Volume 222 Issue 3

Urban green spaces are dynamic contributors to the wellbeing of our cities, offering benefits to the health of humans, society, and natural and managed ecosystems

Craig Williams · Christie Byrne · Shannon Evenden · Veronica Soebarto · Stefan Caddy‐Retalic · Carmel Williams · Yonatal Tefera · Xiaoqi Feng · Andrew Lowe

A discussion on challenges in implementing genomic medicine in Australia and the role of genetic counsellors, their training and relevant skill sets. Evidence for their impact on patient care, clinicians and health services is also reviewed, with barriers to widespread facilitation.

Tatiane Yanes · Eliza Courtney · Mary‐Anne Young · Amy Pearn · Aideen McInerney‐Leo · Jodie Ingles

The use of glucagon-like peptide-1 receptor agonists in the treatment of obesity has the potential to impact one-third of Australians. This warrants due consideration and planning for future funding models, systems and models of care to ensure equitable access

Christopher Kanellis · Kyle Williams · Darcy Q Holt · Jennifer Wong · Rachel David · Ravi Carothers · Suong Le

In 2024, a 30-year-old female resident of Melbourne, Australia, with no past medical history presented to the Royal Melbourne Hospital

Sadid F Khan · Anson V Koehler · Alistair Tinson · Maidhili Chinnappan · Harsha Sheorey · Robin B Gasser

The diaries of captive Australian medical officer Major Kennedy Burnside reveal the role of pathology in the medical infrastructure of Changi prisoner of war camp during the Second World War

Kate Ariotti · Elizabeth Roberts‐Pedersen

Macintyre PE, Jamcotchian MA, Stevens JA. Calling time on the use of modified‐release opioids for acute pain. Med J Aust 2024; https://doi.org/10.5694/mja2.52417 Requirements for individualised opioid titration regimens The opioid prescription The initial dose range of opioid prescribed should vary according to the age of the patient (for opioid‐naïve patients) and the severity of the anticipated pain: ‣ Age is a better predictor of opioid requirements than patient weight ‣ Increasing age is associated with decreased opioid requirements and this appears to be primarily due to pharmacodynamic rather than pharmacokinetic factors; that is, increased sensitivity of the central nervous system with ageing rather than the changes in metabolism and excretion of the drug that might also be seen in older patients ‣ The initial opioid dose range prescribed should be lower in patients with moderate pain than those with severe acute pain; lower doses may also be safer where appropriate monitoring is not reliable Subsequent doses may need to be adjusted according to patient response (analgesic effectiveness and adverse effects) Prescribe an appropriate dose interval (the interval within which additional doses should not be given): ‣ In some settings (eg, where there is 24‐hour medical cover and experienced nursing staff and appropriate monitoring are available) it may be reasonable to order an IR opioid “every two hours as needed”; in other settings “every four hours as needed” may be safer Order “as needed” only and not on a regular (time‐contingent) basis; write maximum 24‐hour dose as “sedation score less than 2” Coprescription of naloxone is suggested The IR opioid should be used for the shortest time possible and in decreasing doses over a short time. Deprescribing starts in hospital and requires involvement of nurses, doctors, ward pharmacists and the patient: ‣ This requires regular patient review ‣ The opioid prescription may need to be rewritten to allow for or assist with decreasing opioid dose trajectories, sometimes on a daily basis Assessment of analgesic effectiveness Unidimensional pain scores are commonly used in the acute pain setting to determine analgesic effectiveness and guide opioid titration: ‣ Do not adjust analgesic regimens, including opioid doses, based on a patient's pain scores alone ‣ Predictors of high pain scores include psychological comorbid conditions (eg, anxiety, catastrophising), pre‐existing chronic pain, and tolerance to opioids, and therefore high scores do not always mean that an opioid — or more opioid — is needed ‣ A patient's pain score trajectory (plotting a patient's pain scores over time) is a more useful indicator of patient progress and can allow identification of psychological distress, the presence of non‐opioid‐responsive pain and post‐operative/post‐trauma complications; pain score trajectories that do not decrease over the first few days are also good predictors of chronic post‐surgical pain. Patients whose pain score trajectories are not decreasing require review ‣ “Chasing” pain scores with opioids to achieve an arbitrarily defined acceptable level of pain or zero pain can lead to increases in the risk of OIVI and PPOU Include an assessment of patient function (eg, using functional activity scores). One example of a functional activity score is: A — no limitation of relevant activity due to pain (relative to baseline) B — mild limitation of activity due to pain C — unable to complete activity due to pain Recognition of OIVI Increasing sedation is a more reliable indicator of developing OIVI than a decrease in respiratory rate: ‣ Respiratory rate can remain within acceptable limits even when OIVI is severe ‣ Record sedation scores (along with pain scores and functional activity scores) at time of administration of the IR opioid and when peak effect is expected (ie, about one hour after administration of an oral IR opioid) One suggested sedation scoring system is: 0 = wide awake, 1 = easy to rouse (and can stay awake), 2 = easy to rouse but unable to remain awake, and 3 = difficult to rouse: ‣ Titrate opioids so that sedation score is always <2 Hypoxaemia may be a very late sign of hypoventilation, especially if the patient is receiving supplemental oxygen Immediate intervention is required if a patient has a sedation score of 2 or 3, regardless of the patient's respiratory rate doi: 10.5694/mja2.52417

People with psychosocial disability or living in lower socio-economic status areas can find it more difficult to gather the evidence required

Jennifer Smith‐Merry · Kyo‐yi J Chang

Australians find it increasingly difficult to have even their most basic health care needs met

Sebastian P Rosenberg · Ian B Hickie

We found inequalities in NDIS access for applicants with physical, psychosocial, and unclassified disability types, particularly for women and girls

George Disney · Yi Yang · Peter Summers · Alexandra Devine · Helen Dickinson · Anne M Kavanagh

Out-of-pocket costs for non-bulk-billed services are particular high for people in remote and socio-economically disadvantaged areas of Australia

Karinna Saxby · Yuting Zhang

The Primary Care Spend model provides a more nuanced analysis of expenditure for primary health care than routine health expenditure reports

Michael Wright · Shona Bates · Andrew W Bazemore · Michael R Kidd

Edible cannabis forms may be less harmful than smoking cannabis, but the acute poisoning risk they pose must be considered

Rose Cairns · Sara Allaf · Nicholas A Buckley

Cathy Latino · Oyekoya T Ayonrinde

Renuka Shanmugalingam · Angela Makris