New limits start today for these medicines

Smaller pack sizes for opioid-based products come into effect in bid to cut death rate.

New limits start for these medicines

Suzanne Nielsen, Monash University

Several changes to the regulation of opioid supply in Australia come into effect today (1 June).

Opioids are strong medicines used for pain. The new rules – including reducing pack sizes and restrictions around prescribing – are part of a range of changes planned for prescription opioid medicines to be phased in over the next year or so.

This comes in response to the growing number of deaths involving opioids in Australia. From 2007 to 2016, opioid-related deaths nearly doubled – from 591 to 1119 deaths per year.

Notably, most of these deaths involved prescription opioids used for pain, rather than illicit opioids like heroin.

What are the changes?
These changes will affect the quantity of opioids provided for short-term pain, limiting amounts to a single supply with a smaller quantity for each prescription. For example, smaller packs may contain 10 tablets rather than 20.

People requiring an additional supply for short-term pain will generally need to visit the doctor again (as opposed to receiving a repeat prescription).

There will also be new restrictions for patients starting on high-strength opioids for chronic pain, such as morphine and fentanyl. A person with chronic pain will need to try other types of pain relief, including lower-strength opioids, before being eligible for high-strength opioids.

Additionally, where opioid use exceeds – or is expected to exceed – 12 months, the patient will need to seek a second opinion to approve ongoing prescriptions.

People who are using opioids for 12 months or more will need to get a second medical opinion. Shutterstock

Are these changes positive?
These changes reflect our improved understanding around the more limited role opioids should play in pain management.

Although opioids are effective for short-term severe pain, we know for every extra day of opioid medicines supplied, the risk the person will end up on opioids long-term increases.

Research in the United States showed the number of days’ worth of opioids given on the first opioid prescription was the strongest predictor of continued opioid use.

Australian research also found receiving a larger total quantity of opioids on the first prescription was associated with a greater chance of long-term use.

This suggests smaller initial supplies may be a critical step in preventing people from developing patterns of long-term use and potentially dependence or addiction.

Reassuringly, hospitals have been able to dramatically reduce the quantity of opioids supplied after surgery with no changes in the amount of pain patients reported, and no change in complications at follow-up.

These kinds of studies indicate we have probably been supplying many more opioids than are needed.

Smaller supplies could save lives
Supplying smaller quantities is also important because although opioids work well in the short term, we know when the duration of use extends beyond the short term, the harms can outweigh the benefits.

Opioids don’t work as well after the body adapts to their effects with long-term use. The dose is often increased to get the same effect, and with an increased dose comes an increased risk of harms, such as fatal overdose.

The other concern with larger supplies of opioids is that leftover medicine in the family home can become a source for non-medical use. Reducing supply of opioids will mean they’re less likely to be sitting around in the medicine cabinet, where they can potentially be misused.

One study showed the likelihood of experiencing an overdose was three times higher if someone in the person’s family was prescribed opioids.

People with chronic pain
Some people using opioids for longer-term pain may find these new regulations challenging.

But the changes will hopefully help people in this group in the longer term, as opioids are not always appropriate for chronic pain. The need for second opinions may help facilitate appropriate use and discussions about alternative approaches to pain management.

However, second opinions might be hard to arrange in practice. Opioid use is higher in places where pain services are harder to access, most commonly outside metropolitan areas.

The large shifts towards telemedicine we’ve seen as a result of COVID-19 may be useful in addressing the disparity of service access in rural areas, if these changes are maintained.

Opioid use is higher in areas where pain services are less accessible. Shutterstock

The other issue that might occur is substitution towards less restricted medicines with the tightening of supply on opioid medicines. If alternative medicines are prescribed that are safer and clinically appropriate, this will be a good outcome. But we don’t want to see more dangerous or less effective medicines prescribed in place of opioids.

There have been concerns around increased and potentially inappropriate use of other pain medicines such as pregabalin – a medicine intended to be used for nerve pain.

We’ve seen a lot of focus on opioids, but these are not the only medicines that can cause harm. The challenge when using high-risk medicines like opioids for pain is with getting the right balance between benefits and harms. But these changes appear to be a step in the right direction.

What don’t we know?
Almost all the studies that help us predict the effects of these changes were conducted in the US. Opioid-related harm in the US is much more severe than in Australia, and the health-care system is vastly different.

That said, Australian trends in opioid-related harms are quite similar, though they are five to 10 years behind the US.

The aim is to use opioids for the shortest period at the lowest effective dose, rather than to avoid their use altogether. While we want to minimise their misuse, opioids are effective and important medicines for pain. In many countries, a lack of supply is a key health issue. We don’t want the pendulum to swing too far.

We will need to carefully monitor the outcomes of these changes to identify any unintended consequences.The Conversation

Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash University

This article is republished from The Conversation under a Creative Commons licence. Read the original article.

Will the new restrictions have an impact on how you manage chronic pain? Do you support the changes?

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    COMMENTS

    To make a comment, please register or login
    tisme
    1st Jun 2020
    4:04pm
    new rules on pain meds , 18 months ++ to see a specialist what next
    Senior without family
    1st Jun 2020
    8:14pm
    I agree. What state are you in and are you in the country.
    Kato
    1st Jun 2020
    8:16pm
    I have doubts as to the veracity of the number of overdoses caused by overuse or misuse being the sole cause there is no mention of old age or illnesses playing any part in these Deaths. To try and link the The American statistics onto those in Australia point blank is misleading.
    The American experience was caused by medico's pushing big pharma made fentanyl for profit. Big doses from the start and old people were hooked then cut off making them turn to street heroin. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140023/
    I have been using opoid patches for over ten years managed and monitored by my GP and are yet to be hooked.
    Ted Wards
    3rd Jun 2020
    9:15am
    Surely Kato you wont know if your addicted unless you stop taking them? If you have been on the constantly for 10 years then the does will have had to be increased when your body gets use to the dose? Its terrible that you've had to use them for pain for that long.
    Laura52
    4th Jun 2020
    8:09am
    Kato, agree with Ted here, being a pharmacist and having worked in a hospital as well. You won't know unless you suddenly ceased your medication which leads to withdrawals, physical and mentally. Unfortunately, more people are ending up in emergency due to overdoses and misuse of prescription medications than due to the usual street medication, especially with people doctor shopping for these drugs ( fortunately stricter online monitoring has started to keep people safe). These prescription drugs are sold on the street for hefty prices from what I have heard. Also, people are combining these medications with other medications such as the benzodiapines, leading to deaths from respiratory depression.
    Senior without family
    1st Jun 2020
    8:25pm
    There is no specialist anywhere near me. I ended up in hospital for 6 weeks after reacting very badly to the steroid medicine I have had to start again now due to a real flair up in rheumatic pain. We can only do it at a very low rate because of it. The pain is terrible. I also have bad effects with many other pain type medicines and they effect my breathing at night with sleep apnea. If they are withdrawn without substituting adequate access to specialists then at my age, with no quality of life or family for support so would think There are risks of suicide. This has exactly the same end product so so don't see the benefit. Unless they can supply adequatevtreatment first.
    80 plus
    2nd Jun 2020
    8:24am
    9 deaths a month= ban it, what next? ban booze, tobacco, motor vehicles if the drug is needed and recommended by a doctor that should be good enough.
    SuziJ
    2nd Jun 2020
    9:36am
    I used to be on fentanyl patches for my pain when I lived in Canberra. Can't get a doctor down here to even acknowledge the condition of fibromyalgia, let alone prescribe anything 'heavier' than Panadol Osteo which does absolutely nothing, as it targets the bones, not the muscles. I can't even have a massage as it hurts far too much.

    Now to get any pain medication, I have to see a second doctor - how and when is my question. I don't think that there's any pain clinic any nearer than Canberra or Melbourne and I can't travel that far by myself.
    Marty1
    2nd Jun 2020
    12:39pm
    I have suffered with chronic pain since 1983 & I’ve been on many medications over the years & yes I’ve been on Fentynl 100mg but I’ve been trying to get off it now in the year & I’ve got down to 12.5mg . My pain & mental health has suffered not just the last year but for many years. This morning I saw the doctor & he said that the government had cracked down on them & he could not give me a prescription so now I’ve got to go cold turkey as I don’t have any patches left. This is cruel as no reduction period was given to tritrate off this medication. I want to know why the government has not contacted people like myself earlier to inform us of these changes, it’s a bloody disscrease
    Laura52
    4th Jun 2020
    7:58am
    Hi Marty1, I am a pharmacist. I have a very young patient who has been trying to get off fentanyl and another opioid for a long time after surgerydue to a genetic condition, hip dysplasia which resulted in 2 surgeries and one surgery affected his nerve, inducing numbness. He finds it hard to sleep at night. He is under the care of a pain specialist but reducing the dose of his medication is a struggle..going from low to high and then high to low doses, due to withdrawal effects. I have been trying to help him by researching in how to reduce doses but everyone differs in withdrawal from such medications.There is a dose reduction for Fentanyl and your doctor should know this ( really he should research it...being medical doctor), otherwise he should refer you to a pain specialist, that is if you can get to see one,afford to to see one or have access in your area. The government needs to invest more in pain specialist clinics in hospitals. Fentanyl is a hard medication to get off as it 100 times stronger than morphine. I actually heard about this change on from the news and I am a pharmacist.Go figure. I wish you all the best, and you have done so well in getting to 12.5mg and I hope you are okay..
    Kouklala
    2nd Jun 2020
    3:01pm
    Every now and then I get post herpatic neuralgia, and I find one or two Targin tablets are a wonderful relief. The pain only lasts a day or two when I take 1 or 2 tablets, not at the same time
    lainee
    2nd Jun 2020
    11:12pm
    These articles never mention the people who've used the lesser opioids like codeine intermittently and frugally for probably 50 years with no desire for overuse much less for addiction. These people are not chronic pain patients, and don't need doctors for their occasional painful conditions The alternatives suggested are often more harmful,(especially for the elders) like for instance 1. NSAIDS which exacerbate tinnitus, and are counterindicated with various Bloodpressure meds etc, 2.anti epileptic drugs which can affect cognition and cause falls especially for those with some mobility issues 3. antidepressants which may also react with other meds and increase side effects. Panadol are not effective enough for things like toothache, ruptured discs,and they don't suppress the cough reflex like codeine, and other OTC cough suppressants may increase blood pressure. Such people are not potential over-users and don't need to be treated as such.
    Laura52
    4th Jun 2020
    8:00am
    I agree Iainee...I have heard from my patients ( I am a pharmacist) that when they see a doctor for stronger pain relief they are treated like an addict. I can tell you now when a toothache is severe, which I have had myself, stronger pain relief required for short term use. Yes, not all people take strong pain everyday and only need it for short, acute conditions
    SKRAPI
    5th Jun 2020
    11:12am
    SMALLER DOSES ALSO MAKES BIG PHARMA RICHER & GIVES CHEMISTS MORE BUSINESS BUT IF PAIN WORSENS OR PERSISTS REVISIT Dr. SOME OF THOSE PEOPLE MAY ALSO HAVE O.D. ON PURPOSE ESP. IF PAIN IS VERY INTENSE & SOME ARE LIKE SPINE FRACTURES
    SKRAPI
    5th Jun 2020
    11:17am
    IF MY PAIN IS VERY BAD IN FUTURE I WILL TAKE WHAT I CAN MY BODY MY PAIN


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