Alert messages

High-risk clinical scenario A: [Patient name] is currently registered on the Queensland Opioid Treatment Program

This alert rule will trigger for prescribing and dispensing events for patients currently registered on the Queensland Opioid Treatment Program (QOTP), irrespective of whether the patient has been ‘picking up’ their doses.

About this scenario

Patients registered on the QOTP have a current opioid use disorder diagnosis and may be particularly at risk of monitored medicine-related harms.

• To support safe, coordinated care and to minimise burdens on patients, it is recommended QOTP patients have one prescriber and one pharmacy for all monitored medicines they are being dispensed (where possible).

• To view details of the patient’s current QOTP treatment episode, click Patient Profile at the top-right of their profile, expand the Approvals and QOTP Episodes section and view the information in the grid. Clicking on a QOTP episode in the grid will display further details about it.

What prescribers must do (mandatory requirement)

Per the Monitored Medicines Standard, you must not prescribe a monitored medicine to this patient unless:

1.

you are the patient’s QOTP service provider (a patient’s ‘QOTP service provider’ includes both the prescriber with whom the patient is registered on the QOTP, and any other health practitioner who both works within the same clinic/service/practice as that prescriber and is authorised to prescribe approved opioids for the patient on the QOTP);

OR

2.

you:

2.1

have agreement from the patient’s QOTP service provider to prescribe the monitored medicine for the patient; AND

2.2

document the details of that agreement;

OR

3.

if you reasonably believe it is urgent and essential to prescribe the monitored medicine for the patient’s wellbeing, but you are unable to contact the patient’s QOTP service provider to obtain their agreement to do so—you:

3.1

prescribe an amount of the monitored medicine that is not more than 3 days’ supply of the medicine or the smallest available size of a manufacturer’s pack of the medicine (whichever is smallest); AND

3.2

document:

3.2.1

the details of your attempt(s) to contact the QOTP service provider; AND

3.2.2

why you believed it was urgent and essential to prescribe the monitored medicine for the patient.

What dispensers must do (mandatory requirement)

Per the Monitored Medicines Standard, if you hold significant concerns about the clinical appropriateness of dispensing a monitored medicine for this patient, you must:

1.

attempt to communicate with the prescriber regarding your concerns prior to deciding whether to dispense the monitored medicine; and

2.

document:

2.1

the details of your concerns; AND

2.2

the details and outcome of your attempt(s) to communicate with the prescriber.

For noting

• This alert will only trigger if the patient is currently registered on the Queensland Opioid Treatment Program. QScript does not record if a patient is registered on an opioid treatment program in another state/territory, and will not trigger an alert on the basis of a patient being registered on an interstate opioid treatment program.

• If a patient is registered on the QOTP with a prescriber from an Alcohol and Other Drug (AOD) service—any QOTP prescriber at that clinic may prescribe opioid dependence treatment medications for the patient. This means the prescriber(s) writing the QOTP prescriptions for the patient may not necessarily be the same prescriber who the QOTP episode is registered against.

• If a patient is receiving QOTP treatment under ‘shared care’ arrangements between an AOD service and another prescriber—their QScript profile will indicate they are registered on QOTP with an AOD service prescriber, but their medication history may show QOTP prescribing by the shared care prescriber.

• If a QOTP patient’s QScript profile does not show any dispensing records for opioid dependence treatment medications—this should not be interpreted as the patient not receiving the medicines. For example, the patient may be stabilising their dose in an AOD service (i.e. having their opioid dependence treatment medications administered to them as opposed to dispensed). If in doubt, check with the QOTP prescriber.

• QOTP medication history in QScript provides only an indication of the amount of medicine a patient has been dispensed. To confirm dispensing details (including date of last dose), contact the dispenser directly.

High-risk clinical scenario B: [Patient name] has previously been registered on the Queensland Opioid Treatment Program

This alert rule will trigger for prescribing and dispensing events for patients who have previously been registered on the Queensland Opioid Treatment Program (QOTP).

About this scenario

Patients previously registered on the QOTP have been diagnosed with an opioid use disorder in the past and may be at risk of harm as a result of relapse to opioid use disorder or drug-seeking behaviours.

• You may wish to consider discussing with the patient any concerns they may have regarding relapse to opioid use disorder and—if necessary—implementing appropriate risk mitigation strategies.

• To view details of the patient’s previous QOTP treatment episode(s), click Patient Profile at the top-right of their profile, expand the Approvals and QOTP Episodes section and view the information in the grid. Clicking on a QOTP episode in the grid will display further details about it.

For noting

• QScript only holds information about QOTP episodes that were open on or after 1 January 2015.

• This alert will only trigger if the patient has previously been registered on the Queensland Opioid Treatment Program. QScript does not record if a patient has previously been registered on an opioid treatment program in another state/territory, and will not trigger an alert on the basis of a patient previously being registered on an interstate opioid treatment program.

• If a QOTP patient’s QScript profile does not show any dispensing records for opioid dependence treatment medications—this should not be interpreted as the patient not having had received them. If in doubt, check with the previous QOTP prescriber.

• QOTP medication history in QScript provides only an indication of the amount of medicine a patient has been dispensed. To confirm dispensing details (including date of last dose), contact the previous QOTP prescriber or dispenser directly.

High-risk clinical scenario C: in the previous 90 days [Patient name] has been dispensed monitored medicine prescriptions written by four (4) or more prescribers.

This alert rule will trigger for prescribing and dispensing events for patients who in the previous 90 days have been dispensed monitored medicine prescriptions written by four (4) or more prescribers.

About this scenario

Patients receiving monitored medicines from multiple prescribers may be at risk of being provided fragmented or poorly coordinated healthcare, which in turn may increase their risk of overdose or other harms as they may:

• receive sub-optimal treatment for their clinical condition(s); and/or

• gain access to excessive quantities and/or high-risk combinations of monitored medicines.

‘Oversupplied’ patients

Where a patient is receiving monitored medicines from multiple prescribers, you should carefully consider whether the patient is ‘oversupplied’ or otherwise at risk of monitored medicine-related harm.

An oversupplied patient may have undiagnosed substance use disorder, be at risk of overdose, be misusing or diverting their medication or may have a medical condition that is not being appropriately managed.

Patients who are not oversupplied

Some patients may be consulting multiple prescribers but are receiving quantities of monitored medicines appropriate for their clinical condition i.e. they are not oversupplied. For example:

• A patient may consult different prescribers (at different practices or at the one practice) depending on their availability.

• A patient may be prescribed monitored medicines from a range of multidisciplinary health practitioners concurrently involved in their care e.g. a dentist, general practitioner, orthopaedic surgeon and psychiatrist.

Drug-seeking behaviour

Drug-seeking behaviour is not limited to users of illicit drugs or patients seeking to use their medicine for non-therapeutic purposes or divert their medicine to others. Patients displaying drug-seeking behaviour may have legitimate medical conditions but have, or are developing, a substance use disorder. Others may have undiagnosed or under-treated medical conditions.

Where there is a concern that a patient may be displaying drug-seeking behaviour or misusing their monitored medicine(s), it is important for you to:

• assess the level of risk of harm to the patient (and others)

• implement risk mitigation strategies proportionate to the risks identified

• avoid making assumptions about or stigmatising the patient.

How QScript counts the number of prescribers

• QScript only counts prescribers of prescriptions which have been (or are currently being) dispensed. Prescriptions that have not yet been dispensed do not contribute to the prescriber count.

• QScript counts every individual prescriber as a unique prescriber, even if multiple prescribers work at the same practice. Reviewing the patient’s QScript medication history may assist in identifying if monitored medicine prescriptions were generated from prescribers practising from the same or different locations.

High-risk clinical scenario D: [Patient name] is receiving an average total daily opioid dose of 100mg OME or greater, and may be at increased risk of harm.

This alert rule will trigger for prescribing and dispensing events for patients whose average total daily opioid dose:

• is currently 100mg oral morphine equivalent (OME) or greater—based on the amount of opioids dispensed over the previous 90 days; or

• will be 100mg OME or greater—based on the amount of opioids dispensed over the previous 90 days (if any) and the amount of opioids currently proposed to be prescribed or dispensed.

About this scenario

Patients consuming high doses of opioids, whether as a single opioid or combination of different opioids, are at increased risk of accidental overdose.

Although Queensland Health has identified a daily dose of 100mg OME daily as being a high-risk clinical scenario, prescribing opioids at any dose carries some risks.

• Health practitioners should not assume that a patient receiving a daily dose of less than 100mg OME is not at risk of harm.

• As a patient’s opioid dose increases, so does their risk of harm.

Abrupt cessation or rapid deprescribing of opioids without the provision of appropriate ongoing supports may result in serious patient harm and is strongly discouraged.

• While it may be desirable for patients who require opioids to be prescribed lower doses, many patients have been on daily opioid doses of over 100mg OME for a long time. Such patients should be managed carefully and provided appropriate therapeutic support to minimise the risk of patient harm.

• Deprescribing of a patient’s opioids should only occur if it is clinically appropriate, safe to do so and undertaken with patient consent.

• Where deprescribing is clinically indicated, prescribers and patients should collaboratively develop a gradual deprescribing plan, incorporating gradual dose reductions, regular reviews and appropriate supports (e.g. non-pharmacological interventions, psychological and social support).

How QScript calculates average daily opioid doses

• To determine whether the 100mg OME threshold has been met, QScript takes into account the strength, quantity and OME of the opioids dispensed to the patient over the previous 90 days (plus any opioid(s) proposed to be prescribed/dispensed), and averages this out over 90 days.

• QScript does not take into account the prescriber’s dosing regimen instructions (e.g. two tablets, twice a day) when calculating a patient’s average daily OME, as this information is recorded in a free-text field and cannot be factored into the calculation.

• Due to the complexities associated with accurately estimating OME in relation to opioid dependence treatment medications, QScript does not take into account those medicines when calculating whether a patient’s average total daily opioid dose is above or below 100mg OME.

High-risk clinical scenario E: [Patient name] is receiving an opioid and a benzodiazepine / z-drug, and may be at increased risk of harm.

This alert rule will trigger for prescribing and dispensing events for patients who in the previous 90 days have been dispensed:

• an opioid and a benzodiazepine/z-drug (zolpidem or zopiclone); or

• an opioid—and it is proposed they are prescribed or dispensed a benzodiazepine/z-drug; or

• a benzodiazepine—and it is proposed they are prescribed or dispensed an opioid.

About this scenario

Patients concurrently consuming opioids and benzodiazepines/z-drugs are at increased risk of accidental overdose.

Although Queensland Health has identified the combination of opioids and benzodiazepines/z-drugs as being a high-risk clinical scenario, combinations of other prescribed medicines, alcohol and illicit substances can also pose a risk of harm.

For noting

Abrupt cessation or rapid deprescribing of opioids or benzodiazepines/z-drugs without the provision of appropriate ongoing supports may result in serious patient harm and is strongly discouraged.

• While it may be desirable to avoid co-prescribing opioids and benzodiazepines/z-drugs, many patients have complex care needs for which such combinations may be an appropriate medicine intervention. These patients should be managed carefully and provided appropriate therapeutic support to minimise the risk of patient harm.

• Deprescribing of a patient’s opioids or benzodiazepines/z-drugs should only occur if it is clinically appropriate, safe to do so and undertaken with patient consent.

• Where deprescribing is clinically indicated, prescribers and patients should collaboratively develop a gradual deprescribing plan, incorporating gradual dose reductions, regular reviews and appropriate supports (e.g. non-pharmacological interventions, psychological and social support).

High-risk clinical scenario F: [Patient name] has not been dispensed an opioid in the previous 90 days.

—or—

High-risk clinical scenario F: [Patient name] has not been dispensed a [benzodiazepine / z-drug] in the previous 90 days.

This alert rule will trigger for prescribing and dispensing events for patients who in the previous 90 days have not been dispensed:

• an opioid—and it is proposed they are prescribed or dispensed an opioid

• a benzodiazepine/z-drug (zolpidem or zopiclone)—and it is proposed they are prescribed or dispensed a benzodiazepine/z-drug.

About this scenario

Careful consideration should be given to commencing (or recommencing) a patient on opioids, benzodiazepines or z-drugs.

• Patients who have not recently consumed these medicines may not be tolerant to them, and therefore may be at risk of overdose if commenced at too high a dose.

• Use of these medicines for acute conditions may result in long-term use, which in turn is associated with increased risk of patient harms, including overdose.

• Careful consideration should be given to the prescribed dose and quantity and whether repeat prescriptions are required.

For noting

The triggering of this alert rule does not preclude the possibility the patient may have recently received these medicines via other mechanisms which are not recorded in QScript e.g. the patient may have recently:

• been dispensed the medicine from a public sector hospital pharmacy

• been supplied the medicine in another state, territory or country

• been administered the medicine e.g. in a hospital, prison or residential aged care facility

• been directly given a small supply of the medicine as a treatment dose e.g. on discharge from hospital

• obtained the medicine from family, friends or illicit sources

• consumed left-over/stockpiled medicine.