I would like to acknowledge the traditional custodians of this land I would also like to pay my respect to their Elders past present and emerging and extend that respect to other Aboriginal ID: 753349
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Slide1
SafeScript
Training Slide2
Acknowledgement of country
I would like to acknowledge the traditional custodians of this land. I would also like to pay my respect to their Elders,
past, present
and
emerging and extend
that respect to other
Aboriginal
people present today.
Facilitators Slide3
AGENDA
Introduction & overview
2
mins
Session 1 – What is SafeScript?
20 mins
Break
Session 2 – High-risk medicines & clinical practice – Case discussion
60 mins
Break
Session 3 – Challenging conversations – Case discussion
45 mins
Q&A
10 mins
Close & evaluations
5
minsSlide4
OVERVIEW
SafeScript is a real-time prescription
monitoring
system that enables prescription records for certain monitored medicines to be stored centrally & accessed by prescribers & pharmacists during a consultation to aid clinical decision making.Slide5
SESSION 1
ABOUT SAFESCRIPT
Handouts in the satchels
References & resources on SafeScript Hub
Slides in satchel & on Hub
Case study in satchelSlide6
KEY INFORMATION
Study area October 2018
All PHNs April 2019
Mandatory April 2020
SafeScript Resources Hub
Online modules
Register to access SafeScript
SafeScript web portal Slide7
MONITORED MEDICINES
Medicine Group
Including …
All Schedule
8 medicines
Selected Schedule 4 medicines
All benzodiazepines (bromazepam, clobazam, clonazepam, diazepam, lorazepam, midazolam, nitrazepam, oxazepam, temazepam)
Z-drugs (zopiclone & zolpidem)
Quetapine
Combination
medicines containing codeineSlide8
WHAT IT MEANS FOR YOU
Clinical support tool
Additional clinical information
Does not replace clinical judgementSlide9
HOW IT WORKS IN PRIMARY CARE SETTING
Slide10
SAFESCRIPT – THE SYSTEM
Slide11
SAFESCRIPT – THE SYSTEM
Slide12
HOW IT WORKS IN HOSPITAL SETTING
No prescribing
& dispensing records
now
SafeScript web portal access – no notifications
Not mandatory in
ED or
for hospital inpatients
Access at discharge
FAQ for hospital staffSlide13
NOTIFICATIONS
GREEN
A green notification will appear when there is no recent history or when monitored medicines have only been prescribed from a single prescriber & there are no alerts
AMBER
An amber notification will appear when there is information in SafeScript which requires review
RED
A red notification will appear when there is an alert which requires further investigation by the practitionerSlide14
NOTIFICATIONS - ALERTS
Alert situation
Details
Multiple providers
When prescriptions from 4 or more prescribers/medical practices/pharmacies have been recorded in SafeScript within last 90 days
Exceeding opioid dose threshold
When daily morphine equivalent dose (calculated based on an average over last 90 days) exceeds 100mg MED daily (i.e. a high-risk dose)
High-risk drug combinations
When prescriptions for certain drug combinations recorded in SafeScript within last 90 days
Methadone
+ a benzodiazepine
Methadone
+ another long-acting opioid
Fentanyl + a benzodiazepine
Fentanyl + another long-acting opioidSlide15
REGULATORY & PERMIT CHANGES
Regulatory requirements
Only view if
involved
in patient’s care
DOB on scripts
or entered
at
dispensing
MATOD
prescription recording
Permit
requirements for S8
medicines
Reduced requirements when
prescribers check SafeScriptSlide16
PATIENTS
Only access &
disclose information when
appropriate
Keep
login details confidential
Counsel patients in private
Advise patients to correct data
where captured
What
it means for patients
Patient anxiety
Be respectful
Safety is the focusSlide17
BREAK
2
minsSlide18
UNDERTAKING CLINICAL ASSESSMENT
Full medicine &
illicit drug history
Risk screening
Physical examinationSlide19
SAFE & APPROPRIATE PRESCRIBING
Review patient medicine history
Review all information available (dispensing, prescribing, SafeScript)
Confirm diagnosis
Drug inxs, disease inxs, contraindications, pregnancy, breastfeeding
Ensure therapeutic
need
Non pharmacological approaches
Non high-risk medicines
Supply
intervalSlide20
SAFE/APPROPRIATE
PRESCRIBING
Observe signs of intoxication (opioids)
Drowsiness Nausea
& vomiting
Drowsiness
Nausea & vomiting
Shallow breathing
Pinpoint pupils (pupil constriction)
Hypotension
Dizziness
Slowed/slurred speech
Unsteady gait
Confused state
Disinhibition
Drooling
Itching/scratching
Hypoventilation
Observe signs of withdrawal (opioids)
Anxiety
Muscle tension/ bone ache/cramp
Sleep disturbance
Hot & cold flushes
Yawning
Lacrimation
Rhinorrhoea
Abdominal cramps
Nausea & vomiting
Diarrhoea
Palpitations
Dilated
pupilsSlide21
SAFE/APPROPRIATE PRESCRIBING
Observe signs of intoxication (benzos)
Sedation
Poor coordination & balance
Impaired memory
Impaired cognitive function
Observe signs of withdrawal (benzos)
Anxiety
Irritability
Palpitations
Tremor
Slide22
SAFE/APPROPRIATE PRESCRIBING
Collaboration & communication
Specify
Concern
Supporting evidence
Appropriate alternatives
Note outcomes in patient
record (not in
SafeScript
)Slide23
SAFE/APPROPRIATE PRESCRIBING
Legal
requirements
Permit
if
required
Report
if
Requested quantities
> reasonably
necessary
Attempted to obtain by false representationSlide24
SAFE/APPROPRIATE PRESCRIBING
Counsel
patient
Specific
requirements for the medicine
Applicable warnings
Risk of dependence
Guidance about storage & disposal
NaloxoneSlide25
DRUG-SEEKING BEHAVIOURS
Requests or complains
Behaviours
Aggressively complaining about need for medicines
Won’t consider other medicines/non-pharmacological treatments
Asking for specific medicines by name
Frequent unauthorised dose escalations after told inappropriate
Asking for non-generic medicines (by brand name)
Finishing prescribed medicine earlier than expected
Asking for medicine dose increase
Unwilling to sign a treatment agreement
Claiming allergies to multiple pain medicines
Refusing or ‘unable’ to provide a urine sample if requested
Refusing to attend diagnostic workup or consultation
Pattern of lost or stolen prescriptions
More concerned about medicine than medical condition
Deterioration in mood/behaviour at home/work, reducing social activities due to medicine side effectsSlide26
DRUG-SEEKING BEHAVIOURS
Inappropriately self-medicating
Inappropriately using GP services
Extra, unauthorised doses on occasion
Multiple doctors for prescriptions
Hoarding medicine
Frequently telephoning the clinic
Using medicine for purposes other than prescribed (enhance mood, sleep aid)
Making repeated unscheduled clinic visits for early refills
Injecting an oral formulation
Consistently disruptive at the clinic
Regularly telephoning clinic outside normal hours or when a particular GP is on call
Using aggressive/threatening language/behaviour towards staffSlide27
HIGH RISK/DEPENDENCE SIGNS
Higher doses than recommended
Length of time
Increase in dose
Withdrawal symptomsSlide28
CONSIDER OPTIONS
Help
patient
recognise the issue
Work
with patient
to set goals for recovery
Help
patient
seek appropriate treatment
Consider evidence-based non-pharmacological options
Consider use of other, lower-risk
medicinesSlide29
SAFE & APPROPRIATE PRESCRIBING
If supplying
Lowest effective dose for shortest possible time
Regular monitoring
Provide patient information
Consider treatment agreement Slide30
STRATEGIES TO MINIMISE PRESCRIBING RISKS & HARMS
One-prescriber, one-practice, one-pharmacy
Smaller
quantities
Staged supply
Take-home naloxone
Tapering/discontinuation
Alternatives to high risk medicines
MATODSlide31
NALOXONESlide32
PRESCRIBING NALOXONESlide33
TAPERING OPIOIDS
Controlled release morphine or other long acting opioid
Scheduled doses
Rate can vary
10% every 2 – 4 weeks
Hold dose if severe withdrawal symptoms
Maintenance dose maybe requiredSlide34
TAPERING OPIOIDS
Example
Slow release morphine 100mg daily – reduce by 10mg per week to 50mg followed by 5mg per week to 20mg followed by 5mg every 2 weeks until off
Fentanyl 100ug patch, suggest reduce by 12.5ug every 2 weeks or month until 12.5ug patch followed by conversion to slow release morphine &
reduction from there Slide35
TAPERING
Slide36
OPIOID TAPERING CALCULATOR
Slide37
TAPERING BENZODIAZEPINES
Taper 15% of starting dose per week
Titrate rate against symptoms
Stabilisation of equivalent diazepam before
reductionSlide38
RECONNEXION BENZODIAZEPINE TOOLKIT
Slide39
TAPERING
Slide40
TAPERING QUETIAPINE
Taper
if taking for >3 months
Dose reduction of 25%-50% every 1-2 weeks
Cease after 2 weeks on minimum dose
Slower withdrawal maybe required if prescribed for longer durationsSlide41
ALTERNATIVES TO HIGH-RISK MEDICINES
Link to
Brainman
videoSlide42
ALTERNATIVES TO HIGH-RISK MEDICINES
Heat
or cold
Referral to other health practitioners
Relaxation techniques
De-sensitisation
Distraction
Aids
& appliances
Review of lifestyle factorsSlide43
ALTERNATIVES - PHARMACOLOGICAL
Simple analgesics
Individually or in combination
Complementary
medicines
Analgesic
adjuvantsSlide44
ALTERNATIVES - PACING
Link to video on pacingSlide45
PAIN MANAGEMENT PLANSSlide46
BETTER PAIN MANAGEMENT
Link to videoSlide47
MATOD
Medication assisted treatment of opioid dependence (MATOD
)
Permit application to treat an opioid dependent person with methadone or buprenorphineSlide48
SUBOXONE
Slide49
SUBOXONE
Slide50
SUBOXONE
Adjust according to clinical response
Day 1: start with 4mg patient may come back later & be given another 4mg (total of 8mg)
Day 2: Up to 16mg
Day 3: Up to 24mg Slide51
DISPENSING MATOD
Any
pharmacy can dispense just need approval Slide52
SUPPORT
HealthPathways
Pharmacotherapy Area Based Networks
RAMPS
DACAS
Victorian Opioid Management ECHOSlide53
IF NOT PRESCRIBING/DISPENSING
Explain the risks/reasons
Help the patient seek appropriate treatment
Consider evidence-based non-pharmacological options for management
Provide referral options if appropriate
Collaborate with other health professionals
Document
Notify MPR if requiredSlide54
MEET JANET
At a medical practice in Maiden
Gully
VictoriaSlide55
QUESTIONS
To work out how Janet came to obtain prescriptions from multiple prescribers, what steps would you
take?
Based
on the information, if you decide to proceed with prescribing oxycodone, what are some approaches you can discuss with Janet to minimize the risks of prescribing? Slide56
JANET
Janet presents at a Pharmacy in Maiden
Gully
Victoria Slide57
QUESTIONS
To work out how Janet came to obtain prescriptions from multiple prescribers, what next steps would you take?
At this stage, what additional information might be required before deciding whether or not to dispense the medicine? Slide58
BREAK
5
minsSlide59
CHALLENGING CONVERSATIONS
Avoid stigma
Patient-centred, shared-decision making
Patient’s readiness to change
Motivational interviewingSlide60
MOTIVATIONAL INTERVIEWING
RULE
R
esist the righting reflex
U
nderstand the patient’s motivations & own reasons to change
L
isten with empathy
E
mpower your patientSlide61
MOTIVATIONAL INTERVIEWING
OARS
O
pen-ended questions
A
ffirmations
Reflections
S
ummariseSlide62
PATIENT RESISTANCE
Agree on direction
Assess readiness to change
Provide brief information about the effects & risks of substance abuse
Create doubt & evoke concern Slide63
MEET JANET
At a medical practice in Maiden
Gully
VictoriaSlide64
QUESTIONS
What
approaches might help Janet recognise this
issue & help
motivate her to change her behaviour? Slide65
LET’S CONSIDER…
What if Janet had been using oxycontin for chronic pain for 6-12 months prior to SafeScript? How will the conversations change
?
What are the treatment options
?
What if your patient has been prescribed quetiapine for sleep or anxiety
?
What if your patient has been taking diazepam for 5 years
?
What if your patient has been prescribed benzodiazepine & a z-drug?Slide66
ACCESS & TRAINING
SAFESCRIPT INFORMATION ACCESS
Only prescribers & pharmacists directly involved in the patient’s care
No patient permission required
No patient access to their SafeScript
record
SafeScript registration
SAFESCRIPT
TRAINING
Training open
to all health
professionals
https://vphna.org.au/safescript-hub/Slide67
HEALTHPATHWAYS & REFERRAL PAGES
https
://westvic.healthpathways.org.au
/Slide68
RESOURCES HUB
https://vphna.org.au/safescript-hub/
Links
References
used in training development
Supplementary training available
Articles of interest
HealthPathways sites
DHHS SafeScript site
…. & more
including these slidesSlide69
ADDITIONAL SUPPORT
PABNs – help manage
patients & optimise available support -
https://www.pabn.org.au/
AMS support – consultations or Opioid Management ECHO
GP
& pharmacist mentoring
HealthPathways
Communities of practice
Clinical consultants
GP Clinical Advisors
DACASSlide70
INFORMATION
Project information - DHHS
SafeScript website -
www.health.vic.gov.au/safescript
Email -
safescript@dhhs.vic.gov.au
Phone - 9096 5633
Pharmacotherapy area based networks
Victorian Opioid Management ECHOSlide71
QUESTIONS
????
EVALUATION
CPD – CERIFICATES
ACRRM
activity
# 13949
– 2 core points
RACGP
activity
# 135060
– 4 Cat. 2 points
APC pending
THANK YOU