tag:theconversation.com,2011:/global/topics/pain-medications-29081/articlesPain medications – The Conversation2024-01-31T19:08:10Ztag:theconversation.com,2011:article/2217472024-01-31T19:08:10Z2024-01-31T19:08:10ZA new government inquiry will examine women’s pain and treatment. How and why is it different?<figure><img src="https://images.theconversation.com/files/572314/original/file-20240131-25-o9jwvw.jpg?ixlib=rb-1.1.0&rect=25%2C12%2C4228%2C2812&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/older-woman-massaging-tensed-rubbing-muscles-2365171835">Shutterstock</a></span></figcaption></figure><p>The Victorian government has announced an <a href="https://www.health.vic.gov.au/inquiry-into-womens-pain">inquiry</a> into women’s pain. Given women are disproportionately affected by pain, such a thorough investigation is long overdue. </p>
<p>The inquiry, the first of its kind in Australia and the first we’re aware of internationally, is expected to take a year. It aims to improve care and services for Victorian girls and women experiencing pain in the future.</p>
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Read more:
<a href="https://theconversation.com/there-is-overwhelming-gender-bias-in-the-ndis-and-the-review-doesnt-address-it-220042">There is overwhelming gender bias in the NDIS – and the review doesn't address it</a>
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<h2>The gender pain gap</h2>
<p>Globally, more women report chronic pain than men do. A survey of over 1,750 Victorian women found 40% are living with chronic <a href="https://www.premier.vic.gov.au/gender-pain-gap-revealed-and-women-arent-surprised">pain</a>. </p>
<p>Approximately <a href="https://pubmed.ncbi.nlm.nih.gov/36038207/#:%7E:text=About%20half%20of%20chronic%20pain,a%20higher%20prevalence%20in%20men.">half of chronic pain conditions</a> have a higher prevalence in women compared to men, including <a href="https://academic.oup.com/painmedicine/article/22/2/382/5961453">low back pain</a> and <a href="https://www.mdpi.com/2077-0383/10/14/3178">osteoarthritis</a>. And female-specific pain conditions, such as endometriosis, are much more common than male-specific pain conditions such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894747/">chronic prostatitis/chronic pelvic pain syndrome</a>. </p>
<p>These statistics are seen <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/stressors-and-bodily-pain/latest-release">across the lifespan</a>, with higher rates of chronic pain being reported in females <a href="https://www.sciencedirect.com/science/article/pii/S0304395911004751?casa_token=fDkFvlrL930AAAAA:SonUMuMgqohViJ2Ok9gGQ7K4G0hChxZYolroR7t5LVSd_uzMnSe_2EBZ4b8blh3GscewZ1bI7Ac">as young as two years old</a>. This discrepancy <a href="https://www.aihw.gov.au/reports/chronic-disease/chronic-pain-in-australia/summary">increases with age</a>, with 28% of Australian women aged over 85 experiencing chronic pain compared to 18% of men. </p>
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Read more:
<a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a>
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<h2>It feels worse</h2>
<p>Women also experience pain differently to men. There is some evidence to suggest that when diagnosed with the same condition, women are more likely to report <a href="https://www.sciencedirect.com/science/article/pii/S1526590011008728">higher pain scores than men</a>. </p>
<p>Similarly, there is some evidence to suggest women are also more likely to report higher pain scores during experimental trials where the same painful pressure stimulus is applied to <a href="https://www.sciencedirect.com/science/article/pii/S0304395911007019?casa_token=ZK8PjH4pXUYAAAAA:UI8K8sKlrWM3OCC7qBucplrA-mct4EU5NZUpQsLQ6WooNWlfxC6MCtTdTKmtyQYjh9kcE08okiQ">both women and men</a>. </p>
<p>Pain is also more burdensome for women. Depression is twice as prevalent in women with chronic pain <a href="https://www.sciencedirect.com/science/article/pii/S0033318207710022">than men with chronic pain</a>. Women are also more likely to report <a href="https://journals.lww.com/spinejournal/FullText/2007/05200/Sex_Differences_in_Consequences_of_Musculoskeletal.17.aspx?casa_token=mgToFxqQuiwAAAAA:Plx0N_ILNIVK_D8NDODFYaYi_HDxbZN2enulMAS0VmIwyCNHd3c62lhEDi_AYDw8Dhz7uX2dPIZ3HoqwnuWoanLH">more health care use</a> and be <a href="https://www.aihw.gov.au/getmedia/10434b6f-2147-46ab-b654-a90f05592d35/aihw-phe-267.pdf.aspx">hospitalised due to their pain</a> than men. </p>
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<a href="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman lies in bed in pain" src="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Women seem to feel pain more acutely and often feel ignored by doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-having-stomach-ache-on-1780468907">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/whats-a-tens-machine-can-it-help-my-period-pain-or-endometriosis-201389">What's a TENS machine? Can it help my period pain or endometriosis?</a>
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<h2>Medical misogyny</h2>
<p>Women in pain are viewed and treated differently to men. Women are more likely to be told their pain is psychological and dismissed as <a href="https://www.tandfonline.com/doi/full/10.1080/03630242.2017.1306606?casa_token=twusk7mU5EcAAAAA%3AG--5Y_nl_bDqsR9k4w-fF8sEMGuGiMlrifAGQKC_j6swOBhYdzzwXeXiNUoR4C9vM2CydSppwLN2">not being real or “all in their head”</a>.</p>
<p>Hollywood actor <a href="https://www.independent.co.uk/life-style/health-and-families/selma-blair-ms-misdiagnosis-symptoms-b2454317.html">Selma Blair</a> recently shared her experience of having her symptoms repeatedly dismissed by doctors and put down to “menstrual issues”, before being diagnosed with multiple sclerosis in 2018. </p>
<p>It’s an experience familiar to many women in Australia, where medical misogyny still runs deep. <a href="https://journals.sagepub.com/doi/abs/10.1177/09593535221083846?journalCode=fapa&">Our research</a> has repeatedly shown Australian women with pelvic pain are similarly dismissed, leading to lengthy diagnostic delays and serious impacts on their quality of life. </p>
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<h2>Misogyny exists in research too</h2>
<p>Historically, misogyny has also run deep in medical research, including pain research. Women have been viewed as smaller bodied men with different reproductive <a href="https://www.sciencedirect.com/science/article/abs/pii/S156925580334024X">functions</a>. As a result, most pre-clinical pain research has used male rodents as the default research <a href="https://journals.lww.com/pain/fulltext/2005/09000/the_case_for_the_inclusion_of_female_subjects_in.1.aspx?casa_token=BcqYDDSRxo4AAAAA:nLvLqpNfuwSm6N4n1kn-Wcj4n9HW__ISaNz57PYp0zX8Nfu9a5cWZdJkjCXVXeU_HKjraI5NbND-rqqzanYuF864">subject</a>. Some researchers say the menstrual cycle in female rodents adds additional variability and therefore uncertainty to experiments. And while variability due to the menstrual cycle may be true, it may be no greater than male-specific sources of variability (such as within-cage aggression and dominance) that can also <a href="https://www.nature.com/articles/s41583-020-0310-6">influence research findings</a>. </p>
<p>The exclusion of female subjects in pre-clinical studies has hindered our understanding of sex differences in pain and of response to treatment. Only recently have we begun to understand various genetic, neurochemical, and neuroimmune factors contribute to sex differences in <a href="https://www.annualreviews.org/doi/full/10.1146/annurev-neuro-092820-105941">pain prevalence and sensitivity</a>. And sex differences exist in pain processing itself. For instance, in the spinal cord, male and female rodents process <a href="https://theconversation.com/pain-really-is-in-the-mind-but-not-in-the-way-you-think-1151">potentially painful stimuli</a> through <a href="https://www.nature.com/articles/nn.4053">entirely different immune cells</a>. </p>
<p>These differences have relevance for how pain should be treated in women, yet many of the existing pharmacological treatments for pain, including opioids, are largely or solely based upon research completed on male rodents. </p>
<p>When women seek care, their pain is also treated differently. Studies show women receive <a href="https://link.springer.com/article/10.1007/s11916-023-01135-0#ref-CR6">less pain medication after surgery compared to men</a>. In fact, one study found while men were prescribed opioids after joint surgery, women were <a href="https://link.springer.com/article/10.1007/s11916-023-01135-0#ref-CR17">more likely to be prescribed antidepressants</a>. In another study, women were more likely to receive sedatives for pain relief following surgery, while men were <a href="https://link.springer.com/content/pdf/10.1007/BF00289259.pdf">more likely to receive pain medication</a>. </p>
<p>So, women are disproportionately affected by pain in terms of how common it is and sensitivity, but also in how their pain is viewed, treated, and even researched. Women continue to be excluded, dismissed, and receive sub-optimal care, and the recently announced inquiry aims to improve this. </p>
<h2>What will the inquiry involve?</h2>
<p>Consumers, health-care professionals and health-care organisations will be invited to share their experiences of treatment services for women’s pain in Victoria as part of the year-long inquiry. These experiences will be used to describe the current service delivery system available to Victorian women with pain, and to plan more appropriate services to be delivered in the future. </p>
<p>Inquiry <a href="https://www.health.vic.gov.au/public-health/inquiry-into-womens-pain-submissions">submissions</a> are now open until March 12 2024. If you are a Victorian woman living with pain, or provide care to Victorian women with pain, we encourage you to submit.</p>
<p>The state has an excellent track record of improving women’s health in many areas, including <a href="https://www.premier.vic.gov.au/groundbreaking-clinic-improving-womens-heart-health">heart</a>, <a href="https://www.health.vic.gov.au/publications/victorian-womens-sexual-and-reproductive-health-plan-2022-30">sexual, and reproductive health</a>, but clearly, we have a way to go with women’s pain. We wait with bated breath to see the results of this much-needed investigation, and encourage other states and territories to take note of the findings.</p><img src="https://counter.theconversation.com/content/221747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Chalmers receives funding from The Hospital Research Foundation. </span></em></p><p class="fine-print"><em><span>Amelia Mardon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women are disproportionately affected by pain in terms of how common it is and sensitivity, but also in how their pain is viewed, treated, and even researched.Jane Chalmers, Senior Lecturer in Pain Sciences, University of South AustraliaAmelia Mardon, PhD Candidate, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2042402023-04-26T19:58:22Z2023-04-26T19:58:22ZAcetaminophen overdose is a leading cause of liver injury, but it is largely preventable<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/acetaminophen-overdose-is-a-leading-cause-of-liver-injury--but-it-is-largely-preventable" width="100%" height="400"></iframe>
<p>Larissa was a 21-year-old Canadian college student recovering from COVID-19 when she died from complications related to an accidental overdose of acetaminophen, a medication in probably every drug store and most medicine cabinets in the country. </p>
<p>At the time of Larissa’s death, her sister Darby was a second-year student at the University of Waterloo School of Pharmacy, where we cover this topic in class. </p>
<p>“We were shocked by how fast it happened,” Darby recalled. “Larissa was healthy and within a week of the overdose, her liver failed, she received a liver transplant, and died from complications. We still don’t know what happened. It’s hard because we realize we likely never will.”</p>
<p>Looking back, Darby recognizes that she will never know how Larissa overdosed, except that she did not mean to. It was probably an attempt to treat her COVID-19 symptoms at a time when she was not eating well. </p>
<p>As a liver specialist and pharmacists, we have cared for hundreds of people with acetaminophen overdoses and worked for years to raise awareness of the dangers of both accidental and intentional overdose. The three of us were developing <a href="https://uwaterloo.ca/pharmacy/resources-services-and-initiatives/health-resources/pharmacy5in5-resources#acetaminophen">educational tools on acetaminophen-related liver injury</a> for health-care providers when we first learned of Larissa’s story.</p>
<h2>Leading cause of acute liver injury</h2>
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<a href="https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An infographic describing the liver risks of acetaminophen" src="https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=776&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=776&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=776&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=976&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=976&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522837/original/file-20230425-20-ybzm1z.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=976&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Acetaminophen is the most common cause of drug-related liver injury in Canada.</span>
<span class="attribution"><span class="source">(Kelly Grindrod)</span>, <span class="license">Author provided</span></span>
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<p>Acetaminophen is in more than 600 products, such as Tylenol, Percocet, Midol, Robaxacet and NeoCitran. Yet, it is also a <a href="https://www.canada.ca/en/health-canada/services/drugs-medical-devices/acetaminophen.html#s4">leading cause of acute liver injury</a>, which can be fatal without a rescue liver transplant. With millions around the world using acetaminophen every day, why are so few people aware of the dangers of overdose?</p>
<p>Approximately <a href="https://www.canada.ca/en/health-canada/services/drugs-medical-devices/acetaminophen.html#s4">4,500 Canadians are hospitalized</a> from acetaminophen overdose each year — 12 hospitalizations per day. Up to <a href="https://www.canada.ca/en/public-health/services/reports-publications/health-promotion-chronic-disease-prevention-canada-research-policy-practice/vol-40-no-4-2020/trends-emergency-visits-acetaminophen-poisonings-2011-2019.html">half of overdoses are accidental</a>, which is what Larissa’s family believes likely happened to her. </p>
<p>The risk is highest for people who regularly drink three or more alcoholic drinks daily or who are malnourished or fasting because for them, an overdose can occur at normal acetaminophen doses (for example, the maximum recommended 24-hour dose for adults is up to 4,000 milligrams, and lower in children). </p>
<p>A common error people make is combining over-the-counter and/or prescription drugs that contain acetaminophen. A <a href="https://doi.org/10.1371/journal.pone.0229070">2020 survey we conducted</a> also found that over half of respondents were not aware extra strength products contain up to twice the dose of acetaminophen compared to regular strength products.</p>
<p>More recently, the shortage of children’s pain and fever products raised concerns about the <a href="https://ismpcanada.ca/wp-content/uploads/ISMPCSB2022-i11-Imported-Acetaminophen.pdf">risk of accidental overdose in children</a>, as parents and guardians looked to use adult products for their children. </p>
<h2>Toxicity and overdose</h2>
<p>Lower doses of acetaminophen are not toxic to the liver: <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4498995/pdf/nihms690826.pdf">most of it is broken down safely by the liver and leaves the body in urine</a>. But the liver has a limited ability to break down acetaminophen.</p>
<p>When too much acetaminophen is taken in a 24-hour period, the liver cannot break it down fast enough. The extra acetaminophen spills over into a back-up pathway in the liver, and the liver breaks the excess down into another product that is toxic to it. The more acetaminophen taken at one time, the more toxic product is made.</p>
<p>In the first 24 hours after an overdose, there may only be mild symptoms such as nausea and vomiting, but many have no symptoms at all. </p>
<p>After one to two days, liver injury begins and symptoms may include abdominal pain, dark coloured urine, and yellow eyes and skin. After three days, symptoms such as bleeding, bruising, confusion and low blood sugar signal that the liver is failing and death can occur.</p>
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<img alt="A open bottle of acetaminophen lying on its side with caplets spilling out" src="https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=440&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=440&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523061/original/file-20230426-221-dv5jxz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=440&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">When buying acetaminophen for common ailments like a headache or arthritis pain, reach for the regular strength product. Extra strength products increase the risk of accidental overdose.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>While the liver may heal itself, around <a href="https://www.canada.ca/en/health-canada/services/drugs-medical-devices/acetaminophen.html#s4">six per cent of people hospitalized for acetaminophen overdose develop liver failure</a>. </p>
<p>Prompt treatment is critical. An antidote is available (an intravenous medicine called N-acetylcysteine) but it is <a href="https://www.ncbi.nlm.nih.gov/books/NBK548162/">most effective if given within 24 hours of overdose</a>. A rescue liver transplant may be needed, especially if treatment is delayed, and many die waiting for a liver or due to complications after liver transplantation.</p>
<h2>Using acetaminophen safely</h2>
<p>Given that acetaminophen remains one of the most common medicines for treating pain and fever, people need to take steps to reduce their risk of liver injury.</p>
<p>Start by <a href="https://safemedicationuse.ca/tools_resources/tips_acetaminophen.html">reading all medication labels</a>. Never take more than one acetaminophen-containing product at a time. Pay close attention to products for arthritis, cold and flu, sleep, menstrual pain and back pain. Do not hesitate to ask the pharmacist for help.</p>
<p>Always check acetaminophen packages for the maximum single dose and 24-hour dose. If the first acetaminophen dose is taken at noon, the 24-hour window ends at noon the next day. Take less if you regularly have three or more alcoholic drinks a day or if you have difficulty eating regularly, such as with an eating disorder, frailty in older age, or during episodes of nausea or vomiting.</p>
<p>When buying acetaminophen for common ailments like a headache or arthritis pain, reach for the regular strength product. Extra strength products increase the risk of accidental overdose.</p>
<p>In the event of an overdose, call <a href="https://www.canada.ca/en/health-canada/news/2023/03/canada-launches-new-toll-free-1-844-poison-x-number-for-poison-centres.html">Health Canada’s toll-free poison control line</a> (1-844-POISON-X) or your local poison control centre for advice on next steps.</p><img src="https://counter.theconversation.com/content/204240/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kelly Grindrod has received research funding from the NSERC PromoScience, Public Health Agency of Canada, Canadian Institutes for Health Research, and the British Academy, and the Canadian Foundation for Pharmacy. </span></em></p><p class="fine-print"><em><span>Eric Yoshida is affiliated with the University of British Columbia and the Vancouver General Hospital. He has participated in clinical trials sponsored by Gilead Sciences, Madrigal, Pfizer, Allergan, Celgene, Genfit, Intercept, Novodisc. He has also received an unrestricted research grant from Paladin Laboratories. He has no conflicts of interest with this current article.</span></em></p><p class="fine-print"><em><span>Trana Hussaini does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Acetaminophen is one of the most commonly used drugs, yet acetaminophen overdose is a leading cause of liver damage. It can be easily prevented.Kelly Grindrod, Associate Professor, School of Pharmacy, University of WaterlooEric Yoshida, Professor of Medicine, University of British ColumbiaTrana Hussaini, Clinical associate professor, Faculty of Pharmaceutical Sciences, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1910672022-09-28T20:02:24Z2022-09-28T20:02:24ZThe TGA is considering paracetamol restrictions due to poisonings – but what does that mean for consumers?<figure><img src="https://images.theconversation.com/files/486715/original/file-20220927-26-1t2wx3.jpg?ixlib=rb-1.1.0&rect=57%2C32%2C5406%2C3604&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/sick-ill-depressed-man-holding-600w-1095874343.jpg">Shutterstock</a></span></figcaption></figure><p>Paracetamol is Australia’s most widely used pain medicine, with <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">65 million packs sold</a> across the country in 2021. It is available everywhere from toilet vending machines, convenience stores, supermarkets, and pharmacies.</p>
<p>The Therapeutic Goods Administration (TGA) is now undertaking a <a href="https://www.tga.gov.au/resources/consultation/consultation-proposed-amendments-poisons-standard-relation-paracetamol-acms-meeting-november-2022">public consultation</a> into access to paracetamol in the community due to concerns about poisonings, especially among young people. </p>
<h2>What is paracetamol and what is it used for?</h2>
<p>Paracetamol (commonly marketed as Panadol, Panamax or Dymadon) is a <a href="https://europepmc.org/article/med/14758787">medicine used</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/15662295">treat pain</a> and reduce fever. </p>
<p>Outside of pharmacies, paracetamol is <a href="https://www.legislation.gov.au/Details/F2022L00730">available in packs of up to 20 tablets</a> (or capsules), while pharmacies stock packs of up to 100 tablets and a range of formulations, including liquids and suppositories. Paracetamol’s wide availability and low cost make it a convenient option for people to self-treat pain without a doctor’s appointment or prescription. </p>
<p>At therapeutic doses, paracetamol is <a href="https://link.springer.com/article/10.2165/00002018-200528030-00004">considered safe for most people</a>, with few side effects when used as directed. </p>
<p>However, it can be dangerous at high doses, resulting in <a href="https://link.springer.com/article/10.2165/00002018-200124070-00003">acute liver toxicity</a>, which in severe cases may lead to death. Although there are <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003328.pub3/full?highlightAbstract=paracetamol">treatments to reverse paracetamol overdose</a>, they need to be given within 2-8 hours to be most effective. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1574257040276525056"}"></div></p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-painkillers-actually-kill-pain-from-ibuprofen-to-fentanyl-its-about-meeting-the-pain-where-its-at-173804">How do painkillers actually kill pain? From ibuprofen to fentanyl, it's about meeting the pain where it's at</a>
</strong>
</em>
</p>
<hr>
<h2>Why is the TGA reviewing paracetamol access?</h2>
<p>The TGA is concerned about harms from paracetamol poisoning, particularly intentional overdoses among young people, which have been seen in <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja2.50296">Australia</a> as well as <a href="https://www.sciencedirect.com/science/article/abs/pii/S0165032720325362?via%3Dihub">internationally</a>. In response, the TGA requested an <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">independent expert report</a> to support its review of paracetamol access. </p>
<p>The report found that between 2007 and 2020, there were 40–50 deaths each year in Australia from paracetamol poisoning. From 2009 to 2017, hospital admissions due to paracetamol poisoning increased from 8,617 to 11,697. They decreased to 8,723 in 2019–20. </p>
<p>Around 80% of these admissions were due to intentional self-poisoning, with young people aged between 10–24 years accounting for 40–50% of these incidents. Hospitalisations among young people due to intentional overdoses from any medicine also increased over this period. Calls to Australian Poisons Information Centres about self-poisonings involving paracetamol also increased over the last decade. </p>
<p>It is important to note that the number of harmful events is low compared to the amount of paracetamol sold in Australia. For every million packs of paracetamol sold, there were 100 hospital admissions for intentional self-poisoning, three hospital admissions for liver injury, and less than one death. And in recent years, both unintentional and intentional self-poisoning admissions per million packs of paracetamol sold have been decreasing. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hand holds two pills" src="https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486717/original/file-20220927-22-d91da.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">More paracetamol involved in intentional self-poisoning was already in the home.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/eindhoven-netherlands-april-14-2022-600w-2147449853.jpg">Shutterstock</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australia-has-a-paracetamol-poisoning-problem-this-is-what-we-should-be-doing-to-reduce-harm-122532">Australia has a paracetamol poisoning problem. This is what we should be doing to reduce harm</a>
</strong>
</em>
</p>
<hr>
<h2>How might paracetamol access change?</h2>
<p>The expert panel made several <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">recommendations</a> including: </p>
<ul>
<li>limiting pack sizes </li>
<li>introducing purchase limits</li>
<li>requiring a prescription to purchase higher amounts and modified-release products (such as Panadol Osteo)</li>
<li>requiring a prescription for people under 18. </li>
</ul>
<p><a href="https://consultations.tga.gov.au/tga/paracetamol_november_2022_acms/user_uploads/pre-meeting-public-notice---paracetamol---november-2022-3.pdf">Additional measures</a> being considered include changes to packaging and how paracetamol is displayed in stores. At the moment, there are no recommendations to make all paracetamol products prescription-only, or to restrict their sale to pharmacies only.</p>
<p>Many of these strategies are focused on reducing potential harm by limiting the amount of paracetamol available. The change to pack sizes available outside of pharmacies would bring Australia in line with countries such as Denmark, Ireland and the United Kingdom. These countries have had restricted pack sizes (maximum 10–16 tablets) for sale outside pharmacies for many years and seen <a href="https://www.bmj.com/content/329/7474/1076">reductions</a> in <a href="https://www.sciencedirect.com/science/article/pii/S016503271932957X?via%3Dihub">hospital admissions</a> and <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040105">deaths</a>. Poisonings among people aged 10–17 years <a href="https://www.sciencedirect.com/science/article/pii/S016503271932957X?via%3Dihub">also went down</a> in Denmark after age restrictions were introduced in 2011. </p>
<p>The <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">expert report found</a> most cases of self-poisoning involve medicines already present at home. So the benefits of these measures may be limited. But limiting pack sizes may help to reduce the overall quantity of medicines available in the home and the risk of a fatal poisoning. </p>
<p>The expert panel also recommended better follow-up care after self-poisoning events. Developing <a href="https://journals.sagepub.com/doi/full/10.1177/0004867415620024">preventative</a> <a href="https://staging.mja.com.au/system/files/issues/198_09_200513/chr11793_fm.pdf">strategies</a> and <a href="https://apo.org.au/node/260121">increasing mental</a> <a href="https://journals.sagepub.com/doi/full/10.1177/0004867418817381">health support</a> is vital to address the drivers of intentional self-poisonings more broadly. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-three-people-with-chronic-pain-have-difficulty-accessing-ongoing-prescriptions-for-opioids-182678">One in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids</a>
</strong>
</em>
</p>
<hr>
<h2>What next?</h2>
<p>Ready access to paracetamol allows people to conveniently self-treat their pain at minimal cost and without visiting a health professional. Reduced paracetamol availability may prompt people to switch to using other pain medicines, such as ibuprofen, which <a href="https://www.healthdirect.gov.au/ibuprofen">carries its own risks</a> and may not be suitable for everyone. </p>
<p>Although limiting harms due to paracetamol poisoning is important, at the same time, the TGA will need to ensure paracetamol remains accessible to those in need. By keeping paracetamol on the shelves of supermarkets and pharmacies in reduced pack sizes, the TGA will be aiming to strike a balance between accessibility and safety. </p>
<p>The biggest potential impact for people living with chronic pain would be brought about by reducing larger pack sizes currently only available in pharmacies (such as those containing 50–100 tablets) and making modified-release paracetamol products prescription-only. The <a href="https://www.tga.gov.au/sites/default/files/2022-09/paracetamol_report_final.pdf">expert report</a> notes that at 665 mg, the modified-release formulation in particular is linked to larger overdoses. As these products are currently only available from pharmacies, authorities would need to show how these changes would significantly reduce harm, without overly burdening people in pain.</p>
<p>The <a href="https://consultations.tga.gov.au/tga/paracetamol_november_2022_acms/consultation/subpage.2020-08-24.4118714205/">TGA is seeking feedback</a> until mid-October to guide its decision. After that the TGA’s expert advisory committee will consider whether to amend the Poisons Standard to change how paracetamol can be accessed. For now, paracetamol is available as usual. </p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call Lifeline on 13 11 14.</em></p><img src="https://counter.theconversation.com/content/191067/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Natasa Gisev receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Ria Hopkins receives funding from the National Health and Medical Research Council and the National Drug and Alcohol Research Centre.</span></em></p>Australians bought more than 65 million packs of paracetamol pain relief last year. TGA efforts to reduce its potential harms will need to take those who use it to manage pain into consideration.Natasa Gisev, Clinical pharmacist and Scientia Senior Lecturer at the National Drug and Alcohol Research Centre, UNSW SydneyRia Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1819412022-04-27T07:19:56Z2022-04-27T07:19:56ZPatients leaving hospital sometimes need opioids. Doctors can reduce risks of long-term use and dependence<figure><img src="https://images.theconversation.com/files/459924/original/file-20220427-18-8sbhf7.jpg?ixlib=rb-1.1.0&rect=50%2C76%2C5597%2C3599&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/illness-asia-patient-women-hospital-concept-540969166">Shutterstock</a></span></figcaption></figure><p>Hospital patients are often given strong, opioid pain medicines when discharged home after surgery and other treatments. This can sometimes lead to <a href="https://link.springer.com/article/10.1007/s40429-018-0227-6">long-term use and dependence</a>. </p>
<p>New <a href="https://www.safetyandquality.gov.au/publications-and-resources/resource-library/opioid-analgesic-stewardship-acute-pain-clinical-care-standard">national standards</a>, released today by the <a href="https://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Health Care</a>, aim to reduce prescribing that increases the risk of dependence. </p>
<p>The standards encourage hospital doctors to consider prescribing alternative pain relief such as paracetamol and ibuprofen for mild to moderate pain where possible. </p>
<p>When stronger pain relief is required – and medicines such as oxycodone, morphine, fentanyl, tramadol and codeine are prescribed – the standards recommend discharging patients with up to seven days’ supply, depending on their circumstances. </p>
<p>So what are the risks of dependence? And how can clinicians ensure pain is adequately managed? </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712">2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year</a>
</strong>
</em>
</p>
<hr>
<h2>Treating pain is a human right</h2>
<p>Acute pain isn’t just unpleasant to experience. Pain causes the body to enter a <a href="https://linkinghub.elsevier.com/retrieve/pii/S0007-0912(17)36344-4">stress response</a>. This can have wide-ranging effects on the body, from raising your heart rate, to reducing the functioning of your immune system. </p>
<p>Uncontrolled pain in hospital may lead to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626380/">poorer patient outcomes</a>: people in pain take longer to recover and may experience longer hospital stays. </p>
<p>Uncontrolled acute (short-term) pain may even <a href="https://pubmed.ncbi.nlm.nih.gov/16698416/">progress to chronic pain</a>, which is much harder to manage and can have significant impacts on a person’s quality of life. </p>
<p>Treating pain is also ethical, and access to adequate pain management has been recognised as a <a href="https://www.apsoc.org.au/PDF/Publications/DeclarationOfMontreal_IASP.pdf">fundamental human right</a>.</p>
<figure class="align-center ">
<img alt="Man sits on the edge of a hospital bed in the dark." src="https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459953/original/file-20220427-14-d1swmt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients have a right to adequate pain management.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-lonely-senior-sitting-hospital-bed-1641717622">Shutterstock</a></span>
</figcaption>
</figure>
<p>There are several reasons why people may experience pain in hospital, including injury, illness or surgery. Internationally, <a href="https://pubmed.ncbi.nlm.nih.gov/26778249/">84% of hospital patients</a> report experiencing pain. And up to <a href="https://pubmed.ncbi.nlm.nih.gov/24237004/">three-quarters</a> of patients experience moderate to severe pain after surgery. </p>
<p>Opioid medicines are commonly used to manage pain in hospital. But with hospitals encouraged to get patients home earlier, many people may still be experiencing pain when they’re discharged. So opioids are also often prescribed on discharge.</p>
<h2>Opioids are high-risk medicines</h2>
<p>Although opioids are effective in treating many types of pain, they are considered “high risk medicines”. They can cause <a href="https://www.painphysicianjournal.com/current/pdf?article=OTg1&journal=42">multiple unwanted effects</a> which <a href="https://pubmed.ncbi.nlm.nih.gov/12891220/">range in severity</a> from nausea and constipation, to life-threatening breathing problems and loss of consciousness. </p>
<p>Prescription opioid use has increased internationally over the past 30 years. In Australia, we’ve seen a <a href="https://www.publish.csiro.au/ah/AH18245">15-fold increase</a> in opioid prescriptions dispensed on the Pharmaceutical Benefits Scheme between 1995 and 2015. </p>
<p>Over the same time period, <a href="https://www.mja.com.au/journal/2011/195/5/prescription-opioid-analgesics-and-related-harms-australia">harms</a> from <a href="https://link.springer.com/article/10.1007/s40429-018-0227-6">opioids</a> have <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">also risen</a>. Between 2001 and 2012, deaths from pharmaceutical opioid overdoses in Australia rose from <a href="https://pubmed.ncbi.nlm.nih.gov/28826104/">21.9 per million population to 36.2 per million population</a>: an increase of 6% per year. </p>
<p>Prescription opioids are now involved in <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">more deaths than illicit opioids</a> such as heroin. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioids-continue-to-be-the-leading-cause-of-overdose-deaths-in-australia-what-else-can-we-do-144422">Opioids continue to be the leading cause of overdose deaths in Australia. What else can we do?</a>
</strong>
</em>
</p>
<hr>
<p>To address these issues, government bodies have <a href="https://www.tga.gov.au/hubs/prescription-opioids">introduced strategies</a> to <a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">improve the safety</a> of opioid use. Although many focus on addressing opioid use in the community, opioids are also commonly used in acute care settings such as hospitals. </p>
<h2>Finding a balance between benefits and risks</h2>
<p>Good pain management aims to ensure pain is well managed while making sure the risk of any unwanted effects is low. </p>
<p>One of the risks is that short-term opioid use may become long-term opioid use. Studies <a href="https://journals.lww.com/annalsofsurgery/Abstract/9000/Postoperative_Opioid_Prescribing_and_New.93116.aspx">have found</a> that among people who receive opioids <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108765">after surgery</a>, 1-10% are <a href="https://pubmed.ncbi.nlm.nih.gov/32584407/">still using</a> them <a href="https://jamanetwork.com/journals/jamasurgery/fullarticle/2618383?resultClick=1">up to one year later</a>. </p>
<p>Existing opioid <a href="https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf">treatment guidelines</a> recommend <a href="https://journals.lww.com/jorthotrauma/fulltext/2019/05000/clinical_practice_guidelines_for_pain_management.11.aspx">doctors prescribe</a> the <a href="https://pubmed.ncbi.nlm.nih.gov/22227789/">lowest dose</a> of opioids needed for sufficient pain relief, for the shortest amount of time possible. </p>
<p>However, this does not always occur in practice. There is <a href="https://journals.lww.com/annalsofsurgery/fulltext/2017/04000/wide_variation_and_excessive_dosage_of_opioid.15.aspx">wide variation</a> in what patients are prescribed at discharge, even within the <a href="https://pubmed.ncbi.nlm.nih.gov/30049481/">same hospital or surgical unit</a>. </p>
<figure class="align-center ">
<img alt="Doctor in scrubs shows patient a form." src="https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/459952/original/file-20220427-22-sgqx43.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Good pain management means balancing the risks and benefits of medicines.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-consulting-her-female-patient-sitting-633840107">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Guiding principles for clinicians</h2>
<p>Clinical care standards are a set of quality statements written by an expert writing group for consistent and high-quality health care. They aren’t rules; they’re guiding principles that inform patients and clinicians about “best practice” for a clinical area. </p>
<p>In many ways, the new opioid standards aren’t new – they’re consistent with current guidelines and research. However, they provide “indicators” for health care organisations to measure their performance against. Given ongoing issues with opioids, indicators may provide important feedback on how opioids are being used. </p>
<p>Building on <a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">regulatory changes implemented in 2020</a>, such as smaller pack sizes when filling prescriptions from community pharmacies, these <a href="https://www.safetyandquality.gov.au/standards/clinical-care-standards">new standards</a> come at a good time and will play an important role in ensuring opioids and other analgesic medicines are used appropriately and safely for short-term pain. </p>
<p>However, they don’t cover chronic pain, cancer pain, palliative care, or patients with opioid dependence. </p>
<p>It’s now up to clinicians to ensure they’re implemented, with patients given adequate pain relief and prescribed the lowest dose for the shortest time possible.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">Smaller pack sizes from today: could new opioid restrictions stop leftover medicines causing harm?</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/181941/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ria Hopkins receives funding from the Australian National Health and Medical Research Council.</span></em></p><p class="fine-print"><em><span>Natasa Gisev does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New national standards aim to change doctors’ prescribing habits for hospital patients with pain when they’re discharged home. But clinicians also need to ensure patients’ pain is well managed.Ria Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW SydneyNatasa Gisev, Clinical pharmacist and Scientia Senior Lecturer at the National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1395582020-05-31T19:52:00Z2020-05-31T19:52:00ZSmaller pack sizes from today: could new opioid restrictions stop leftover medicines causing harm?<figure><img src="https://images.theconversation.com/files/338481/original/file-20200529-51477-s284f7.jpg?ixlib=rb-1.1.0&rect=0%2C10%2C6700%2C4393&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Several changes to the regulation of <a href="http://www.pbs.gov.au/info/news/2020/05/revised-opioids-pbs-listings-from-1-june-2020">opioid supply</a> in Australia come into effect today (June 1).</p>
<p>Opioids are strong medicines used for pain. The <a href="https://www.tga.gov.au/prescription-opioids-information-consumers-patients-and-carers">new rules</a> – including reducing pack sizes and restrictions around prescribing – are part of a <a href="https://www.tga.gov.au/alert/prescription-opioids-hub">range of changes</a> planned for prescription opioid medicines to be phased in over the next year or so.</p>
<p>This comes in response to the to the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2016%7EMain%20Features%7EDrug%20Induced%20Deaths%20in%20Australia%7E6">growing number of deaths</a> involving opioids in Australia. From 2007 to 2016, opioid-related deaths nearly doubled – from <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/table-of-contents">591 to 1,119 deaths per year</a>.</p>
<p>Notably, most of these deaths involve prescription opioids used for pain, rather than illicit opioids like heroin. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioid-dependence-treatment-saves-lives-so-why-dont-more-people-use-it-122537">Opioid dependence treatment saves lives. So why don't more people use it?</a>
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<h2>What are the changes?</h2>
<p>These changes will affect the quantity of opioids provided for short-term pain, limiting amounts to a single supply with a smaller quantity for each prescription. For example, smaller packs <a href="https://www.smh.com.au/healthcare/painkiller-packs-cut-down-to-size-as-opioid-crackdown-intensifies-20200527-p54x1b.html">may contain</a> 10 tablets rather than 20. </p>
<p>People requiring an additional supply for short-term pain will generally need to visit the doctor again (as opposed to receiving a repeat prescription).</p>
<p>There will also be new restrictions for patients starting on high-strength opioids for chronic pain, such as morphine and fentanyl. A person with chronic pain will need to try other types of pain relief, including lower-strength opioids, before being eligible for high-strength opioids.</p>
<p>Additionally, where opioid use exceeds, or is expected to exceed, 12 months the patient will need to seek a second opinion to approve ongoing prescriptions. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338486/original/file-20200529-51527-vp4l6y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">People who are using opioids for 12 months or more will need to get a second medical opinion.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Are these changes positive?</h2>
<p>These changes reflect our improved understanding around <a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">the more limited role</a> opioids should play in pain management. </p>
<p>Although opioids are effective for short-term severe pain, we know for every extra day of opioid medicines supplied, the risk the person will end up on opioids long-term <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5660650/">increases</a>.</p>
<p>Research in the United States showed the <a href="https://www.healio.com/primary-care/addiction/news/online/%7B03e1a840-a16b-4080-ae16-c1dddd709ab5%7D/duration-of-initial-opioid-prescription-strongest-predictor-of-long-term-use">number of days’ worth of opioids given</a> on the first opioid prescription was the strongest predictor of continued opioid use. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5980567/">Australian research</a> also found receiving a larger total quantity of opioids on the first prescription was associated with a greater chance of long-term use. </p>
<p>This suggests smaller initial supplies may be a critical step in preventing people from developing patterns of long-term use and potentially dependence or addiction.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712">2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year</a>
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<p>Reassuringly, hospitals have been able to <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2717556">dramatically reduce the quantity of opioids supplied</a> after surgery with no changes in the amount of pain patients reported, and no change in complications at follow-up. </p>
<p>These kinds of studies indicate we have probably been supplying many more opioids than are needed.</p>
<h2>Smaller supplies could save lives</h2>
<p>Supplying smaller quantities is also important because although opioids work well in the short term, we know when the duration of use extends beyond the short term, the harms can outweigh the benefits. </p>
<p>Opioids don’t work as well after the body adapts to their effects with long-term use. The dose is often increased to get the same effect, and with an <a href="https://pubmed.ncbi.nlm.nih.gov/29498021/">increased dose</a> comes an increased risk of harms, such as fatal overdose. </p>
<p>The other concern with larger supplies of opioids is that leftover medicine in the <a href="https://pubmed.ncbi.nlm.nih.gov/29626777/">family home</a> can become a source for non-medical use. Reducing supply of opioids will mean they’re less likely to be sitting around in the medicine cabinet, where they can potentially be misused. </p>
<p>One study showed the likelihood of experiencing an overdose was <a href="https://www.sciencedaily.com/releases/2019/07/190716132257.htm">three times higher</a> if someone in the person’s family was prescribed opioids. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<h2>People with chronic pain</h2>
<p>Some people using opioids for longer-term pain may find these new regulations challenging.</p>
<p>But the changes will hopefully help people in this group in the longer term, as opioids are <a href="https://theconversation.com/taking-opioids-for-chronic-pain-heres-what-the-experts-recommend-122285">not always appropriate</a> for chronic pain. The need for second opinions may help facilitate appropriate use and discussions about alternative approaches to pain management.</p>
<p>However, second opinions might be hard to arrange in practice. Opioid use is <a href="https://www.painaustralia.org.au/static/uploads/files/finalmr-healthcare-atlas-highlights-growing-opioid-use-wfjscubijzuf.pdf">higher in places where pain services are harder to access</a>, most commonly outside metropolitan areas. </p>
<p>The large shifts towards <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/covid-19-whole-of-population-telehealth-for-patients-general-practice-primary-care-and-other-medical-services">telemedicine we’ve seen as a result of COVID-19</a> may be useful in addressing the disparity of service access in rural areas, if these changes are maintained. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=500&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=500&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338489/original/file-20200529-51527-f2g0vt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=500&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioid use is higher in areas where pain services are less accessible.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The other issue that might occur is substitution towards less restricted medicines with the tightening of supply on opioid medicines. If alternative medicines are prescribed that are safer and clinically appropriate, this will be a good outcome. But we don’t want to see more dangerous or less effective medicines <a href="https://www.nejm.org/doi/10.1056/NEJMp1704633?url_ver=Z39.88-2003">prescribed in place of opioids</a>. </p>
<p>There have been concerns around increased and potentially <a href="https://theconversation.com/prescription-drugs-pregabalin-and-gabapentin-have-been-reclassified-but-it-wont-stop-problem-use-114403">inappropriate use</a> of other pain medicines such as <a href="https://www.mja.com.au/journal/2019/210/2/pregabalin-misuse-next-wave-prescription-medication-problems">pregabalin</a> – a medicine intended to be used for nerve pain. </p>
<p>We’ve seen a lot of focus on opioids, but these are not the only medicines that can cause harm. The challenge when using high-risk medicines like opioids for pain is with getting the right balance between benefits and harms. But these changes appear to be a step in the right direction.</p>
<h2>What don’t we know?</h2>
<p>Almost all the studies that help us predict the effects of these changes were conducted in the US. Opioid-related harm in the US is much more severe than in Australia, and the health-care system is vastly different. </p>
<p>That said, <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/table-of-contents">Australian trends</a> in opioid-related harms are quite similar, though they are <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/dar.12916">five to ten years behind the US</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ambulance-call-outs-for-pregabalin-have-spiked-heres-why-106163">Ambulance call-outs for pregabalin have spiked – here's why</a>
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<p>The aim is to use opioids for the shortest period at the lowest effective dose, rather than to avoid their use altogether. While we want to minimise their misuse, opioids are effective and important medicines for pain. In many countries, <a href="https://theconversation.com/the-other-opioid-crisis-people-in-poor-countries-cant-get-the-pain-medication-they-need-56205">a lack of supply is a key health issue</a>. We don’t want the pendulum to swing too far.</p>
<p>We will need to carefully monitor the outcomes of these changes to identify any unintended consequences.</p><img src="https://counter.theconversation.com/content/139558/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen has received research funding from Indivior and Seqirus for to conduct research to better understand harms with pharmaceutical opioids, and treatment for opioid dependence. She currently services as Chair for the Advisory Committee for Medicines Scheduling for the Therapeutic Goods Administration. None of these organisations had any knowledge of the decision to write this article or any involvement in this piece, which reflects the authors opinions only.</span></em></p>New rules attempt to curb opioid-related deaths in Australia. These changes are a step in the right direction – but we need to tread carefully to avoid unintended consequences.Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1149692019-04-10T20:11:34Z2019-04-10T20:11:34ZPrescription monitoring is here, but we need to tread carefully to avoid unintended harms<figure><img src="https://images.theconversation.com/files/268505/original/file-20190410-2898-w0nezm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new prescription monitoring program in Victoria aims to identify people using prescription medicines unsafely.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Drug-related deaths in Australia have <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2016%7EMain%20Features%7EDrug%20Induced%20Deaths%20in%20Australia%7E6">almost doubled</a> over the past ten years, in large part because of the increased use of opioids. In 2016, middle aged people using combinations of prescription drugs were the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2016%7EMain%20Features%7EDrug%20Induced%20Deaths%20in%20Australia%7E6">most likely</a> to die a drug-related death.</p>
<p>Prescription monitoring aims to tackle this issue by allowing health professionals who are prescribing or dispensing high-risk medicines to see a patient’s prescription history.</p>
<p>This may help a doctor to make decisions about a patient’s care, or a pharmacist to decide if they should dispense certain medicines to a patient; with the aim of reducing harm.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/making-more-drugs-available-over-the-counter-would-be-a-win-for-the-public-and-the-health-care-system-113453">Making more drugs available 'over the counter' would be a win for the public and the health care system</a>
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<p>But as a new prescription monitoring program, <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/safescript/about-safescript">SafeScript</a>, is rolled out across Victoria, we need to tread cautiously for a couple of reasons.</p>
<p>First, our health professionals and systems will need to be properly equipped to deal with the volume of people who will be identified by this program as needing support.</p>
<p>And second, evidence from the United States tells us restricting access to prescription drugs may drive people towards using illicit drugs instead.</p>
<h2>What is SafeScript?</h2>
<p>Right now SafeScript is optional for doctors and pharmacists to sign up to, but it will become mandatory in April 2020.</p>
<p>The system automatically captures a range of <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/safescript/medicines-monitored">high-risk medicines</a>, such as strong pain medicines, and medicines for anxiety and sleep. These medicines are generally those commonly implicated in drug-related deaths. </p>
<p>Tasmanian health-care providers have had access to <a href="https://www.dhhs.tas.gov.au/psbtas/publications/general/dora">voluntary prescription monitoring</a> since 2012. But SafeScript will be the first mandatory real-time prescription monitoring system in Australia.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268506/original/file-20190410-2905-60ixtg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pharmacists can also use the SafeScript software.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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</figure>
<p>When a health-care professional goes to prescribe or dispense a listed high-risk medicine, they will see a green, amber or red pop-up notification.</p>
<p>They will be alerted to risk factors such as a patient taking higher doses of medicines, risky combinations of medicines, or where a person may be seeing multiple prescribers for the same or similar medicines. In rare cases, they may be seeking more medicines than they need for themselves so they can supply them to others.</p>
<p>The software links the health-care providers to additional information including the patient’s prescription history. From there, it’s up to the health-care professional to use that information to inform their clinical decisions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
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<p>Anecdotal reports from health-care providers using the system suggest they are finding the information useful. After a six month trial starting in western Victoria, the system <a href="https://www.pharmacynews.com.au/news/safescript-proves-its-mettle-first-four-months">has already identified</a> a few thousand “at risk” patients.</p>
<p>But the system is still in its very early stages, so we don’t yet have information about longer term, or patient specific outcomes, such as whether prescription drug-related harms are decreasing, or whether patients are receiving appropriate care when risks are identified.</p>
<h2>What are the concerns?</h2>
<p>Although the system identifies certain risky behaviours, it’s up to the health-care professional to assess whether the patient requires treatment for a substance use disorder, or if it is safe for a patient to continue to supply a high-risk medicine to them.</p>
<p>Typically, GPs and pharmacists are <a href="https://files.eric.ed.gov/fulltext/ED452442.pdf">not confident</a> talking about sensitive topics like substance use.</p>
<p>To address this, a number of <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/safescript/training">voluntary training</a> sessions are being run across the state to upskill health-care providers in having these difficult conversations.</p>
<p>A telephone hotline has also been established for GPs to seek clinical advice regarding patient care.</p>
<p>A doctor may choose to prescribe <a href="https://www.cochrane.org/CD011117/ADDICTN_opioid-maintenance-medicines-treatment-dependence-opioid-pain-medicines">drug treatments</a>, such as buprenorphine, for dependence to strong pain medicines. They may also decide to refer the patient to a pain service, or a drug treatment service.</p>
<p>But where there are likely to be a greater volume of patients referred to these services, there are also significant concerns around access.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/268507/original/file-20190410-2905-tmroyv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When SafeScript identifies a patient who may be at risk, it’s up to the health professional to decide what to do.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>In Australia, there is a need to <a href="https://www.mja.com.au/journal/2016/204/4/alcohol-and-other-drug-treatment-policy-australia">double the capacity of alcohol and drug treatment services</a> to meet current needs. This means if a referral is made, there may be delays in accessing care.</p>
<p>Referral to a pain service may be more appropriate for some patients, though <a href="https://www.mja.com.au/journal/2012/196/6/waiting-pain-systematic-investigation-provision-persistent-pain-services">waiting lists</a> for these services can also delay access to care. </p>
<p>Further, in regional and rural areas where prescription drug problems are <a href="https://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-illicit-drugs-0615.pdf">often higher</a>, treatment access may be more limited.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
</strong>
</em>
</p>
<hr>
<h2>Could there be harms associated with prescription monitoring?</h2>
<p>International experience and research with prescription monitoring has been inconclusive. A <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015770/">recent large review</a> could not determine whether prescription monitoring programs decreased or increased fatal or non-fatal drug overdoses.</p>
<p>The review did however <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6015770/">identify three studies</a> in the United States that showed heroin overdoses increased after the implementation of prescription monitoring.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/not-everyone-who-takes-painkillers-for-fun-is-an-addict-some-have-just-found-a-different-way-to-cope-57269">Not everyone who takes painkillers for fun is an addict; some have just found a different way to cope</a>
</strong>
</em>
</p>
<hr>
<p>We don’t know if we’ll see the same patterns in an Australian setting. But restrictions on access to prescription drugs may mean some people shift to using illicitly sourced drugs, and this could increase harms.</p>
<p>With the implementation of prescription monitoring, we need to increase capacity of both evidence-based treatment and harm reduction services. We know that drug treatment capacity does not meet current needs – and these needs are about to grow.</p><img src="https://counter.theconversation.com/content/114969/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen receives funding from the Australian Government, including a current NHMRC Career Development Fellowship. She is a named investigator on research grants from Indivior (for studies examining the implementation of a new treatment for opioid dependence, and studying opioid overdose prevention). She is also a named investigator on a research grant from Seqirus (examining population-level harms from pharmaceutical opioids). Finally, her institution has received payment for training that she has delivered on identifying and treating opioid dependence from Primary Health Networks, the Pharmaceutical Society of Australia, The Pharmacy Guild, The Royal Australian College of General Practice and Indivior.</span></em></p>Prescription monitoring offers a way to prevent accidental overdoses and identify patients with dangerous addictions. But looking after these patients is going to be a challenge.Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/831282017-09-24T23:12:50Z2017-09-24T23:12:50ZSeven ways to soothe your child’s pain in the hospital<figure><img src="https://images.theconversation.com/files/187103/original/file-20170921-21005-1l35ph9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are real consequences to ignoring children’s pain in hospital. These include increased sensitivity to pain, abnormal social behaviours when older and higher levels of anxiety before a future procedure.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine this: You are having a lovely day at the park, when your sweet boy, only seven years old, falls from the monkey bars and screams loudly. His wrist is swelling quickly and looks deformed. You rush to the local hospital, where they tell you he will need x-rays and an IV. And his bones will need to be reset in the emergency department. </p>
<p>He is still crying, scared and in pain. What can you do, as a parent, to make this experience less stressful and painful for your child?</p>
<p>As a pediatrician who specializes in emergency care, I have had the privilege of caring for children with unexpected injuries and illness for over 15 years. During this time, I have seen and reflected on the tremendous pain that children sometimes experience, due in part to their injuries but also in part to the medical tests and procedures we must do. </p>
<p>For years, I did everything I could, as a doctor, to offer the best pain relief. When I realized that there were many unanswered questions about pain treatment, I took advantage of my position as a professor in the Faculty of Medicine and Dentistry at the University of Alberta to research the issue. Over the last decade, I have worked with various teams to research <a href="https://www.ncbi.nlm.nih.gov/pubmed/28077923">the best treatments for both presenting pain</a> (such as headaches, fracture-related pain and abdominal pain) and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26720064">procedural pain</a> (such as blood tests, urine catheter insertions and IV insertions). </p>
<p>Based on current research, there are several straightforward things that parents can do — to help minimize their child’s pain and distress during a hospital visit.</p>
<h2>1. Give pain medicine early</h2>
<p>Often parents believe treating their child’s pain before visiting the doctor will make it harder to diagnose the problem. This is not the case! It is a myth that doctors need “all the pain” to be present in order to figure out what is going on. Truthfully, it is very difficult to examine a child when they are writhing in agony, and much easier when they are comfortable. Remember, no over-the-counter pain reliever is capable of masking serious ailments. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187109/original/file-20170921-21005-11yi7ax.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pain in infancy can have long term effects, such as increased sensitivity to pain and anxiety before procedures.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>So, treat your child with over-the-counter pain relievers (e.g. Tylenol or Advil) <em>before</em> you go the hospital (if they are able to swallow and are not vomiting). Use proper weight-based doses; your health professional can help you with this. If you arrive at the hospital and were unable to give your child medication before coming, ask for pain relievers EARLY! In many emergency departments, the triage nurse can treat your child’s pain even before a doctor sees them.</p>
<h2>2. Advocate for your child</h2>
<p>Health professionals now have <a href="https://www.ncbi.nlm.nih.gov/pubmed/?term=11533354">decades of research</a> that demonstrate the benefits of proper pain treatment. Properly treating pain actually <a href="https://www.ncbi.nlm.nih.gov/pubmed/15967972">improves success rates</a> and can prevent the need for repeat attempts at the same procedure. Further, there are real consequences to ignoring children’s pain. Children who experience moderate levels of pain during infancy may have <a href="https://www.ncbi.nlm.nih.gov/pubmed/11533354">long-term physical, psychological, and behavioural changes</a>, including increased sensitivity to pain, abnormal social behaviours when older and higher levels of anxiety before a future procedure. </p>
<p>Surprisingly, health professional sometimes forget to prioritize pain treatment. It is not a malicious thing. They are often busy, under-resourced, unaware of the evidence that exists and focused on “fixing the problem” — sometimes at the expense of adequate pain management. </p>
<p>As a parent, you can advocate for your child’s pain treatment and remind the team not to forget this key aspect of your child’s hospital visit.</p>
<h2>3. Use physical comfort measures</h2>
<p>There are many things we can do to make a child more physically comfortable. If they have an injured limb, splinting it can relieve a great deal of the pain. Using ice on a limb or joint injury reduces swelling and pain as well. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187104/original/file-20170921-21037-nujmwo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Holding a child can also help a child reduce anxiety and soothe pain.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If you have a baby, swaddling them in blankets and rocking them can soothe them when they are in pain. Even simply cuddling your child can go a long way in comforting them during painful tests or while waiting for results.</p>
<h2>4. Use distraction</h2>
<p>Distraction helps children feel less distress and pain. There are low-tech options, such as bubble-blowing, playing i-Spy games, reading books, talking and listening to music. These can be offered by you or the health care team at little cost. For some children, especially as they get older, digital technology is a preferred option. Choices include tablets, smart phones, video games, and more recently, robots and virtual reality. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187105/original/file-20170921-30334-1imx54n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A child uses a Virtual Reality headset in a clinic.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>If you have time to plan, bring one of these options with you to your hospital visit. If you didn’t have time to plan, ask your health care team what they can offer. Many children’s hospitals even have “child life specialists,” whose very job it is to make your child’s hospital stay less stressful.</p>
<h2>5. Ask for numbing cream</h2>
<p>IVs and blood-work hurt. A lot. In fact, children tell us that getting an IV is the worst and most painful part of their hospital stay. There is <a href="http://dx.doi.org/10.1002/14651858.CD004236.pub2">indisputable research</a> that tells us that numbing creams (e.g. EMLA, Maxilene), when applied 30 to 60 minutes before a blood test or IV, reduce much or all of the pain of the procedure. </p>
<p>These products are available at most, if not all, hospitals and emergency departments, but you need to ask for them early, so that they do not cause your child’s tests or treatments to be delayed. Ideally, the health care team will offer them to you. If they don’t, ask about them!</p>
<h2>6. Remember that sugar eases pain</h2>
<p>Concentrated sugar drops, dripped onto a baby’s tongue two minutes before and during a medical test (such as a urine catheter insertion or a blood test) <a href="http://dx.doi.org/10.1002/14651858.CD001069.pub5">reduce pain for babies under 12 months of age</a>. It only takes two millilitres of this seemingly magical liquid to make a medical procedure easier for a baby! There are virtually no side effects to it, and it is safe even for premature newborns. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/187110/original/file-20170921-20991-1bipz5s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Parents have many options to help reduce their child’s pain in hospital.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>When combined with a pacifier, the sugar drops seem to work even better for many babies. Breastfeeding is well known to help ease pain and distress, as well, and should be chosen over sugar and pacifiers, if available for a baby.</p>
<h2>7. Ask for a pain management plan for home</h2>
<p>Emergency department visits and hospital stays are often just a “blip” in the timeline of your child’s journey back to health. In other words, most of your child’s pain will be dealt with by you, without the benefit of nurses and doctors. When it is time to leave the hospital, ask your health care team what to do <em>at home</em>. Ask what medications to use, and what non-medication things you should do. Ask them what to do if the first-choice medicines don’t work. And don’t forget to get advice on return to activity.</p>
<p>Children’s pain matters, and should not be ignored. There is absolutely no reason that a child should be in pain while the doctor is trying to figure out what is going on. As parents, we should feel empowered to ask for the best pain treatment possible for our children.</p><img src="https://counter.theconversation.com/content/83128/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samina Ali receives unrestricted research funding from the Canadian Institutes of Health Research, Alberta Innovates, and the Women & Children's Health Research Institute.</span></em></p>From broken limbs to blood tests, hospital visits can cause unnecessary pain for children. An emergency care pediatrician offers seven easy strategies for parents to lessen this pain.Samina Ali, Professor of Paediatrics and Emergency Medicine, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/621442016-07-06T19:10:45Z2016-07-06T19:10:45ZOpioid crisis: How did we get here?<p>Lawmakers meet <a href="http://www.nytimes.com/2016/07/07/us/politics/congress-to-hash-out-final-bill-aimed-at-opioid-epidemic.html">today</a> to try to finalize legislation to solve the nation’s opioid crisis. It’s an issue that The Conversation has been covering for many months. </p>
<p>How can it be that nearly half a million people in the U.S. are addicted to heroin and another two million have <a href="https://www.cdc.gov/drugoverdose/">substance use disorders</a> related to prescription drug abuse? In 2014, opioid overdose killed more than <a href="https://www.cdc.gov/drugoverdose/">28,000 people</a>.</p>
<p>Here are three articles from our archives that explain how we arrived at this crisis point.</p>
<ol>
<li><p>Theodore Cicero and Matthew Ellis of Washington University in St. Louis write that the roots of the epidemic can be traced back to changes in <a href="https://theconversation.com/roots-of-opioid-epidemic-can-be-traced-back-to-two-key-changes-in-pain-management-50647">pain management</a>. When pain began to be treated as the “fifth vital sign,” prescriptions to treat it soared. </p></li>
<li><p>Richard Gunderman of the University of Indiana argues we should not let pharmaceutical companies, particularly Purdue Pharma, off the hook. The company aggressively marketed OxyContin, Gunderman says, knowing that it could be easily <a href="https://theconversation.com/oxycontin-how-purdue-pharma-helped-spark-the-opioid-epidemic-57331">abused</a>. Prescriptions for the powerful – and highly addictive – drug for non-cancer pain soared from 670,000 in 1997 to 6.2 million by 2002. </p></li>
<li><p>Jeannie DiClementi, of Indiana University-Purdue University Fort Wayne explains how the abuse of prescription pain drugs spread to <a href="https://theconversation.com/from-the-clinic-to-the-street-how-the-explosion-in-prescription-painkillers-has-created-more-heroin-users-50344">abuse of heroin</a>. It wasn’t a big leap, as the chemical structures are similar. </p></li>
</ol>
<p>Almost everyone agrees we need to stop this scourge, yet there is disagreement over how to do that. Even today, lawmakers are expected to argue rather than agree. Democrats said they would oppose the bill if it did not include more money for treatment.</p>
<p>The Obama administration moved forward Tuesday on its own. It announced a <a href="https://www.whitehouse.gov/the-press-office/2016/07/05/obama-administration-takes-more-actions-address-prescription-opioid-and">new rule</a> that would allow certain doctors to almost triple the number of patients they can treat with buprenorphine. That drug treats addiction, but addicts can abuse it, too. Prescribing rights are therefore limited. To prescribe it, doctors must have a special waiver. And, until now, they could treat only 100 patients. </p>
<p>The new rule increases the prescribing limit to 275. But according to Jeffrey Horn, a policy research fellow at the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania, and Krisda H. Chalyachati, also a Robert Wood Johnson Foundation fellow at the University of Pennsylvania, those rights should be extended even further. In a <a href="https://theconversation.com/why-its-easier-to-be-prescribed-an-opioid-painkiller-than-the-treatment-for-opioid-addiction-60137">recent article</a> they argue that nurses and physician assistants also should be allowed to prescribe buprenorphine, given the scope of the opioid addiction epidemic.</p><img src="https://counter.theconversation.com/content/62144/count.gif" alt="The Conversation" width="1" height="1" />
As congressional leaders today discuss legislation to curb the opioid epidemic, we look at three articles that explain how it happened and one that suggests some solutions.Lynne Anderson, Senior Health + Medicine Editor, The Conversation, USLicensed as Creative Commons – attribution, no derivatives.