleman with a history of mild hypertension (currently 140/85), osteoarthritis, barretts oesophagus, and mild hypercholesterolaemia (initially his Total was 6.2, LDL 2.3). He uses Frusemide PRN for idiopathic bilateral leg swelling. His renal function is normal. You assess his medications and consider which medication would you recommend ceasing.
Which medication do you suggest he ceases?
D) Panadol osteo
Q2. Sandra Salt is a 76 year old woman who is rapidly frailing. She has had multiple falls in the past 4 weeks. You are assessing her medications.
Which medication may contribute to falls in Sandra?
Q3. Paul Francis is a 54 year old man who has been diagnosed with metatstatic prostate cancer. He requires a script for oral morphine.
When prescribing an S8 in Australia which of the following rules is correct?
A) S8 Scripts are valid for 6 months
B) S4 and S8 medications are the only ones that can go together on the same script
C) S8 scripts can be written for the prescriber and their family in Australia
D) The patient must be physically seen at the time of prescribing
E) All S8 medications are tracked and monitored by the government
The KFP Case:
Stacey is a 45 year old professional who has come to you asking for help regarding weight loss. She has a stressful job and busy family life. She finds it hard to exercise because of knee pain. At the end of the consult she says ‘Oh and I need another script for my oxycodone please?’
You look at Stacey’s medication list and note the following:
Oxycodone 10mg; 1 tablet prn
Panadol Osteo 665mg; 2 tablets tid
Omeprazole 40mg; 1 tablet daily
Temazepam 10mg; 1-2 tablets nocte prn
Perindopril 4mg; 1 tablet daily
Q1. What 3 further questions do you wish to ask Stacey about her history?
Stacey says she is doing just fine on her current medications that her usual doctor prescribes for her. Can she just get another script please. She has to get back to work.
You decide to complete an opioid risk assessment questionnaire with Stacey. She is a bit defensive about this process but obliges.
Q2. Name 5 risk factors for opioid addiction.
Stacey scores 8 on her opioid risk assessment, being 45 years old (1 point), having a previous alcohol addiction which she states is not currently an issue (3 points), and a mother who abused sleeping tablets (4 points). She is adamant that she uses only the medications her doctor prescribes her and they are because she really does have knee pain.
Q3. What are the 5 next things you are going to do to manage Stacey?
The answers are below this line
2. A – Temamazepam – “http://jppr.shpa.org.au/lib/pdf/gt/2008_06_Zeimer_GT.pdf” – There is no current evidence that prednisone contributes to falls (refer to reference)
3. A – They are valid for 6 months – “http://www.public.health.wa.gov.au/cproot/3565/2/prescribing_s4_s8_080825.pdf”
KFP– (all of the following answers would earn 1 mark – If more than one answer on any one line then marks will be deducted from the entire paper)
Q1. The three further questions to ask Stacey could include:
- What functional ability does she have with her knee pain?
- How long has she been on these medications?
- What side effects does she suffer?
- What is her absolute cardiovascular risk?
- Does she take these medications regularly?
- Is she concerned about any of her medications?
Q2. 5 risk factors for opioid addiction are:
- Family history of substance abuse
- Personal history of substance abuse
- Age 16-45 years old
- History of preadolescent sexual abuse
- Psychological Disease
Q3. The 5 next steps to managing Stacey may include:
- Show empathy that her situation must be quite challenging
- Explain that her history puts her at high risk of opioid addiction
- Assess readiness for change
- Document a plan for ceasing endone
- Arrange follow up appointment for monitoring and managing future pain
- Refer to physiotherapist
- Discuss lifestyle changes to manage weight
- Calculate cardiovascular risk
- Consider deprescribing temazepam/omeprazole/perindopril as indicated