New skills, fewer scripts and less screen time: 3 resolutions for the new year

Richard Branson said we should put our resolutions in black and white, because that helps us stick to it. Just in case he is right, I wrote down 3 professional & personal resolutions for the new year.

1. Learn a new skill

Rightly or wrongly, one of my fears is deskilling – at a personal level, but also at a macro level as a profession. As Dr Margaret McCartney wrote in the BMJ, the enterprise to streamline medicine by outsourcing certain tasks to protocol-driven non-doctors, runs the risk of deskilling generalist doctors.

There are probably other reasons for losing our skills, such as policy changes and the costs of consumables and maintaining skills. But we can’t always blame others for everything, so I have decided to learn at least one new skill every year.

2. Change prescribing habits

I have made a conscious effort over the years to reduce unnecessary antibiotic prescriptions. I am doing the same with opioid analgesics for chronic non-cancer pain, in line with new RACGP guidelines.

In the case of antibiotic prescribing I had to overcome a few hurdles, such as the fear of not meeting my patients’ expectations or leaving a serious infection untreated.

Talking to colleagues was helpful and I found that – after a careful history, examination and explanation – most patients accept a ‘watch & wait’ approach, with appropriate safety netting.

I feel better for practising less defensive, ‘play it safe’ medicine, which in the end may not be as safe as we’d like to think.

There are parallels when it comes to prescribing opiates. After the GP17 Conference in Sydney I took the RACGP’s 12-point challenge to GPs (see image) and found that I am now spending more time talking with patients about the pros and cons of opioids.

Yes, it is easy to slip up, especially under time pressure and just before lunch or closing time. However, by perseverance the snail reached the ark. I find every small successful dose reduction or non-pharmacological intervention satisfactory. I hope this will be a drive to continue the conversations with patients.

12 point challenge
Image: The 12 Point Challenge to GPs. Source: RACGP

3. Spend less time behind screens

Excessive screen time for children may be linked to several adverse health outcomes, so at home we use an app to limit the recreational time our children spend on their devices – making sure they have opportunities to learn, create and connect in the digital space. This sounds great but in reality it is a never-ending balancing act. It also made me realise that I may not be the best role model here.

It turns out most adults spend more time on their digital devices than they think, which was certainly true in my case. Some of the time behind screens, such as in the consulting room, is difficult to cut back but not all screen time is essential.

I took a social media ‘holiday’ during the month of December and it felt good. So this year I will unplug more often from the social media fire hose. I may even read a book.

This article was originally published in newsGP.

Time for real-time prescription monitoring

It’s a sobering fact: apparently more people die from drug overdose than road traffic crashes.

Perhaps even more concerning is that most of these overdose deaths in Australia are not caused by illicit drugs, but by the fatal mixture of two or more pharmaceuticals – often medications I and my colleagues prescribe to help people improve the quality of their lives.

Take-home message one: The combination of opioids (like oxycontin) and medications such as benzodiazepines (e.g. valium) can be fatal – even more so if mixed with alcohol.

Dealing with drug dependence

Abuse of prescription drugs is a big problem and doctors and pharmacists are often unaware that some of their patients collect prescriptions from several prescribers and pharmacies. This can go unnoticed because our computer systems are not yet linked and the reporting systems have flaws.

For several years the RACGP, AMA and other health bodies have called for the introduction of Australia-wide Electronic Reporting and Recording of Controlled Drugs (ERRCD). Coroners have also been advocating fiercely for an ERRCD system.

Prescribers and dispensers should be able to access and share prescription information but this has only been happening in real-time in Tasmania.

Since 2009 doctors and pharmacists in Tasmania can access prescription information if there is a legitimate clinical need, via a secured, encrypted website. The information includes what opioid medications have been dispensed and when, and if there are concerns about drug dependence or ‘drug seeking’ behaviour.

The Tasmanian real-time prescription monitoring system has stopped doctor-shopping for restricted drugs. Similar data comes from overseas: New York has seen in a 75% drop in patients seeing multiple prescribers after the introduction of ERRCD.

Some sources claim the Tasmanian system has reduced opioid-related deaths, although it has been argued we need a better way of analysing prescription drug deaths.

ERRCD is an essential tool to help prescribers and dispensers, but is only one part of the solution to reduce opioid prescription misuse. We also need to review how we look after at-risk patients, including those living with mental health problems or substance use disorder.

Road to recovery

Chances are that I may actually not improve the quality of my patients’ lives by prescribing opioids or benzodiazepines long-term. There are drawbacks: side effects, risk of dependence, serious bodily harm and death. Occasionally the drugs can make the pain worse, a phenomenon called opioid-induced hyperalgesia.

Take-home message two: There is limited evidence of the long-term efficacy of opioids for the management of chronic non-cancer pain.

Some have argued that opiates such as Endone (oxycodone) have become the new paracetamol and that we also need to reappraise the treatment of pain in the acute setting.

GP teams, allied health practitioners and pharmacists will play a crucial role to help tackle the issues around drugs of addiction – while supporting their patients at the same time. Sometimes input will be required from addiction, mental health or pain disciplines.

Many resourcestools and education opportunities are available to assist doctors. Meanwhile, state governments need to get on with the much-needed introduction of real-time prescription monitoring programs that will ultimately connect into a national network.