SafeScript NSW: a push for prescription oversight of monitored medications

Drug overdose is a leading cause of death in Australia for all age groups and the increasing misuse of monitored medications has become a major public health concern. In 2020, one Australian died every four hours from drug overdose. Of the 2200 overdose fatalities recorded that year,1654 were accidental.^[1] Pharmaceutical opioids dispensed from pharmacies are a significant contributor to these figures.

Proprietors must recognise their professional obligations and understand that they have an overarching responsibility for everything that occurs in their pharmacy. This includes ensuring that staff pharmacists are complying with applicable legislation and guidelines when dispensing medication.

SafeScript NSW

SafeScript NSW (SafeScript) is a prescription monitoring system which provides access to real-time information about a patient’s prescription history for monitored medications. Medical practitioners, nurse practitioners, dentists and pharmacists registered with the Australian Health Practitioner Regulation Agency (AHPRA) are eligible to access SafeScript.

SafeScript is designed to assist practitioners to exercise clinical and professional judgement. It aims to improve the safety of monitored medications and assist practitioners in exercising informed and tailored clinical decision making. While SafeScript NSW is not a mandatory system, NSW Health encourages all practising prescribers and pharmacists to implement the tool as part of its broader efforts to reduce the risk of harm to patients from monitored medications.

How it works

SafeScript collects prescribing and dispensing information about monitored medications through the electronic prescription exchange service (PES). PES is connected to most prescribing and dispensing systems throughout NSW and collects information, whether supplied on the Pharmaceutical Benefits Scheme (PBS) or privately.

When a practitioner uses the integrated version of SafeScript they will be notified of information held in SafeScript by a desktop pop-up notification. Colour-coded warnings indicate the level of risk associated with a patient’s prescription history. A ‘yellow’ or ‘red’ warning indicates that a patient has been supplied the same medication within the past 90 days from more than one medical practice. These warnings should be investigated. By clicking on the warning notification, a practitioner gains access to the patient’s full monitored medication history.

High-risk scenarios (red)

The following situations are deemed high-risk scenarios in SafeScript:

• a patient has received prescriptions for monitored medications from four or more prescribers within the previous 90 days;
• the average daily dose exceeds 100mg oral morphine equivalent over a 90-day period (excluding medicines used for opioid replacement therapy); or
• there is concurrent prescribing of potentially harmful substances.

Monitored medications

Monitored medications consist largely of opioids, benzodiazepines, other sleeping aids and psychostimulants. A full list of monitored medications appears in the Poisons and Therapeutic Goods Regulation 2008 (Appendix E).^[2]

Medications are considered by a panel of experts from NSW Health as to whether they ought to be included as monitored medications. The criteria for consideration includes: evidence of harm; prescribing trends; substitution effect; chilling effect; regulatory burden; and the utility of information for clinical care, and consistency with other jurisdictions.

SafeScript for detecting forged prescriptions

Due to increasing numbers of forged prescriptions, doctor shopping, drug diversion and unsafe use of monitored medications, pharmacists must be vigilant in carefully scrutinising each Schedule 8 prescription they receive before dispensing. Pharmacists need to be able to identify common ‘red flags’ which may indicate a forged prescription. Those red flags include:

• private prescriptions for large quantities of Schedule 8 medications;
• mobile number listed as the contact number of the purported prescriber;
• supplies at shorter intervals or at quantities larger than therapeutic recommendations;
• patient’s listed address or the purported prescriber’s address being well outside the immediate area of the pharmacy;
• medication inconsistent with the patient’s dispensing history;
• patient being in a hurry;
• patient presenting on weekends or late in evenings when the purported prescriber is difficult to contact;
• spelling, format and/or language errors in the prescription, and incorrect use of abbreviations and terminology; and
• purported prescriber is listed on the ‘Lost, Stolen or Forged’ list with NSW Health. ^[3]

Pharmacists must be highly vigilant and on alert for forged prescriptions and must understand the way SafeScript data can be accessed and utilised by regulatory bodies. Pharmacists must be diligent and use the tools available to them to ensure they are complying with their professional obligations.

Lessons learned from other jurisdictions

Real-time prescription monitoring systems have already been successfully implemented overseas and in other Australian jurisdictions.

National systems

Project STOP is a real-time recording system rolled out nationally in 2008 to assist in reducing the diversion of pseudoephedrine into the illicit drug market. Studies have demonstrated that since the implementation of Project STOP the problem of pseudo-runners has been declining.^[4]

Tasmania

In 2009, Tasmania introduced^[5] the Drugs and Poisons Information System Online Remote Access (DORA). The system is not mandatory. Between 2010 and 2014 (after the implementation of DORA) the average prescription opioid related death fell by 34%.^[6] DORA is a valuable tool which, together with other governance and regulatory initiatives, is assisting Tasmanian practitioners and leading to a reduction of patient risk.

Victoria

In 2018, Victoria commenced a trial system of real-time prescription monitoring. From April 2020, SafeScript has been mandatory for health practitioners in Victoria. Commentary suggests a reduction in the number of multiple provider episodes and a decrease in the average morphine equivalent dose.^[7]

Outside of Australia

Real-time prescription monitoring systems have already been implemented in the United States and Canada. Studies show that prescribing rates in the United States fell by 24.2% and the use of opioids in Canada dropped 50% as a result of those systems.^[8]

Key recommendations

While SafeScript is not currently mandatory for practitioners in NSW, we strongly recommend its adoption as a matter of best practice to ensure compliance with professional obligations and to mitigate risks associated with supplying monitored medications.

NSW Health has created a step-by-step guide for integrating SafeScript into various dispensing software.

If you would like to discuss the risks that apply to your pharmacy, how to implement and get started with SafeScript, or have any other questions about professional obligations, please contact a member of our team (details below).

[1] Penington Institute (2022). Australia’s Annual Overdose Report 2022. Melbourne: Penington Institute.
[2] Poisons and Therapeutic Goods Regulation 2008, Appendix E: Monitored Medicines.
[3] Pharmacy Council of NSW, Newsletter: Council News, May 2022.
[4] Jason Ferris, Madonna Devaney, Lorraine Mazerolle Michelle Sparkes-Carol, ‘Assessing the utility of Project STOP in reducing pseudoephedrine diversion to clandestine laboratories’, Australian Institute of Criminology (8 March 2016).
[5] Peter Boyles, ‘Real-time prescription monitoring: lessons from Tasmania‘, NPS MedicineWise, Australian Prescriber: An Independent Review, 2 April 2019.
[6] ‘Prescription opioid misuse: Contemporary challenges – 2′, Medicine Today (March 2017).
[7] Dagnachew M Fetene, Peter Higgs, Suzanne Nielsen, Filip Djordjevic and Paul Dietze, ‘The impact of Victoria’s real time prescription monitoring system (SafeScript) in a cohort of people who inject drugs’, Medical Journal of Australia.
[8] Ziyue Zhang, Lin Guo, Ran Si, Leanne Chalmers, Patricia Filippin, Jane Carpenter and Petra Czarniak, ‘Pharmacists’ perceptions on real-time prescription monitoring (RTPM) systems – a cross-sectional survey’, Exploratory Research in Clinical and Social Pharmacy (March 2022).