News
Shoalhaven Medical Association Update: October 2020

Important Information regarding SMA Conference Saturday 17th October 2020.

ZOOM Meeting to replace face to face Conference.

Hi to all members and associates of the Shoalhaven Medical Association,

COVID19 has forced change in how we function normally. After discussion with Dr Bill Pratt (Infectious Disease) the recommended position is;

  • No large indoor gatherings can be supported.
  • Dinner to be postponed.
  • Mingling around feeding/coffee stations and trade displays is seen as a real risk.
  • Conference can be held by video format (Zoom or similar).
  • Conference hub will be at the Golf Club with a small number of people, the organising committee and those presenters who would prefer to present from the hub with more control over their Powerpoint or content. Those involved in the panel session may wish to be present. Those presenters who would otherwise need to travel may wish to present remotely. There will be IT support at the Golf Club.

Program Brochures will be distributed with Registration Details in the next few weeks.

Registration for the SMA Conference will be via email or phone.

An invitation to join the Zoom meeting with identifier and password will be sent in the week before the Conference.

Free Zoom activation is recommended via – https://zoom.us and click on (sign up, it’s free) for those not currently using Zoom.

The potential for interactive questioning or comments will be maintained by video or type-in.

CPD points are available.

If you know of colleagues who aren’t associated with the SMA please let them know of this event as it is free to all health professionals and they may wish to establish contact.

With a little under two months to the Conference we are looking forward to adapting to change whilst realizing there may be real opportunities involved. ‘Tis a brave new world.

Hope to see you there.

Cheers

Warren Bruce

Chairman

SMA    www.shoalhavenmedical.com.au

News
COVID and Type 1 Diabetes Late Diagnosis

The Australian Paediatric Society is a special society of the Royal Australasian College of Physicians and the voice of rural child health.

While supporting the Government measures to limit spread of COVID-19, we are concerned about the potential impact that late or non -attendance of a sick child to a general practitioner or emergency department may have on the lives of many children.

In particular, we are concerned about the potential late diagnosis of Type 1 Diabetes. Diagnosis in a toddler is particularly difficult.

Symptoms of:

  • thirst,
  • excessive wetting (including starting to wet the bed again),
  • vomiting,
  • tiredness and /or
  • weight loss

may be attributed by a parent or in a phone consultation as “gastro”, the “flu” or urinary infection. Delayed diagnosis of Type 1 diabetes may result in death or permanent damage.

Please distribute this message to your members to remind them to think “is it Type 1?”

Check a blood (or urine) glucose immediately and refer to the nearest Emergency Department immediately if positive or if in doubt.

Newly diagnosed Type 1 diabetes is a medical emergency.

Dr Peter Goss FRACP (Vic)

On behalf of Dr Tim Warnock FRACP (Qld), Dr Joanne McCubbin FRACP (Vic) , Dr Mark DeSouza FRACP (NSW) Dr Allan Kerrigan FRACP (NSW) Paul Bauert FRACP(NT) Nigel Stewart FRACP (SA)
Australian Paediatric Society Committee

Conference
March Conference Postponed

Regretfully our March 21 Conference and Black Tie Dinner has now been postponed due to COVID-19.

The current position is fluid and dynamic and whilst there are presently no documented cases in the Shoalhaven, “social distancing measures” are being pursued by national and local authorities, with the vast majority of large meetings and events cancelled or postponed.

Lecture Notes
Opioid prescribing: Dr Frank McLeod – “The Issues”

Drug dependency and addiction are complex. The terminology can also be inconsistent and confusing, for example we might consider a postoperative patient who gets withdrawls if missing a dose to be dependent, but the legal definition by NSW Ministry of Health is different:

An authority from the Ministry of Health is required to prescribe or supply a drug of addiction for:
– a drug dependent person
– a non-drug dependent person who is prescribed or supplied with the following drugs of addiction continuously for more than 2 months:
– any injectable form of any drug of addiction
– any drug of addiction for intranasal use, or for spray or application to mucous membranes
– alprazolam
– buprenorphine (except transdermal preparations)
– flunitrazepam
– hydromorphone
– methadone

If a person is on an opioid-substitution program, they are defined as opioid-dependent and there are important restrictions on their prescribing. To check if a patient is already known to be drug-dependent, call the Pharmaceutical Regulatory Unit (02) 9424 5923. It is illegal to prescribe drugs of addiction to these people unless in an emergency or an inpatient for <14 days.

Common flags of a patient with a drug seeking problem include knowing the exact drug names, doses and generics, coming in late in the day / out of hours and having run out of medication, may be loud and demanding, anxiety, spurious claims of illness, may have mental health issues or homelessness or have track marks visible, but equally these patients may have none of these signs. Many of these patients have personality disorders and many have been sexually or physically abused.

Non drug-dependent patients

Some patients have inadvertently become drug-dependent. If the patient has not escalated, sought early scripts, lost medication or sought alternative sources, they may not be considered legally drug-dependent. However, if you are not sure, you can apply for an authority to prescribe – especially if the patient is on >100 mg oral morphine equivalent daily dose. (Use the free online Opioid calculator)

Steps for managing opioids in non-dependent patients:

  • Discuss the situation and advantages of dose reduction
  • Advise regarding problems including dependence, overdose risk, side effects (constipation, sweating, libido, thyroid and adrenal problems), hyperalgesia
  • Calculate the total daily dose using an Opioid calculator
  • Encourage and agree to a plan of reduction, i.e. 10% maximum reduction at a time, and agree on a time scale
  • Go slower as you get lower, do not exceed the 10% reduction
  • Manage it with a gentle hand and allow delays
  • If the patient begins to have withdrawls, hold at that level before reducing again
  • Keep the patient in the decision chain and remember they have done nothing wrong
  • Consider staged supply (daily dispensing controlled by pharmacy) if needed

Lecture Notes
Opioid Prescribing: Dr John Thomson – The General Practice Perspective

Dr John Thomson is a GP in Berry who works in palliative care at Karinya. He finds managing chronic pain a challenge, as do most GPs who form the front line of chronic pain management. There are now more opioid-associated deaths than road deaths. We have made some progress through codeine upscheduling, with a 50% decrease in prescribing and in overdoses. Luckily we haven’t seen the feared surge in demand for prescribing higher potency opioids since codeine was changed. Unfortunately there are many challenges remaining for GPs in this setting.

Strategies:

  • Discuss duration of treatment, side effects and withdrawl issues before starting
  • Be prepared to continue prescribing if you start them on opioids
  • Start low dose and use for shortest duration
    • Use short scripts to begin with – there is no role for authorities for a month supply to begin with
  • Be aware of NSW Health legal requirements for prescribing a S8 or benzodiazepine
    • This includes patients on Jurnista who will need an authority (even if not drug-dependent) if on it for >2 months.
  • Multidisciplinary team care: physiotherapists, rehabilitation specialists, pain specialists, pain psychologists
  • Use the Prescription Shopping Information Service (PSIS) 1800 631 181 or PRODA to find information about past scripts
  • Check scripts dispensed on MyHealth Record
  • Nyxoid is an intranasal preparation of naloxone that is available at pharmacy – talk to your patients about this if there is a risk of overdose
  • Opioid-substitution treatments are becoming more available, including methadone, buprenorphine / naloxone
  • Smaller pack sizes are coming in 2020

Challenges:

  • Managing the inherited pain patient
  • Doctor shopping behaviour
  • Funding