Unintended consequences of using real time prescription monitoring systems

To the Editor: More Australians die of prescription medication overdose than of illicit drug use or motor vehicle accidents.1 Real time prescription monitoring systems have been recommended to track patients’ supply history for potentially high risk medicines, including strong opioids and benzodiazepines. These programs aim to assist in the early identification of high risk medicine use to inform clinical care, and have received broad support from pharmacy and medical professional groups.

However, the use of prescription monitoring systems by prescribers and pharmacists is voluntary and uptake has been limited.1 From April 2020, Victoria will be the first state in Australia to mandate the use of its newly implemented real time prescription monitoring system, called SafeScript (https://www2.health.vic.gov.au/safescript). An automated algorithm will place a red, amber or green flag against a patient's profile to highlight medication‐related risk based on the patient's prescribing and dispensing history. All Victorian community prescribers and pharmacists will be required by law to check a patient's SafeScript profile before prescribing or dispensing monitored medications. Similar programs across North America led to decreases in prescription rates of monitored medicines and in reductions in multiple provider episodes or “doctor shopping”.1

Nevertheless, these programs have been associated with unintended harms, including increased use of and overdose deaths from more accessible, illicit substances (eg, heroin or fentanyl); refusal of health care; and undertreatment of pain resulting in significant physical and psychological patient distress.2,3 Perceived scrutiny from the monitoring systems has resulted in some prescribers’ and pharmacists’ refusing to supply potentially high risk medications despite appropriate clinical indication. The abrupt discontinuation of benzodiazepines and opioids carries a risk of seizure and overdose death, especially in chronic opioid therapy.3

Addiction elicits some of the highest stigma in health care4 and may undermine the quality of care for patients with chronic pain (a population that has historically relied heavily on these medicines), who report feeling abandoned by the health care system. The use of the traffic light algorithm may also have a strong impact on clinical decision making, a phenomenon known as “automation bias”, where health care professionals place more emphasis on the default settings of automated systems (eg, red, amber or green flag) at the expense of other relevant emotional and psychosocial patient information.5

With the introduction of mandatory implementation of SafeScript, the number of people identified as being at risk of medication‐related harm will increase.1 In the face of potential unintended harms, it is critical that specialist pain and alcohol and other drug treatment services are appropriately resourced and that there is affordable access to multimodal pain management and psychological services. Prescribers and dispensers need comprehensive training and resourcing so patients can access affordable services.

Ongoing evaluations of SafeScript are required to examine the impact of the system on prescribers’ and pharmacists’ clinical practice, patient psychosocial wellbeing, stigma, clinical care, and patient–provider relationships. These evaluations would inform decisions around national implementation of real time prescription monitoring systems, practitioner training, and the provision of sufficient drug treatment services, and would help minimise any unexpected harms.