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Shownotes

Clinical Snippets April 2023

1.  Syphilis

(i)  A recent Te Whatu Ora Waikato newsletter notes here has been a sharp increase in infectious syphilis notifications during 2022. This is particularly in the upper half of the North Island including Waikato and largely due to a sharp rise in reported cases among men. Notifications among men who have sex with women (MSW) have more than doubled between 2022 Q1- 2022 Q3. Infectious syphilis notifications among Māori MSW more than tripled. Notifications among men who have sex with men (MSM) increased by 40%.

(ii) The number of infectious syphilis notifications among women of reproductive age (15-49) and pregnant women remain high. In Q3 about half of the women who have sex with men (WSM) notified were pregnant – we are not testing enough young women.  Congenital syphilis (CS) notifications remain high and individuals of Māori ethnicity continue to be overrepresented in maternal and CS cases.

(iii)  HealthPathways recommends testing for syphilis in the following situations:

• All patients having a routine sexual health check. Recommend a repeat test 3 months from the time of last sexual intercourse if particular concern.
• All pregnant women (first antenatal bloods). Offer re-screening between 28 to 38 weeks gestation for women at increased risk: who have had a new sexual partner during pregnancy; with more than one sexual partner during pregnancy; with an STI diagnosed during pregnancy; whose partner is diagnosed with an STI.
• All MSM, especially if HIV positive. Arrange serology at least annually.
• Any rash or genital symptoms in MSM
• HSV genital ulcer(s), atypical or non-healing genital ulcer(s)
• Unusual clinical presentations e.g., lymphadenopathy, unexplained abnormal liver function tests, alopecia, pyrexia of unknown origin
• Patients who have had sexual contact with a person diagnosed with syphilis (serology usually carried out by sexual health clinic)

(iv)  Syphilis can be asymptomatic. Consider syphilis testing in cases with unusual skin rashes, oral, genital or perianal ulcers, lymphadenopathy, hepatitis and/or neurological symptoms. Syphilis in its secondary stage can affect any body system and cause end organ damage, hence its reputation as the ‘Great Pretender’.   Management guidelines can be accessed through HealthPathways and the Aotearoa New Zealand STI Management Guidelines. 

2.  Verifying death

(i)  The Ministry of Health Guidelines for Verifying Death note that medical practitioners, nurse practitioners, registered nurses, enrolled nurses, midwives, emergency medical technicians, paramedics and intensive care paramedics are authorised by the Chief Coroner to verify death, including deaths which meet the criteria for reporting to the Coroner.  

(ii)  A health practitioner can verify death when:

• the body shows signs of rigor mortis incompatible with life, or
• the body has visible injuries incompatible with life, or
• the body shows signs of decomposition incompatible with life.

Alternatively, health practitioners can verify death once they have undertaken two assessments (a minimum of 10 minutes apart) to establish death. The health practitioner must confirm the following:

• no signs of breathing for one minute (requires exposure of entire chest and abdomen)
• no palpable central pulse (femoral, carotid or brachial). In most circumstances this will

require palpation for 5–10 seconds

• no audible heart sounds
• pupils dilated and unreactive to light (requires a focal light source eg a torch)
• where available, a cardiac monitor or defibrillator is used and shows asystole

The reason given for the second assessment is that the person may be in asystole for 5–10 minutes and then spontaneously develop return of a beating heart. This is sometimes called auto-resuscitation or the Lazarus reflex.

(iii)  Medical practitioners and nurse practitioners can now use Death Documents to report deaths to the coroner. This new function asks a series of screening questions to guide the practitioner through the reporting requirements then provides a firm recommendation to either complete and submit a Coroner Report or complete a medical certificate of cause of death (because the death does not need to be reported to the coroner).  GPs have previously phoned the coroner to report a death. They are now encouraged to report the death using Death Documents.  The coroner’s office (NIIO) is notified immediately, and the death is reported to Te Whatu Ora so that the NHI record can be updated with the date of death.  NIIO will register the report and contact the practitioner by phone within 2 hours to confirm whether they have taken the case.  If the coroner decides to investigate the death, you must notify the police of the death if they are not already involved.

3.  Opioid prescribing

A recent BPAC article on opioid prescribing (Quick reference here) includes some potentially useful resources related to the prescribing recommendations, and an oxycodone prescribing audit which can be used for Te Whanake CPD credits.  There is a link to the Live Well with Pain website which is an initiative developed by clinicians in the United Kingdom. It includes a comprehensive suite of freely available resources designed to inform and support health professionals working with patients who have persistent pain and to help guide the appropriate use of opioid medicines.  Free registration is required. 

Key recommendations in the BPAC article include:

• Establish a treatment plan when initiating an opioid, including measurable goals and the timeframes for achieving these, information about adverse effects and a plan to stop use. This jointly agreed plan can be verbal, but it should be documented in the patient notes. BPAC has provided an editable pain management plan template.

• In some cases, a formal written and signed opioid contract may be suitable to ensure safe and effective opioid use.  BPAC has provided an example opioid contract if you think it might be suitable for a specific patient.

• Ideally select an immediate release formulation due to the lower risk of sedation, respiratory depression and overdose (particularly during initiation). Modified-release opioids are a strong risk factor for opioid dependence. N.B. modified-release formulations may still be considered in certain scenarios depending on clinical judgement.

• Use the lowest potency and dose possible to effectively manage pain. Reassess the benefits and risks of treatment when considering each dose increase if pain is insufficiently controlled. Prescribe in combination with non-opioid analgesics and/or adjuvant medicines as this may reduce the dose of opioid required to achieve pain relief.  Be alert for potential signs of misuse and dependence, e.g. requests for early repeats or escalating doses

• If initiation of a strong opioid is being considered in primary care, ensure morphine is trialled first before prescribing oxycodone (unless the patient has a documented allergy or intolerance)

• Prescribe for the shortest possible duration (ideally three days or less). If this is not practical and longer-term use is required, advise intermittent dosing (i.e. as-needed within the daily dosing limits), rather than continuous use. Intermittent dosing reduces the risks of dependence without compromising potential benefits.

• Prescribe a laxative if use will exceed 2 – 3 days duration and advise patients to remain hydrated. 

• If longer-term use is required, check in with the patient at each new prescription to assess the need for continued use. The opioid dose or potency should be gradually titrated down as pain improves (as per treatment plan).  A link is provided to the Te Pou publication Substance withdrawal management: Guidelines for medical and nursing practitioners 

4.  Drug Driving

(i)  The Land Transport (Drug Driving) Amendment Act 2022 was introduced on 11 March, 2023.  The key changes, recommendations and resources are included in a recent Medsafe Alert.

(ii)  The key changes are the addition of Schedule 5 and new blood tests to measure the amount (concentration) of drugs in the blood.

• Schedule 5 contains 25 ‘listed qualifying drugs’ (4 illicit drugs and 21 prescription medicines). These drugs have been identified as having the highest risk to road safety.
• Police will continue to stop drivers at random to check for alcohol or drug driving. If a person fails a Compulsory Impairment Test (a behavioural test to check for impairment), they will be required to take a blood test to check for the presence of drugs. With the law change, blood concentration levels will also be measured for Schedule 5 drugs. The blood concentration determines the type of offence, which may be a fine, demerit points, licence disqualification, or a criminal conviction.

(iii)  If a qualifying drug is identified, a medical defence is available for the use of prescription medicines for drug driving offences:

• if the driver can demonstrate that they took the medicine according to a current and valid prescription from health practitioner, and
• they have followed any instructions from a health practitioner or manufacturer of the medicine.

(iv)  Advice for healthcare professionals

• Please discuss with your patients whether their medicines (both prescription and over the counter) could impair driving.
• Advise patients to check whether they have any side effects that could impair driving, and not to drive if these occur.
• Check section 4.7 of the medicine data sheet for the effects of a medicine on driving.
• Find the prescription medicines currently included in Schedule 5, for which blood concentration levels will be measured.

(v)  Points to consider

• MCNZ statement on good prescribing practice:  Ensure that the patient … is fully informed and consents to the proposed treatment and that he or she receives appropriate information, in a way they can understand, about the options available; including an assessment of the expected risks, adverse effects, benefits and costs of each option.

• Use of NZ Formulary Patient Information section and Patient Information Leaflets

• NZ Formulary Caution Advisory Labels (CALs) which are promoted by the NZ Pharmaceutical Society but do not appear to be a mandatory requirement

(vi) Additional resources

• Health Navigator Driving and medicines – contains both general and medicine-specific information for consumers including which medicines are most likely to affect driving, symptoms of impairment, when and how long to avoid driving  There is a special ‘Heavy transport and medication’ section included.
• NZ Police site explaining the new legislation from a consumer perspective
• Waka Kotahi information for consumers and  health professionals regarding substance impaired driving including a link to a substance impaired driving health professional CME online course

5. Phenobarbitone brand change

• Pharmac has notified the funded brand of phenobarbitone tablets (15 mg & 30 mg) is changing because a supplier is leaving the market.  Approximately 400 people in New Zealand take the drug.  Current stock is expected to run out in July.

• Patients taking phenobarbitone tablets for epilepsy require alerting to the impending brand change and required actions.  Two appointments with a healthcare provider are needed: at one month before (June 2023) and one month after the brand change.

• Serum phenobarbital testing is required to check that concentrations remain at the same level before and after the brand change. Testing is recommended:

• three weeks prior to the change
• within the week prior to the change
• within the first week of the change
• one month after the change

Laboratory reference ranges are for trough levels with test taken shortly before the scheduled dose.

• The brand change necessity may provide health professionals with an opportunity to review patient clinical management.  Funding is available from Pharmac to cover the patient co-payment for the two visits associated with this change.

• Waka Kotahi recommends that patients consider a voluntary driving stand-down period of eight weeks following an antiepileptic medication brand change.

• Detailed guidance on the brand change is available on the He Ako Hiringa website

6.   Take a breath

A recent Goodfellow Gem looked at two ways of breathing to improve mood/anxiety based on research from Stanford University which reported how the breathing exercises for 5 minutes per day were better for mood and anxiety than mindfulness meditation, where the breathing is just watched.   

• ‘Sighing’, characterized by deep breaths (a large breath and an extra inhalation) followed by extended, relatively longer exhales, has been associated with psychological relief, shifts in autonomic states, and a resetting of respiratory rate.
• ‘Box breathing’ or ‘tactical breathing’, which military members have used for stress regulation and performance improvement, is inhaling for a count of 4, holding for a count of 4, exhaling for a count of 4 and holding again for a count of 4. The researchers asked participants to breathe in through their noses and out through their mouths.