Topics

Emergency medicine

Indigenous health Research letters 13 June 2022 Free

Value of single troponin values in the emergency department for excluding acute myocardial infarction in Aboriginal and Torres Strait Islander people

Aboriginal and Torres Strait Islander people may benefit from culturally appropriate cardiac risk factor management

Jaimi H Greenslade · Sara Berndt · Laura Stephensen · Katrina Starmer · Greg Starmer · William Parsonage · Victor Lau · Tileah Drahm‐Butler · Tania Davis · Virginia Campbell · Richard Stone · Robert Bonnin · Sarah Ashover · Tanya Milburn · Elizabeth Mowatt · Karlie Proctor · Anthony Brazzale · Louise Ann Cullen

Mja2 51544
Emergency medicine Letters 13 December 2021 Free

Ambulance ramping, system pressure, and hospitals in crisis: what do the data tell us?

To the Editor: Recent media reports imply there is an increased pressure on Adelaide’s metropolitan emergency medical system which has resulted in additional ambulance ramping and consequent industrial action.1,2,3 We collected a novel dataset of emergency department (ED) capacity state observations at 30‐minute intervals from the public South Australia ED Dashboard4 to investigate the claims of increased pressure. The dashboard uses a traffic light system to indicate ED busyness. The 7‐day moving average of the daily percentage of EDs in “green” status (≤ 80% of capacity) oscillated around 25% between 3 October 2019 and 16 March 2020 and then steeply increased to 80%, coinciding with the first wave of coronavirus disease 2019 (COVID‐19) cases in South Australia, which drove a major reduction in ED presentations (Box).5 The graph then shows a slow return to a baseline fluctuation of around 25% until January 2021. Since then, the moving average of EDs in “green” has been lower than 25%, showing an overall trend of increasing pressure over the subsequent months. This pattern is mirrored in the daily percentage of “red” and “white” status (ED at ≥ 95% of capacity). The 7‐day moving average of the daily percentage of EDs in “red” and “white” status exceeded 75% for the first time in February 2021. Four new record highs have been recorded since 10 May 2021, with the highest daily percentage of “red” and “white” observations at 98% on 27 May 2021. The average daily proportion of “red” and “white” observations pre‐pandemic (from 4 October 2019 to 19 March 2020) was 55% and has since increased to 64% (from 5 December 2020 to 29 June 2021), indicating that EDs are currently under significantly more strain. These issues are not new; EDs are one component of a complex interdependent health care system. EDs operating for extended periods at or near capacity is often the most conspicuous symptom of a broader system under pressure. It is doubtful that a solution to this problem can be found within the ED. Long term ED congestion relief lies in redesigning multiple aspects of the health and social care systems, which should involve health care consumer groups. Suggestions include: i) reducing hospital access block, ii) increasing social and community care, iii) adequate hospital beds, iv) alternatives to traditional care such as urgent care facilities or virtual wards, and v) cohort‐specific interventions to reduce ED presentations (eg, rehabilitation centres for alcohol and substance misuse). Box – Seven‐day moving average of the daily proportions of observations of the six metropolitan public hospitals (excluding the Women’s and Children’s Hospital) classified as alert codes “green” (0–80% occupied capacity), “amber” (80–95% occupied capacity), “red” (95–125% occupied capacity), and “white” (> 125% occupied capacity) between 4 November 2019 and 19 June 2021* * Due to problems in the data collection system, the data for the period between 14 and 31 July 2020 are missing.

Laura M Boyle · Mark Mackay · Keith Stockman

Mja2 51335
Cardiovascular diseases Research 5 July 2021 Free

Cardiac arrests in general practice clinics or witnessed by emergency medical services: a 20‐year retrospective study

Objective: To compare the frequency and outcomes of cardiac arrests in general practice clinics with those of paramedic‐witnessed cardiac arrests. Design, setting: Retrospective study; analysis of Victorian Ambulance Cardiac Arrest Registry data, 1 January 2000 – 30 December 2019. Participants: Patients with non‐traumatic cardiac arrests whom emergency medical services staff attempted to resuscitate. Main outcome measures: Survival to hospital discharge. Results: 6363 cases of cardiac arrest were identified: 216 in general practice clinics (3.4%) and 6147 witnessed by paramedics (96.6%). The proportion of patients presenting with initial shockable rhythms was larger in clinic (126 patients, 58.3%) than paramedic‐witnessed cases (1929, 31.4%). The proportion of general practice clinic cases in which defibrillation was provided in the clinic increased from 2 of 37 in 2000–2003 (5%) to 19 of 57 patients in 2016–2019 (33%); survival increased from 7 of 37 (19%) to 23 of 57 patients (40%). For patients with initial shockable rhythms, 57 of 126 in clinic cases (45%) and 1221 of 1929 people in paramedic‐witnessed cases (63.3%) survived to hospital discharge; of 47 general practice patients defibrillated by clinic staff, 27 survived (57%). For patients with initial shockable rhythms, the odds of survival were greater following paramedic‐witnessed events (adjusted odds ratio [aOR], 3.39; 95% CI, 2.08–5.54) or general clinic arrests with defibrillation by clinic staff (aOR, 2.23; 95% CI, 1.03–4.83) than for general practice clinic arrests in which arriving paramedics provided defibrillation. Conclusion: Emergency medical services should be alerted as soon as possible after people experience heart attack warning symptoms. Automated external defibrillators should be standard equipment in general practice clinics, enabling prompt defibrillation, which may substantially reduce the risk of death for people in cardiac arrest.

Brian Haskins · Ziad Nehme · Peter A Cameron · Karen Smith

Mja2 51139
Ethics Ethics and law 24 May 2021 Free

Transparent triage policies during the COVID‐19 pandemic: a critical part of medico‐legal risk management for clinicians

A lack of clear protocols elevates risks for clinicians for the consequences of decisions that they have a professional duty to make in the interests of their community Clinicians, ethicists and lawyers have long debated the parameters of triage in response to the inevitable disasters that sporadically overwhelm the health care system. Almost universally, they have advocated for open, transparent and consultative triage protocols, guidelines and legislation to combat biases and to support clinicians making unavoidable decisions in the interests of the community as a whole. The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the importance of transparent triage. While there is considerable debate about ethical aspects of triage protocols, including concerns that the traditional focus on utilitarianism is discriminatory, largely missing from this discussion in Australia is that triage protocols are also important from a legal perspective — as a mechanism to promote lawful decision‐making processes and as a justification or defence to support clinicians’ decisions if a matter is litigated. The purpose of this article is twofold. First, after providing an overview of current COVID‐19 triage policies in Australia, we assess their legal status. Second, we argue that beyond ethics, transparent policies are needed so their compliance with law can be tested, and to enable practitioners to better understand their obligations before making sometimes “impossible” decisions. Australian COVID‐19 triage policies Australian clinicians have seen numerous ethical and professional guidance documents addressing COVID‐19 triage.1,2,3 These documents anticipate that if Australia’s health care system is overwhelmed as in other countries, clinicians will need guidelines to allocate limited resources, including ventilators, beds and highly trained personnel. The umbrella term “triage policy” denotes: (i) broad ethical or operational guidelines with suggested decision‐making principles;1,2,3 and (ii) more specific triage protocols,4 with set inclusion and exclusion criteria, and a process to prioritise individual patients when the system is overwhelmed. Many Australian COVID‐19 triage policies are ethical guidelines, but some Australian hospitals have also developed triage protocols.5 Internationally, the availability and content of such protocols varies widely. In a study from the United States, over half of responding institutions lacked a COVID‐19 triage protocol.6 In 2020, Mitchell and colleagues exposed insufficient transparency and significant variation in Victorian protocols.5 In Australia, primary responsibility for the administration of hospital services lies with the states, which have the power to promote a statewide approach to triage. Although every Australian state and territory has disaster management plans,7 publicly available COVID‐19 triage protocols are lacking. From March 2020 to 27 November 2020, the lead author (EC) regularly searched health department websites for COVID‐19 triage policies, examining both the websites’ content dedicated to COVID‐19 and searching keywords alone and in various combinations (COVID; intensive care; critical care; ICU; triage; framework; guidelines; policy; ethical). These searches revealed few relevant documents (Box 1). New South Wales is the only state to mention a triage guideline, but its COVID‐19 framework does not link to it.8 Queensland Health released an extensive ethical framework for COVID‐19 in April 2020,5 which has since been removed.9 Western Australia has a four‐page ethical framework but no publicly accessible protocol.10 The Commonwealth Government’s COVID‐19 strategy indicates the Commonwealth will work with state and territory governments to “agree on novel coronavirus triage criteria (if required)”,11 but there are no such criteria to date. Given constitutional arrangements, there is no expectation that the Commonwealth Government would provide these. The National Health and Medical Research Council has conducted consultation on an ethics framework for pandemics, but this is limited to ethical guidance. Legal status of COVID‐19 triage policies The prospect of deciding between patients who would benefit from life‐sustaining treatment is distressing. Compounding this is the potential for legal liability. Many of the legal issues that arise in pandemic triage are untested, and various areas of law may be engaged and applied in complex, fact‐specific ways. As other work has detailed, health authorities have wide discretion in making resource allocation decisions, which are generally respected by the courts.12,13 However, in some circumstances, clinicians (and institutions) may be found liable, and decisions may also be challenged on public law grounds (Box 2).13,14,15 These concerns are not merely academic; after Hurricane Katrina one doctor faced possible murder charges and civil lawsuits after several patients died during a hospital evacuation.16 Overseas, some governments have enacted immunity or indemnity laws to protect clinicians making COVID‐19 triage decisions.14,15 No such laws exist in Australia, and they do not appear to have been considered. Absent such laws, triage protocols may provide the next strongest legal defence. Under civil liability legislation, a clinician will generally not be negligent if acting in a manner widely accepted in Australia by peer professional opinion as competent medical practice (professional practice defence).12,13 Concrete advice on the legal significance of triage policies is difficult because the relationship between law and professional guidance is complex and each case is evaluated according to its unique facts. Whether the professional practice defence applies generally depends on the guideline’s nature, author and purported authority.17,18 A policy may create additional obligations beyond those imposed by law (eg, a specific hospital COVID‐19 triage protocol that must be followed by its clinicians), which may inform the legal standard of care.18 However, policy is not necessarily determinative of the standard of care, especially when couched as broad guidance (eg, COVID‐19 ethical guidelines from a professional college).18 Rigid adherence to policy can also be problematic; to meet the standard of care (and broader public decision‐making standards), clinicians must use judgment appropriate to the circumstances.17 Moreover, while policy can establish obligations in addition to the law, law may also impose more onerous obligations than a policy.18 When this occurs the legal standard will prevail. In other words, COVID‐19 triage policies can shape a regulatory response but only within the boundaries of the law. COVID‐19 triage policies may infringe laws in various nuanced ways.14 Liddell and colleagues note that the utilitarian “save the most lives possible” principle underlying most triage policies can infringe patients’ legal rights, many of which are unchanged in a disaster.14 In the United Kingdom, a legal challenge to the National Institute for Health and Care Excellence (NICE) COVID‐19 critical care protocol was initiated on the basis that its heavy reliance on the Clinical Frailty Scale constituted unlawful discrimination.19 In response, NICE revised the protocol to reduce reliance on the Clinical Frailty Scale for some patients. These issues have significant implications for clinicians: Absent a COVID‐19 triage policy, not providing beneficial life‐sustaining treatment is potentially risky because it may be harder to establish the professional practice defence in a negligence action. An institution’s failure to promulgate a policy could also result in claims. Additionally, a triage protocol (with its greater degree of specificity) would generally provide more legal protection than ethical guidelines. While it is lawful for governments and professional bodies to issue COVID‐19 triage policies, these policies should rely on appropriate evidence and must comply with specific jurisdictional laws, such as guardianship and human rights legislation (Box 2). Triage policies promote quality and consistency in decision making and guide clinicians to consider appropriate factors. However, clinicians must still exercise judgment which is reasonable and responsive to individual circumstances. Policies should provide guidance for when an individual is denied life‐sustaining treatment, since the duty to exercise reasonable care remains. Where reasonably possible, this may include communicating to the patient (or family) the reasons for the decision, providing appropriate palliative care, and information about complaints or dispute resolution processes. Transparency — not just about ethics From an ethical perspective, legitimate triage decisions require “accountability for reasonableness” — a fair process based on relevant criteria, a publicly accessible rationale, and (to the extent possible given the urgency of decisions) mechanisms for appeal, review and enforcement.20 Transparency is also important from a legal perspective because it subjects triage policies to public scrutiny before public health emergencies reach crisis levels. While internal legal advice on triage policies may have been sought, the NICE example illustrates that public scrutiny, consultation and litigation play an important role in testing legal boundaries. In addition to protecting individual patients, this promotes rigorous policy development and evaluation, and also benefits clinicians who are then not relying on policy later found to be deficient.17 It may also alleviate stress caused by uncertainty about protocols. Disclosure of triage policies also delivers a measure of natural justice by providing notice to patients and their families of decision‐making criteria and processes. Conclusion So far, Australia has avoided the scale of pandemic that has overwhelmed health systems elsewhere. While in this context, governments’ reluctance to develop and/or release triage protocols until a crisis has arrived is politically understandable, such a course of action carries significant risks. Public confidence is enhanced when governments have the political courage to embark on these difficult public debates in advance of need. Prioritising some individuals over others when the demand for resources exceeds supply is confronting for clinicians and the community alike, and challenges us to reflect on our deeply held values as a society. When clinicians are allocating scarce resources, they need standards to support their decisions which have been subject to public consultation and rigorous legal review. Australia’s successful management of the COVID‐19 pandemic is offering us the luxury of time to consult and reflect. [Corrections added on 9 June 2021 after first online publication: an additional row was added to Box 1.] Box 1 – Australian triage protocols and ethical guidelines for resource allocation during the coronavirus disease 2019 (COVID‐19) pandemic Jurisdiction COVID‐19 triage protocol or ethical guidelines Type of guidance Publicly available Commonwealth Australian Health Ethics Committee of the National Health and Medical Research Council: An ethics framework for pandemics (in development). Ethical guidelines Anticipated Australian Capital Territory None located on ACT Health website (https://health.act.gov.au). New South Wales NSW Health provides a COVID‐19 framework entitled “NSW adult intensive care services pandemic response planning”.8 The framework indicates that the NSW guideline for resource‐based decision making includes the “use of allocation frameworks and tools” with a reference (but no link to) a document entitled the “NSW Health COVID‐19 intensive care guidance drawn from principles in the NSW Health Influenza Pandemic Plan (PD2016_016). Sydney: NSW Health; 2020”. This 2020 document is based on the NSW Health Influenza Pandemic Plan (PD2016_016), which references the NSW Health policy “Influenza Pandemic – Providing Critical Care (PD2010_028)”. PD2010_028 contains a triage tool (https://www1.health.nsw.gov.au/pds/Pages/a-z.aspx). However, as the updated COVID‐19 intensive care guidance is not publicly available, we cannot confirm that it contains the same guidance as PD2016_016 or the PD2010_028 triage tool. Triage protocol and ethical and operational guidelines No Northern Territory None located on the NT Health Department website (https://health.nt.gov.au). Queensland On 20 April 2020, Queensland Health released a comprehensive ethical framework (developed in consultation with numerous stakeholders) but this has since been removed from its website.9 Ethical guidelines No (initially available but subsequently recalled) South Australia None located on the SA Health website (https://www.sahealth.sa.gov.au). Tasmania None located on the Tasmanian Department of Health website (https://www.health.tas.gov.au). Victoria None located on the Victorian Department of Health and Human Services website (https://www.dhhs.vic.gov.au/clinical-guidance-and-resources-covid-19). Western Australia The WA Health Department website includes a framework to guide decision making on the appropriateness of intensive care management during the COVID‐19 pandemic (last updated 26 June 2020) in its section on COVID‐19 guidance for health professionals.10 Ethical guidelines Yes Box 2 – Examples of potential areas of legal risk in response to pandemic triage decisions* Civil law Withholding or withdrawing beneficial life‐sustaining treatment from one patient to provide it to a patient with a better prognosis could amount to a breach of the duty of care and liability in negligence (subject to the peer professional practice defence for clinicians and the resource allocation defence in the case of hospitals). Criminal law Withdrawing a ventilator from one patient who is stable to provide it to another patient with a greater chance of survival could lead to charges of murder or manslaughter if the first patient dies as a result (charges would be subject to prosecutorial discretion and jurisdiction‐specific defences such as necessity). Commonwealth and state antidiscrimination laws A triage protocol could violate state and territory antidiscrimination legislation if the decision was made on the basis of a protected attribute such as age, disability or race (although specific protections may apply under the legislation for decision makers). Guardianship legislation This applies to patients who lack decision‐making capacity; for example, because they are unconscious, sedated or have cognitive impairment. At common law, medical practitioners have no legal duty to provide treatment that is non‐beneficial. However, the Guardianship and Administration Act 2000 (Qld) makes it an offence to withhold or withdraw life‐sustaining treatment from patients who lack capacity without the consent of an appropriate decision maker, even if providing that treatment would be “inconsistent with good medical practice” (ie, even if that treatment is non‐beneficial). This may preclude some triage decisions in Queensland. A decision to withhold or withdraw beneficial life‐sustaining treatment from a patient who lacks capacity to provide it to someone with a better prognosis may violate state or territory guardianship legislation, which requires health care decisions to be made in a person’s best interests. (This could also result in an emergency application to the Supreme Court to intervene in its parens patriae jurisdiction to protect the patient’s best interests.) * This is a non‐exhaustive list of examples. For an expanded discussion of legal challenges in Australia, see Close et al.13 See further Liddell et al14 for the UK context, which has some similarities to Australia.

Eliana Close · Lindy Willmott · Tina Cockburn · Simon Young · Will Cairns · Ben P White

Mja2 51079
Anaesthetics Perspectives 26 April 2021 Free

Should we be routinely co‐prescribing naloxone for patients on long term opioids?

Community naloxone supply to prevent fatal overdose needs to consider patients using pharmaceutical opioids Pharmaceutical Benefits Scheme (PBS) opioid prescriptions in Australia have increased from 2.4 million in 1992 to 7 million in 2007 to 15 million prescriptions in 2016.1 The corresponding rate of opioid mortality over this time almost doubled from 3.8 deaths per 100 000 Australians in 2007 to 6.7 in 2017,2 with fatal opioid overdoses increasing from 482 in 2002 per 100 000 Australians to 900 in 2018.3 Most of these deaths involved prescription opioids, and contrary to what many assume, only one‐third of prescription opioid‐related deaths involved intravenous drug use.4 Among deaths associated with common prescription opioids (including fentanyl, morphine, oxycodone, tramadol and codeine), 49% involved people with chronic pain.4 Naloxone, a rapidly acting semi‐synthetic opioid antagonist, has an important role in reducing opioid overdoses by acting as an emergency reversal agent.5 It is currently available in Australia for intramuscular injection or nasal spray. The intranasal formulation was listed on the PBS in November 2019 as an unrestricted General Schedule medication. New South Wales, Western Australia and South Australia are trialling a program of take‐home naloxone available free to people using prescription or illicit opioids and at risk of opioid‐related death or those who may witness an overdose.5 Various aspects of patient history including current opioid medications (especially if the opioids are higher doses or slow release preparations) and comorbidities (such as complex diseases, mental illnesses or respiratory conditions) can help identify people who should be recommended to carry naloxone.5 Take‐home naloxone provided to laypeople to administer in the event of overdose was found to successfully reverse more than 96% of community overdoses in a systematic review.6 The evidence of naloxone’s therapeutic effect and life‐saving role has resulted in the drug being carried in most emergency medical kits and included on the World Health Organization Model Lists of Essential Medicines (https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists). Community members, general practitioners and pharmacists frequently perceive naloxone as a medication for people who use illicit opioids, namely heroin.7 However, opioid‐related mortality in people taking pharmaceutical opioids for chronic pain is common. There is a clear evidence–practice gap demonstrating the need for increased discussion about opioid‐related risks and naloxone in this population. In the context of rising pharmaceutical opioid harm, the United States Centers for Disease Control and Prevention provided recommendations for co‐prescribing naloxone for at‐risk patients with chronic pain; such patients include those taking an oral daily morphine equivalent dose of 50 mg or more, taking concurrent benzodiazepines with opioids, having a history of substance use disorder, or having a history of overdose.8 Using these indications, an Australian study reported that 78% of patients on Schedule 8 opioids for chronic non‐cancer pain qualified for take‐home naloxone.8,9 Yet current national data show that less than 3% of all naloxone supplied is on individual PBS prescriptions, with most naloxone prescriptions accounted for by harm reduction programs.10 An additional negligible amount of naloxone is sold over the counter by pharmacists.10 Between 2014 and 2018, an estimated 10 642 units of naloxone were supplied in Australia. Even if a large proportion of this were dispensed to people taking pharmaceutical opioids for chronic pain, it would be vastly insufficient given the 300 000 Australians receiving long term opioids each year.10,11 The majority of Australian patients on pharmaceutical opioids who are at risk of overdose do not appear to be prescribed this emergency medication. Health care provider attitudes towards pharmaceutical opioid‐related risk may be contributing to low naloxone prescribing rates. In qualitative work, Australian GPs described hesitancy in prescribing opioids to younger and middle‐aged patients with chronic pain due to perceived risks of opioid‐related harm.12 In contrast, GPs were more comfortable prescribing opioids for older patients, as they believed there was a lower risk of serious opioid‐related harm in this population.12 These findings highlight doctors’ subjective judgements of overdose risk, which may be a barrier to recognising patients who would benefit from take‐home naloxone. Similar qualitative work highlighted that the biggest barriers to naloxone prescribing were low levels of awareness about naloxone, and unwillingness by doctors to prescribe it.7 This may be driven by incorrect beliefs that patients on pharmaceutical opioids are at low risk of overdose, lack of knowledge, and incorrect patient reporting of actual opioid use.7 GPs and pharmacists are ideally placed to provide and advocate for routine take‐home naloxone. GPs prescribe just over half of all opioids in Australia13 and are the main health care professional seen regularly by people taking opioids for chronic pain. Conversations about naloxone initiated by health care providers present an opportunity to highlight proactive steps to reduce opioid‐related risk, and also raise awareness of overdose management. Unfortunately, community knowledge about opioid‐related risk is low, and most people prescribed opioids for pain are unable to identify common signs of potentially fatal opioid toxicity.14 Improved naloxone prescribing alone is therefore unlikely to be effective without education and increased awareness of opioid overdose signs by patients, family members, friends and carers — who are the expected administrators of naloxone in the event of overdose. One commonly cited barrier to prescribing take‐home naloxone is fear that patients may be offended by the offer or recommendation.7,14 However, Australian research shows that when informed about naloxone, most people prescribed opioids for pain would want or in fact expect their doctor to prescribe it to them.14 Sensitivity around language is key to openly communicating with patients about this issue. Terms like “overdose” still carry considerable stigma and are poorly understood by laypeople. A more patient‐centred approach (and to avoid having important health messages dismissed as irrelevant by patients), might involve changing our language to use terms like “severe opioid‐related side effects” or “life‐threatening opioid toxicity” instead of “drug overdose” to explain the same concept. Discussing naloxone may also help patients recognise the level of harm associated with non‐indicated opioids. The therapeutic benefit of opioids for chronic pain is limited and guidelines strongly caution their use.13 Presenting naloxone as a necessary medication for people on long term opioids may help patients better understand the implications of taking these strong analgesics. This may intuitively encourage patients to request opioid deprescribing or dose reductions. Conversely, increased prescribing of naloxone may risk providers (and patients) justifying high dose opioid prescriptions by relying on naloxone as a safety net. These fears are common with opioid harm minimisation efforts but are not supported by evidence6 and should not detract from the expected number of lives that could be saved by naloxone. A novel approach may be to consider routine co‐prescription of naloxone for patients on strong long term opioids. Laxatives and antiemetics are commonly co‐prescribed with opioids by providers cognisant of common opioid side effects; however, this concept does not seem to extend to naloxone. Take‐home naloxone for people on opioids is analogous to intramuscular glucagon for patients with diabetes on insulin, or auto‐injectable adrenaline for anaphylaxis. Most people are unlikely to need these emergency medications, but in the case of profoundly dangerous adverse events, naloxone, like glucagon or adrenaline, has a life‐saving role. Changing the narrative around take‐home naloxone from “overdose treatment” to “routinely prescribed emergency medication” may help provider attitudes and encourage the normalisation of naloxone prescribing. Our conservative estimate suggests that about 200 000 naloxone scripts would be indicated annually using this approach, at a cost of $40–50 each on the PBS.8 This is comparable with the PBS cost of an adrenaline auto‐injector or glucagon, which are both listed at $40.15 The estimated volumes of naloxone required would also be similar to combined PBS prescription volumes of glucagon (about 44 000 prescriptions) and adrenaline auto‐injectors (about 110 000 adult prescriptions and 28 000 paediatric prescriptions) according to Medicare statistics of PBS prescriptions from July 2019 to June 2020, excluding doctor’s bag prescriptions.15 We present these comparisons between naloxone and other widely accepted emergency medications to show the severity of current naloxone under‐prescribing. From a health economics perspective, increased naloxone prescribing at the rates we suggest would cost the Australian a similar amount to glucagon and adrenaline combined through PBS reimbursement. Further, naloxone would still cost only a fraction of current PBS‐subsidised opioid prescriptions (oxycodone alone costing over $61 million in 2018–201915) and overdose‐related hospitalisation costs. Naloxone may assist with reducing opioid prescription rates and cost, and most importantly would save lives. GPs and pharmacists should consider discussing and co‐prescribing take‐home naloxone with opioids for patients with chronic pain. Australia’s increasing prescription opioid overdoses demands this conversation. However, normalising the role of naloxone as a routinely co‐prescribed emergency medication will require major changes in community and health care provider attitudes, improved awareness of the role of naloxone, and reduction of overdose‐associated stigma. Ongoing collaborative efforts are needed to embrace higher prescribing and dispensing of naloxone.

Pallavi Prathivadi · Suzanne Nielsen

Mja2 51026

Subscribe to MJA email alerts

No spam, you can unsubscribe anytime you want.

By providing your information, you agree to our Terms of Use and our Privacy Policy.

Thanks for Subscribing! Tell us more

Your email updates will use your name.

Good one! Your updates are coming

Thank you for subscribing to the MJA email alerts. Receive the latest content in your inbox.