Legislative Council Fifty-Fourth Parliament, Second Session (54-2) 54 2 Parliament of South Australia Legislative Council published Bills Controlled Substances (Confidentiality and Other Matters) Amendment Bill Controlled Substances (Confidentiality and Other Matters) Amendment Bill Controlled Substances (Confidentiality and Other Matters) Amendment Bill Second Reading Second Reading Adjourned debate on second reading. (Continued from 17 June 2020.) The Hon. K.J. MAHER Legislative Council Leader of the Opposition The Hon. K.J. MAHER (Leader of the Opposition) (16:06): I rise to speak on this bill and indicate that I will be the lead speaker for the opposition. This legislation facilitates the introduction of a real-time prescription monitoring system for drugs of dependence to combat the potential misuse of these drugs. The implementation of real-time prescription monitoring is an important tool for clinicians to have information at hand at the time of prescribing. This in turn prevents overprescribing of dangerous substances and helps identify drug dependence treatment needs that might otherwise go unnoticed. This was an election commitment of the government that they said was urgent; however, it is one they did not act on urgently, taking two years and three months to get to the point of legislation into parliament. We have seen Victoria and Queensland implement their monitoring systems well before us now and, given the existing delays, it is highly questionable whether the government will meet its commitment to have this system up and running across all pharmacies and GPs before the next election. However, it is good to see that the selection of a provider has finally occurred, with Fred IT winning the tender to provide the monitoring system. SA Health has indicated to the opposition that its system would be rolled out in a voluntary form in March 2021 with stakeholders beginning trials ideally in October and November this year, and with the use of that system to be mandatory potentially one or more years after that. I would welcome the minister placing on record the predicted rollout, when the minister expects the mandatory enforcement of this across the system. We will be closely monitoring those time lines and seeking strong justification for any extensions needed. We understand SA Health is willing to consider allowing some extensions on the rollout, depending on stakeholder readiness, as a result of COVID-19 disruptions. Where there are any delays occurring, we will be consulting with stakeholders to ensure that delay is indeed at the request of the stakeholders and not merely as a result of funding or administrative delays on the part of SA Health. A response we have heard from several stakeholders has been that while they are supportive of the legislation, they have warned that everything depends upon the system rollout process. This includes ensuring that the appropriate provision of technology and training happens prior to the system going live, and especially before it becomes mandatory. Another important point raised by multiple stakeholders is that, while a real-time prescription monitoring system is a great step forward, improving mental health and drug treatment services for the treatment of drug dependency is also a crucial step. While it will be a great improvement for individuals with serious drug dependence to be identified and refused prescriptions, we need to understand what else is being done to support that individual: who is taking steps to ensure that they are not spiralling and potentially ending up in an emergency department? These are all very important concerns we seek the government to address. One particularly detailed submission came from the Royal Australian and New Zealand College of Psychiatrists (SA Branch), they stated: RANZCP SA supports the introduction of an RTPM system, as pharmaceutical drugs are the most frequent contributing drugs to overdose deaths each year. As a number of the medicines to be monitored by the system are prescribed by psychiatrists, our members are cautiously optimistic about its advantages as a clinical tool. However we would also like to take this opportunity to raise a number of matters surrounding the execution of a RTPM system which will need consideration as part of future legislative or regulatory changes, and in particular as part of its implementation. The rollout and detail of the new system are where issues may potentially arise. The College of Psychiatrists is concerned about protections for patient privacy and scrutiny over the access of patient information. They say that while the issue has clearly been identified they have concerns about the implementation and list several concerns and suggestions to alleviate those concerns. Specifically, they advise: Feedback from our Victorian counterparts has been that identifying patients based on their name as an identifier is not sufficient, due to the potential for errors. Our view is that best practice would be to use Medicare numbers to identify patients. We acknowledge this would need integration and cooperation from the Commonwealth Department of Health in order to achieve and is therefore not the easiest method—however also note that should a national prescription monitoring system be implemented, doing so now would allow for much easier integration in future. Steps will need to be taken to ensure transparency between prescribers and consumers regarding the use of the RTPM system. …In principle, an RTPM system should not be accessed in circumstances other than when the prescriber is making a prescription for their patient. Where circumstances require access to the system to make a prescription without the patient in the room, we would suggest there be a mechanism by which the patient can be notified their record has been accessed. The college is also concerned about accessibility of the new system for clinicians, and seeks the introduction of clinical guidelines to help inform decisions made about the prescription of medication in the event an alert pops up. Specifically, they list several areas they believe need to be fully explored before the system is rolled out, including, and I quote: Clinical guidelines for actions prescribers should take when a RTPM notification identifies an issue with an individual's prescription history. In many cases, it is not as simple as deciding to continue or stop a patient's medication. While we absolutely agree that the final decision should be based on the clinical decision of the health practitioner, the provision of a certain measure of advice and guidance is not inappropriate. Guidelines as to how primary and secondary care, as well as pharmacists and other prescribers, should communicate regarding notifications about individuals in the RTPM system…where health professionals should direct an individual identified as having a substance misuse issue for assistance. Alcohol and Other Drug (AOD) services are often very stretched, and it is likely the RTPM system will lead to identification of additional individuals who require assistance. It may be necessary to consider increased resources for these services in order to meet an anticipated growth in demand. While many of these concerns might be alleviated through answers during the committee stage, it is important to note that some simple consultation with that college much earlier in the piece could have gone a long way. It is vital that there is effective consultation between the government and key stakeholders as the rollout of the system commences, particularly regarding the move to make the system mandatory, as we have heard from doctors that this will be of great difficulty if the system is not user-friendly, efficient, and works for busy general practitioners. The bill itself is light on detail and grants significant regulatory powers. This is something my colleague in another place has pursued with diligence throughout briefings and, of course, the Legislative Council is regularly not minded to leave too much up to regulation but quite rightly as policymakers we prefer to have the essential elements of the scheme in legislation that we pass as a chamber. It must be said that no-one was as big an opponent of too much regulatory use of powers than the health minister when he was in opposition. During the briefing on this bill to the shadow health minister, the member for Kaurna, the government claimed that parliamentary counsel had advised the changes were best placed in regulation rather than within the bill, but I know that at the briefing our colleagues were also told the regulations were three to four weeks from being finalised. I am informed the opposition received a copy of the regulations at 2.47pm on the Monday before a sitting day, giving the opposition approximately half a day to scrutinise the regulations before debate on this bill was due to commence. As a practice, this is wholly unsatisfactory. These regulations are important and, in the absence of legislation, the regulations are essential to understand. Thankfully, debate on this legislation was delayed, in recognition of this fact. Furthermore, these draft regulations were labelled as embargoed, with the minister offering this explanation on their distribution: The draft regulations are embargoed as I need to undertake formal consultation before they are progressed to Cabinet. This begs the question: if the government had not even brought the substance of the reforms to stakeholders or to cabinet, why back then were they asking Legislative Council members to force this bill through as quickly as possible when how it would actually work was not even known to their own cabinet or to stakeholders? In summary, the minister was asking the Legislative Council to pass the bill. However, the government did not even want to consult on the detail contained in the regulations before council members voted on the bill. While the opposition does support the bill and does support the implementation of real-time prescription monitoring, we remain gravely concerned about the process that this minister has overseen and the lack of detail regarding the practical rollout of the system. Having tried to force the legislation through before regulations were able to be consulted on or even before regulations had gone through the minister's own cabinet process, the regulations still provide little clarity. During the committee stage we will have questions for the minister on why he has brought the legislation to parliament with so little detail behind it with such a sense of urgency, despite the two years of prior delay. As I said, the Labor opposition is supportive of the system and the legislative change; however, there is much more explanation that needs to be provided to this council to convince us and to give us comfort that the government is on the right track. The Hon. T.A. FRANKS Legislative Council The Hon. T.A. FRANKS (16:16): I rise on behalf of the Greens to welcome this legislation and the fulfillment of this government's election commitment, on top of a national commitment that will allow real-time monitoring of the prescription or supply of drugs of dependence. The key focus of this legislation is harm prevention and that is a welcome one indeed. The Controlled Substances (Confidentiality and Other Matters) Amendment Bill 2020 is a recognition that prescription drug abuse is a rising problem in our nation and pharmaceutical drugs have been significant contributors to overdose deaths. Prescription drug abuse is a worldwide problem of increasing concern to governments and the United Nations. Research data indicates that prescription drug abuse is increasing in Australia. The 2013 National Drug Strategy Household Survey found that 4.8 per cent of Australian adults used pharmaceuticals for non-medical purposes in the past year. That is an increase from 3.8 per cent in 2004. The number of people in needle and syringe programs who reported that the drug they last injected was a prescription opioid increased from 7 per cent in 2000 to 23 per cent in 2015. The importance of a real-time prescription monitoring system is highlighted and indeed echoed in an article published in the Australian Family Physician, a magazine of the Royal Australian College of General Practitioners. In an article titled 'Prescription drug abuse-A timely update' the authors noted that: Regulatory changes in pharmaceutical medications can have an impact on patterns of drug prescribing and subsequent misuse. Implementation of real-time monitoring programs may assist doctors in making more appropriate prescribing decisions. This is the very same article that highlights the statistics that I have just quoted. I am pleased to see that South Australia, along with the rest of the country, is moving to address this issue. I believe the passage of this bill would make us the third jurisdiction in the country to have a system that is compatible with the national database. Victoria's system is almost implemented and Queensland is a month or so ahead of us. Currently, the ACT has a limited version of such a system in place and Tasmania has a system that allows for almost real-time monitoring but is not yet linked to the national database. This bill is largely administrative, with enabling amendments that will see us implement ScriptCheck in South Australia as well as allowing the system to connect to the national database and collect information in real time. In an overdue leap into the 21^st century, this bill also allows for doctors to make applications for authority to prescribe drugs of dependence via the ScriptCheck system, rather than having to mail in a physical form request, as is the current practice. This will allow for better information being available around what drugs are being prescribed by whom, for whom and at what frequency, and it also allows doctors and patients more timely access to those prescribed drugs. The changes to penalties under the act are appreciated, as the amendments ensure they are more proportional. This bill allows for expiations on larger offences to support the system that will be in place. This is quite useful as, for example, the only way currently to address someone not submitting their data is to take them to court. This bill will enable warnings and the possibility of a fine without the offence being recorded, as opposed to taking an individual to court in what should be more an administrative approach. I particularly appreciated the added clarity that doctors and pharmacists can only access information in the database for the purposes of treating a patient and that health practitioners can only share information with others providing treatment and SA Health as the government regulator. It was deeply concerning to learn in our briefing about some of the behaviour of SAPOL officers who have engaged in demanding information from health practitioners under certain pretences and then have gone after the individuals to whom the information related for something entirely other than their health needs. So it is very welcome to see an assurance for health practitioners that they will not be required to share information relating to the prescription of drugs of dependence with SAPOL. I have a question for the minister, and I would like it to perhaps be taken on notice because I did not give prior notice of this question. In the past five years—or three years, depending on what is the easiest data to collate—how many times has SAPOL attempted to put pressure on our health professionals with regard to information about the prescription of drugs of dependence? This bill is timely and we look forward to its swift passage and implementation. It is indeed good to see our systems being brought into the 21^st century, albeit 20 years into the 21^st century, and also good to see the harm minimisation approach to tackle the very serious issues of dependency on prescription pharmaceuticals. As a subscriber to the SANDAS (SA Network of Drug and Alcohol Services) email list—which I have been for well over a decade, well before I was a member of this place, in my previous roles, particularly as policy officer for the Mental Health Coalition—I must note that this bill has been well consulted and that currently there is an email out that is specifically consulting those practitioners who are directly affected with regard to the regulations. I find it extraordinary that the Labor opposition would come in here as if we normally look at the regulations that are associated with an act before we pass a bill to create that act. It is extraordinary to gild the lily a little there as if somehow that is common practice. I note that, if the opposition were so minded, there is a whole website devoted to information on this process. Indeed, the website is very cognisant that some of our health practitioners have had a little thing called COVID-19 to deal with just lately and have had a lot else on their plate but are currently being asked for their specific input on how they will be affected and whether or not they need exemptions from the operation of this act. With those few words, I commend the bill to the council. The Hon. C. BONAROS Legislative Council The Hon. C. BONAROS (16:23): I also rise to speak in support of the Controlled Substances (Confidentiality and Other Matters) Amendment Bill. As we know, the bill makes a number of commonsense amendments to the Controlled Substances Act that flow on from the impending rollout of the real-time monitoring system. A national strategy has progressed since 2017 to address the growing prevalence of the non-medical use of certain pharmaceuticals, particularly those that pose the greatest risk of misuse or dependence. South Australia will be the third state to integrate into the national register. Victoria is already up and running and Queensland will likely pip us to the post by a month or so. I understand that the South Australian and Queensland systems will go a step further, not just in terms of monitoring schedule 8 medicines but also schedule 4 medicines, which when coprescribed can also be harmful. When used properly, these medications are of course meant to provide relief, but inappropriate use can have all sorts of detrimental and harmful effects on individuals, their families and the community. They can be highly addictive and help in terms of escaping from the stresses of life and reality, and we know that their use is on the rise. The Australian Institute of Health and Welfare report into the 'Non-medical use of pharmaceuticals: trends, harms and treatment', 2006-07 to 2015-16, has made some disturbing findings. During the study of that period, it found that prescription medications were responsible for more deaths than illegal drugs. In 2016, there were 1,808 drug-induced deaths in Australia: 663 of those deaths were caused by the misuse of benzodiazepines, traditionally prescribed to treat sleeping disorders and stress; 550 of those deaths were attributed to opioid analgesics, painkillers such as oxycodone, morphine and codeine, traditionally prescribed for pain management and heroin addiction; and over the decade there was a 127 per cent increase in the misuse of benzodiazepines and, even greater, a 168 per cent increase in prescription opioids. In fact, misuse was at higher levels than for any other illegal drugs except cannabis. So we know this is a huge problem. I think it would surprise many in the community that real-time access to data is not currently available to assist decision-making for medical practitioners and pharmacists alike. I suppose in a sense they are working in the dark at the moment, and they have been up until now. The bill provides for the implementation of a system that is intended to help combat the phenomenon of doctor shopping, where patients visit multiple medical practitioners seeking prescriptions they intend to either misuse themselves or sell on the black market. At present, there can be a significant delay in information being captured in the system. It is important to note the importance of this, particularly in relation to the black market and the sale of those prescription medications illegally to minors, because we know that minors, if they cannot get their hands on anything else, are very likely to get their hands on Xanax or whatever else they can get their hands on, depending on whether they are seeking an upper or a downer, and it is extremely accessible to them. In my view, that is something we need to address as best we can. This measure certainly goes some way towards doing that. We know that the lag in terms of the current system can sometimes be a month and sometimes more, as pharmacists currently manually download the previous month's prescriptions from their database. We know that locums and emergency departments still regularly handwrite prescriptions, which are manually recorded by pharmacists at the dispensary, adding to the length of delay in some instances. With the implementation of the new scheme, prescriptions will be immediately captured at the time they are dispensed and avoid those lag times. So this does make perfect sense in terms of capturing real-time data. The national rollout of the real-time system will prevent doctor shopping over borders too, and I am told it is not uncommon for patients to play both sides of the South Australian and Victorian border in terms of accessing these medications. The substituted confidentiality clause in the bill addresses any potential inappropriate use of data stored in the system. I share the concerns that have been raised by the Hon. Tammy Franks. I know that was one of the issues canvassed at our meeting in relation to SAPOL accessing data. I am pleased the government has made it clear that this information is not to be accessed by SAPOL for their investigations generally. That is not the intention, but SAPOL have used some questionable methods in the past in terms of trying to gain access to the records of access to medication by individuals, which was flagged with us at the briefing. As I understand it, that is the reason for these particular provisions in the bill. The bill makes it crystal clear that information cannot be shared over the counter or by phone to an unauthorised party. I understand that a comprehensive training and education program will ensure the dos and don'ts are understood by users. Of course, information sharing can still be sought through the appropriate FOI channels for use in the same wide variety of legal matters. It will not be real-time sharing, which itself has the potential for inadvertent misuse. A pharmacist will be able to confidentially refuse an over-the-counter police request for information, for example, and that is, I believe, at the heart of the comments the Hon. Tammy Franks was just making and the concerns that were also raised by us at the briefing. As I said before, I think many would assume real-time prescription monitoring was already in place. Those exploiting the system presumably know that it is not. We support any legislative measures targeting the illegal use of drugs in South Australia and acknowledge that this is a serious public health issue. We recognise only too well that illegal drugs are not the only drugs that can ruin lives and that the inappropriate use of such prescription medicines can create just as much havoc, whether through addiction, accidental overdose or suicide. I will end by reflecting on a very tragic inquest that I was involved in some years ago, where a young lady who suffered from a terrible gambling addiction accessed over-the-counter drugs at the supermarket, but accessed them in enough quantities to effectively end her own life. It was a tragic set of circumstances. I know that this bill is not intended to deal with those particular circumstances, but it did highlight to me very clearly at the time just how dangerous medication, whether legal or illegal, can be when it is misused and just how careful we have to be in terms of how readily available these medications are. I, for one, think it makes perfect sense. After experiencing the harrowing effects of that inquest with that family I think there are good grounds for further regulation of these sorts of products, which certainly do not fall within the classes that this bill addresses but are normal sorts of over-the-counter painkillers that we would access in the supermarket or over the counter at the chemist. I think there are very good grounds for some of those medications, which we often think of as rather harmless, to be further regulated, because I know, as a result of that inquest, that taking a couple of boxes of Nurofen will end in your death, whether you like it or not. With those words, I acknowledge again the importance of this bill, commend the minister for his work in this area and indicate our support for the bill. The Hon. S.G. WADE Legislative Council Minister for Health and Wellbeing The Hon. S.G. WADE (Minister for Health and Wellbeing) (16:32): I thank the Hon. Kyam Maher, the Hon. Tammy Franks and the Hon. Connie Bonaros for their contributions. I thank the honourable members for putting matters on the record that they would like to have addressed. In particular, both the Hon. Tammy Franks and the Hon. Connie Bonaros sought information that is not within my portfolio, so I intend to approach the relevant minister and seek his advice. In that context, I propose that we consider the second reading and I will see what information I can provide at clause 1. Bill read a second time.