Episode 19: Opioids special #1: Tapering opioids in partnership with patients with chronic non-cancer pain

Voiceover:

Welcome to the NPS MedicineWise podcast, helping health professionals stay up to date with the latest news and evidence about medicines and medical tests.

Dr Jill Thistlethwaite:

Hello and welcome. I'm Jill Thistlethwaite, GP and medical advisor at NPS MedicineWise, and I've been a health professional educator for many years. I work with Anna Samecki and Steve Morris at NPS MedicineWise, the hosts of many of our podcasts. This is a slightly longer and special edition of our podcast series developed with funding from the TGA to support the recent changes in the regulations for prescribing opioids. The topic of opioids use in chronic non-cancer pain is a complex one. NPS MedicineWise is running a program for health professionals and consumers with tools and resources to help reduce the harms of opioids while ensuring adequate pain management and quality of life for people with chronic non-cancer pain. Please see our website for more details of this program.

In this podcast today, we will be mainly focusing on tapering opioids. I am joined by Associate Professor Michael Vagg, Dean of the Faculty of Pain Medicine for the Australian and New Zealand College of Anaesthetists and Don Firth, a representative from Pain Australia's consumer advisory group. Welcome, Mick and Don. Before we start the discussion, would you like to say a few words about yourselves?

A/Prof Michael Vagg:

Thanks, Jill. So I'm a rehabilitation physician and specialist pain medicine physician based in Geelong. And I'm currently the Dean of the Faculty of Pain Medicine, which is the professional body that's responsible for the specialty of pain medicine in both Australia and New Zealand. And in fact, we're unique in the world in that, in those two countries, pain medicine is established as a particular specialty by itself rather than being a sub-specialty of something else. So that makes our faculty and our environment in Australia and New Zealand a bit unique compared to the rest of the world.

Jill Thistlethwaite:

Thank you, Mick. And Don.

Don Firth:

Yes, hello, thank you for the opportunity to tell some of my pain journey. At one point I was contemplating back surgery due to the excessive pain that I had that fortunately, I found out, was in large part due to the opioid levels I was taking to get rid of the pain. More of that later, of course. So I hope it will be of help to fellow chronic pain sufferers to hear some of my story.

Jill Thistlethwaite:

Thank you both for being here. Taking opioids can be challenging as we know, both from the literature and our own experience and from talking to GPs during the course of our program. GPs such as myself may find it hard to know where to start with the tapering process. So Mick, how would you start? And could you step us through the process?

Michael Vagg:

Sure. In some respects, tapering is easier than you think, in some respects, it's more difficult. Anyone who has the cognitive and motor skills to write a smaller number consecutively on each prescription that you write can taper opioids because in essence, the rate of reduction of the medication and how quickly it's done is kind of the easy part. What is critical for succeeding, if you were tapering is actually setting the ground or setting the scene for it to be successful. We're using what we understand to be the best, most successful techniques for doing that. And the number one thing that is helpful is that the person who's on the opioids really needs to buy into the decision and if possible, to actually drive the process. There's good evidence these days that the success rate for long-term dose reduction is much higher in people who actually initiate it themselves and who are given a certain amount of autonomy over the process and people who are working in collaboration with their healthcare team to achieve a dose reduction.

That's the ideal way to do it. So a lot of the issues with getting started in tapering opioids is to do with addressing the person's concerns or their fears about reducing the dose and being able to reassure them that in fact, although there are issues that will need to be sorted out along the way that in fact, the likeliest outcome from a dose reduction overall is that people's pain will be much the same and the quality of life will usually be significantly better. So that's really the key to start is to actually be able to provide a sufficiently good therapeutic alliance with the patient and enough education and information for the person to come to that decision themselves and then enlist you as an expert advisor to help them do it.

Jill Thistlethwaite:

So it's very important as you say, for the patient to be motivated, to undertake this challenge of tapering, and they're going to be quite concerned and anxious to start with as they do this. So in terms of where you start from the dose reduction, you mentioned it's about reducing in a stepwise fashion. How do you actually plan that and what sort of time would you take to do that?

Michael Vagg:

Sure. So depends a little bit on the individual circumstances of the person that you're working with. For someone who has been on a very long-term high dose regime, I would usually go at about 10% per month of their starting dose. And my initial goal would be to try and get them to 50% of their starting dose within about six months or so. And if you can do better than that, great. But again, just like people who've been on prednisolone for a long time and whose adrenal glands have become so suppressed that they can't safely come off it, there's evidence that that happens in some people with long-term opioid therapy. And it might be that people's brains are not able to produce enough endogenous opioids to maintain mood, to maintain motivation and people's ability to think straight. So sometimes you have to settle for not getting all the way down to zero. And it may be also that you come to a decision point where you need to choose between a higher level of pain and a lower dose. And that's where the patient's preference is also pretty important.

Jill Thistlethwaite:

Yes, I can see that. So it's getting to the lowest effective dose [that] is the goal. And sometimes that might be off the opioids completely, and sometimes it might be staying on that low dose for a length of time. And then presuming you could revisit that decision later to see if you can get off that.

Michael Vagg:

Absolutely. Yes, and we used to think that the nervous system was relatively fixed and that it couldn't really adapt very quickly. We now understand much better than that, obviously in a whole range of areas and persistent pain is one of the most complex neurobiological phenomenon that occurs. And so when somebody may not be ready or able to reduce their dose at a particular point in time, waiting around for 18 months, two years, and then trying again, you often will succeed where you didn't succeed before if you just keep having a go at it every so often. And if the person understands that in fact, there usually does for most patients on moderate or high dose opioids, there usually comes a time where those drugs are not working as well as they used to. And that's a good time to initiate the dose reduction.

Jill Thistlethwaite:

Hmm. So Don, you've been prescribed opioids for chronic non-cancer pain in the past. And you managed to taper off them very successfully. Could you tell us a little bit about that journey and how you felt?

Don Firth:

Yes, I've had chronic pain most of my life from a series of injuries and gradual worsening osteoarthritis. This was exacerbated by building an underground house about 10 years ago, and also having to have a knee reconstruction, a full knee replacement, which was acute pain and correctly, I was prescribed Endone and Oxycontin in fairly heavy doses. In fact, my doctor gave me a script for 100 tablets and said use them as you need. So the level of those opioids took care of most of my other pains for a time. As I gradually weaned off them, I got to a level where the pain came back on the other injuries and osteoarthritis pains, such that I gradually increased the level of such minor opioids as Tramadol in varying forms.

And I discovered that I was not waking up until well after 9 o'clock in the morning and my will to live had gone. And so I thought I got to do something about this and booked in to see a surgeon for surgery. At the same time, I managed to find a telehealth service from St. Vincent’s Hospital who said "By all means, go and see him, but why don't you try this?" And it involved tapering. After that, I joined the ACT chronic pain support group and did a number of local hospital courses and found out an amazing amount of things that I didn't know about my body and that some of that pain could be in my mind. And that if I was to reduce the opioid dose, I may not be in any more pain after a while.

Jill Thistlethwaite:

Thank you. That's really interesting to hear these stories that these things, tapering can be successful. So Don, how long did it take you to taper off your opioids?

Don Firth:

Well, I was, it was quite amusing. The first interview I had with St. Vincent’s Hospital telehealth, I assured them that I had no intention of giving up my opioid levels, but was looking for further help. And they assured me that they had no intention of taking me off them. Indeed, they might up them. And that reassured me to carry on working with them. And I mean, I still am not completely off, but compared to where I was four years ago, so it has taken that long, I think maybe three years to get down to almost no opioids and then just an occasional for acute episodes rather than continuing chronic ones.

What has been the greatest difficulty, and I feel for other fellow sufferers, is that I have a great ability to research things and join groups and find things out. And it has taken me an awfully long time to understand that the pain in my head from precisely one point in my lower back is a memory pain rather than an actual, necessarily real pain. And that has been the longest part of it. And once I've been able to accept that, I found it very much easier to reduce the amount of opioids that I've been taking. If that sort of answers your question.

Jill Thistlethwaite:

It's really useful to hear from people talking about their experiences. So Mick, opioid induced hyperalgesia or OIH is not a well known adverse effect of opioids and can often be confused with tolerance. Can you tell us a little bit about what OIH is and how you would differentiate it from tolerance?

Michael Vagg:

So opioid induced hyperalgesia is a phenomenon that is produced by the adaptions that the nervous system makes to long-term usually high dose exposure to opioids. That said, it has been documented to occur in as little as a few hours if you are using extremely potent opioids like some of the fentanyl derivatives that are used in anaesthesia. So there are case reports of people becoming severely hyperalgesic from one or two doses of some of those very powerful fentanyl derivatives. But essentially what it means is that the net result of those adaptions the nervous system makes is to leave you more pain sensitive overall. And this is something which explains a phenomenon that we had observed for a long time, but never really understood, which is that when people who say we're on opioid therapy for chronic back pain had a broken ankle or a dislocated shoulder or needed an appendix out or something, they seem to have very severe pain.

And their opioid requirements were far in excess of what you would have predicted even accounting for tolerance. So tolerance is the effect that when you are exposed repeatedly to a particular opioid, your body gets better at handling that particular opioid, it adapts to it. And so you eventually need more to get the same effect. So tolerance is a one way thing where you just need to have a higher dose to get the same effect over time. And opioid hyperalgesia is actually going a couple of steps further than that, where it's you're not just needing what you may well be tolerating. In fact, you probably are tolerating if you're developing opioid hyperalgesia, but you're also becoming more pain sensitive in areas that have nothing to do with the original pain. And that's only been relatively recently recognized and not all opioids have the same potential for causing hyperalgesia. And basically the more powerful the opioid, the more likely it is to cause hyperalgesia and codeine is the only exception to that rule.

Jill Thistlethwaite:

So as you say, you don't need to be on opioids for a long time to get this hyperalgesia, right, it can happen quite quickly?

Michael Vagg:

Not if you’re on very strong ones.

Jill Thistlethwaite:

So now I'd like to ask you some questions about the recent changes to opioid prescribing through the TGA and in the PBS. So there's been some updates to indication, amendment of clinical criteria for PBS prescriptions, and the introduction of these 12 monthly reviews to those patients requiring more than maximum constitutes and repeats. Could you just explain a little bit about these changes and what they're for?

Michael Vagg:

Yes, so the intention of the changes, it's been brought about by increased awareness of what's the optimum way to use opioids, and in particular, the move to introduce reduced pack sizes for immediate release opioids was something that has been flagged as an evidence based intervention for quite a while. What was happening was that if people are going home from hospital, it was more cost-effective for the intern who was doing the discharge prescribing to give them a whole box of Endone compared to say five tablets, which might be all they needed, but because of the five tablets or 10 tablets was a non PBS script, it cost the patient more money. And it also increased the leakage of strong opioids out into the general community. Because if you give someone a box of 20 and I might only use three or four of them, then there's the rest of the box sitting around potentially being available to anyone who wants to access it.

So for various good reasons, that was always on the cards, that particular change. There were a number of other changes the TGA looked at including changes to the prescribing information, changes to the pack sizes, limiting certain doses or certain formulations to specialists only. And so what was introduced was felt to be a reasonable compromise between practicality and not completely cutting people off from an appropriate supply of opioids, but also being a little bit more restrictive as far as forcing people to maybe justify to themselves or to their colleagues a little more as to what was the grounds for continuing to prescribe. And it certainly was not designed, and I can tell you this from having attended multiple consultations with the TGA over the last few years, it was certainly not designed to be a way of trying to force people onto an opioid taper.

It was certainly not designed to try and punish or weed out inappropriate prescribers. And the fact that it has sort of coincided with a move, particularly in Victoria where I am, to real time prescription monitoring has created this real climate of paranoia among a lot of GPs, that is actually, was never the intention of these regulations and these reforms. I do think we in the Faculty of Pain Medicine have very strongly provided this feedback along with our colleagues at Pain Australia and the Australian Pain Society. We've provided the feedback that there has been significant unintended consequences of those changes, where it has resulted in a lot of restriction of access to what would otherwise have been potentially appropriate patients.

And the TGA is taking steps to try and remediate that, but it probably would have been better as was done with the codeine up-scheduling, to have a longer lead-in time to allow people to get their heads around what that was going to mean before it was introduced. So in retrospect, maybe it would have been better if they'd waited a few more months and put some more educational activities like these podcasts, done that before the reforms actually came in.

Jill Thistlethwaite:

So maybe many GPs who are concerned about how these changes may impact on providing care to people in residential aged care, what do you think the impact might be?

Michael Vagg:

So apart from possibly a little bit more regulatory red tape, I think the difficulties with providing appropriate pain management in aged care are more than just related to the prescribing. There are significant problems with adequate assessment of elder patients in pain. Some people are non-verbal or they aren't able to communicate their pain properly. We also know that pain is often underestimated in older people because their pain centrally sensitizes more quickly. So what may seem to be a relatively innocuous bump on the leg or an ingrown toenail or something, because as you get older, you lose some of the inhibitory in the neurons in the spinal cord. So those pains can become much more severe, much more quickly. And so using conventional painkillers, such as anti-inflammatories or opioids or paracetamol for centrally sensitized pain is not going to work.

So there are issues with being able to accurately diagnose pain and to assess pain in the frail elderly. They're also more prone to side effects. So medications may not be, even if they're helpful, they may not be appropriate to prescribe because they might cause significant other knock-on problems for that individual patient. So really the key to managing in an aged care setting where resources may be limited is actually to emphasize as much as possible the non-pharmacological measures such as positioning ergonomics, put water bottles or cold packs, compression elevation, and also to be prepared actually to have a slightly lower threshold to go to, or to involve the care of a pain specialist, because it is a more challenging environment.

Jill Thistlethwaite:

Yes. And we've already been discussing how challenging tapering can be, but it can also have some very positive outcomes. Are there any particular strategies to adopt when thinking about tapering opioids for someone who is in residential aged care?

Michael Vagg:

Yes. I think the main benefit is lack of sedation and lack of constipation. That's the key. And then those are enormous draws of quality of life in older patients. If someone is in residential aged care and they're sleeping through their visitors, that's really disheartening to all involved. I think also the hands-on care that is provided to position a patient correctly, to use cushions or aides to get someone in a position that they're comfortable in ensures that that patient feels more supported and it can have a significant benefit on social connectedness and quality of life if people are not constantly drowsy for medications. But I think a key thing with older patients too, is that just as in the young, also in the old, the distraction strategies tend to work quite well.

So using things like music, using things like familiar people or objects to provide something that that person's brain will find to be extremely engaging, that will have a significant, a much more positive effect on the person's mood, as well as their pain compared to someone say in their 30s or 40s. So there's a publication that the Australian Pain Society has put out about guidelines for residential aged care pain management, which is a really, really valuable document. And if I could do one thing to improve pain management in aged care would be to make that document more widely known throughout the aged care sector.

Jill Thistlethwaite:

Those strategies you're talking about are reliant on the members of the team who are caring for the elderly in aged care. And I think that's quite important that GPs aren't alone in what they do. So I was wondering Don, how important was it for you to be supported and who supported you through your journey in your tapering, or the health professionals or the people that did that for you?

Don Firth:

Well, it was hugely important to have support. I wouldn't have done it on my own. They didn't even recognise my situation until my wife pointed it out to me and I thought, "Gosh, yes, I have deteriorated. I'm at the end of my life at 68." Now that I've, well almost fully tapered, I've probably got another 30 years. Go and not just seeing your doctor, but almost everywhere, even if it is through telehealth, there are group therapy sessions that you can go through a whole range of support, ways of managing your pain other than using the opioids.

Jill Thistlethwaite:

Yes and Mick in your experience, what's the role of psych practice nurses, nurse practitioners, psychologists, and other people in helping support patients with chronic pain and true tapering?

Michael Vagg:

Well, certainly we've known for probably 30 years that the major contributing factors to poorly managed pain and disabled people as a result for pain, the key risk factors are psychosocial in nature. So the things that somebody does to try and adapt to having the chronic pain are actually the most important things that determine outcomes. So if all we're giving people to try and manage their pain is medication that at best will work in every third or fourth patient you give it to, your outcomes are not going to be very positive. So in the Faculty of Pain Medicine, we actually, instead of the old bio-psychosocial model, we actually have turned that around to try and talk about a socio psycho biomedical model, where you need to understand the social context that somebody is operating in before you, and their psychological reactions to their situation before you can even really adequately assess their biomedical problems.

So what that implies is that if someone has a problem with pharmacological management of their pain and that's all you're doing to try and manage their pain, that there is enormous potential gains to be made by properly assessing and addressing those socio psycho aspects of that, and that's where Don describes really nicely the fact that it would never have occurred to him that there was another way to think about having pain other than the medical model, which is you go to the doctor, the doctor diagnoses it, gives you a treatment and you get better. And if anything, in medicine over the last 50 years, we've been sort of victims of our own success things like cancer and heart disease, where we are incredibly effective at treating it now, but chronic pain, the more research we do, the more we understand that actually there are still some advances to be made in the biomedical side of things.

Michael Vagg:

But actually if we just could implement in practice, what we already know about the psychosocial management of chronic pain, we would make far more progress. So, having access to people who've got the right information that can actually engage with you and explain how chronic pain works, what's the best strategies for trying to go about chronic pain and how to try and set up your life so that you only really have the pain that you can't avoid. And many people will be able to manage quite well with that level of pain.

So really what our issues with our opioid medication and people being stuck on relatively ineffective, high doses of opioids, it's really because in many, many cases, those people have never actually had access to things that might help them more. And so it's defaulted back to the opioids. So certainly introducing, if there's not regional access in people's areas to a properly trained and constituted and equipped multidisciplinary pain type, then get on the phone to your local politicians and health ministers and demand one, because that is the evidence based way to manage chronic pain in 21st century.

Jill Thistlethwaite:

That's given our listeners something to think about doing after this podcast. So just going on to the last area for discussion before we finish, we've heard about successful tapering and the strategies that can lead to that success. But what about patients who are resistant to tapering or cannot be tapered off opioids in primary care, despite our best efforts with the team, what would you suggest would be the next step for those patients?

Michael Vagg:

Sure. So there are a number of, if you like, enhanced strategies that can help people get to lower doses. And in my practice, which is, it's a large, comprehensive, private pain service in a regional area. So we're certainly not typical of the average pain practice, but we're able to provide inpatient infusions with ketamine, lignocaine and supervise inpatient dose reductions so that if someone is stuck on a particular dose, we can bring them in and intensively manage them over a week or so, and at least take a chunk out of that dose to get them to settle at a lower one, and that might be enough when they plugged in with the rest of the team to be able to kick off a little bit more reduction. But I think the key thing is if you're trying to understand if you have a legacy patient, the so-called legacy patients, you need to understand why are they resistant to reducing their medication?

It may be that they actually have very, very good reasons for it. It may be that it's been done several times in the past badly, and they're simply not willing to consider it unless they feel as though they're driving the process. And it's challenging for doctors to actually sit back and say, "You know what, I'm going to let you choose what you want to do. And I'm going to do what you asked me to do in this regard," because as doctors we're used to being the ones who people come to for advice and giving that advice and that advice working. And so a lot of the ill feeling that can occur between patients on opioids and doctors who are trying to manage them is because of that mismatch between expectations and mismatch between the communication that has occurred.

So, the first step, if you have a new patient who you've just taken on, who is on what seems to be somewhat eyebrow-raising doses of opioids, there will be a history there that you have to understand. And, it may be that that person actually has very good reasons why they're on those doses. And if there's a pain specialist involved, there should also be a backup letter or some sort of explanation as to what's going on, if you're able to contact that specialist. But if it is somebody who has just been put up on those doses by someone who doesn't necessarily understand pain management and they're stuck there, then there is definitely a lot of education and a lot of support that those people will need before they understand enough to be okay with coming down with the dose.

And as you say, there are some people who it's not in their best interests or indeed the communities or the health system's best interest for those people to be forced off their doses of medication. And so we have to be prepared with a certain number of people to say, "Yep, we'll just keep doing it every couple of years. We'll assess you actively for the harms that may be caused, the endocrine problems, the mood problems. And we will provide you with take home intra-nasal naloxone so that if you're ever found unconscious, that can be very quickly reversed. If it's an opioid problem and opioids can be excluded as a cause, if it's not due to that."

So there are things you can do to contain the dose, to contain the distress of the patient and just keep coming away and hanging in there over a period of time. And it's appropriate for those patients, for you to just keep coming back to it, not every few months, but every year or two, and seeing whether there is potential at that point in time to achieve a bit off the dose. And if there's not, there's not, and you have to be prepared to accept that in some cases.

Jill Thistlethwaite:

So you've mentioned referrals to pain specialists and their role. What about drug and alcohol services? When might you think of referring to them?

Michael Vagg:

Yes, I would say there's two reasons that you would do that. One is if it becomes clear from that person's lack of willingness to engage with multidisciplinary pain management or other strategies, if that person has erratic prescribing behavior, which is, again, every GP is familiar with the warning signs, but if you form the opinion over a period of time that this person actually primarily has an addiction problem, then that should be managed by a drug and alcohol service and the pain service or the GP can consult on non-opioid related ways of managing that pain. But in some patients, you will need to make a decision based on that person's susceptibility to addiction, that you're just not going to use opioids to manage their pain. The other time that I would suggest referring to a drug and alcohol services, if you have someone who's been stable for a long time on very high doses, and he's very sedated and not getting anywhere, rotation to suboxone may actually be a very, very valuable strategy.

Again, here in Victoria, we're in the fortunate position where our state government commits a small number of pain specialists to do the training and become suboxone prescribers under the pharmacotherapy program. And I'm one of those prescribers. So I have probably about a dozen patients who I've rotated onto suboxone and a couple of them have not persisted with the suboxone for various reasons, but most of those patients have done extremely well. And suboxone has proven to be one of the best things I've ever been able to do for them. So if you're not local, if the local pain service is not able to do that, or if the state regulations where you are say that that should happen, it's worth having a conversation with your local drug and alcohol service to see whether they can provide that rotation onto suboxone for patients where they're on high stable doses, and just don't seem to be able to get it down.

Jill Thistlethwaite:

Thank you. Lots of information, lots to take in. We're coming towards the end of our time now. So just to see if there's anything either of you would like to say before we finish. So Don, any further comments or tips for GPs?

Don Firth:

Firstly, I was intrigued by Mick’s correct statement that the pharmaceutical delivery of opioids had suddenly been cut off to many patients. And my group have been very concerned about that. We've had a lot of cries for help and that perhaps they should have actually considered a slightly more tapering approach to reducing the medicines whereas a few months ago I had a six months prescription of a whole heap of drugs, I'm now reduced to a single script at a time, which I personally can manage very well, but for others who are beginning the journey of tapering, that's going to be far more alarming. The other thing, although it isn't our topic and I'm sure we'll have this as a separate podcast, but pacing is a very important aspect of being able to manage tapering.

Jill Thistlethwaite:

So do you want to just elaborate a little bit more about that?

Don Firth:

Well, obviously one of the many, many things that I learned from the support groups was when you pace yourself to not go beyond a particular pain threshold, you gradually build up your ability to withstand that level of pain or not get into a zone where you are in such pain and gradually you are able to do more work combined with other physical methods. So I have found that extremely helpful to get my body back into a productive form.

I haven't explained that well. I'm sure somebody else can do this.

Jill Thistlethwaite:

Mick, any final comments from you?

Michael Vagg:

Sure. Apart from completely endorsing what Don just said about pacing, pacing more than any other individual strategies is a key skill for anyone with long-term pain and everyone should learn how to do it. Even those of us who don't have chronic pain, but the thing that I really would like to impress upon GPs is that we have very good evidence that for people who are well-established on opioids, if the patient decides to taper and they are allowed to choose the rate at which they taper, the commonest outcome is that their pain does not change over the long term. So they will still have a similar amount of pain to whatever it was they started with. People worry that their pain is going to get worse when they reduce the opioids. And there are multiple studies now that show, in fact, the least likely thing to happen to that person is that six months later their pain is going to be significantly worse.

Far more often the pain is either the same or slightly better. And in fact, we also have evidence from a very large retrospective study which was recently done that if you have a decision point where somebody is already on a moderate to high dose of opioids and you increase the dose by 20% a year later their pain is worse and the quality of life is significantly worse in most cases. So, it's all about using these drugs for what they're good for. And our appreciation for the therapeutic range of opioids has contracted significantly. And the vast majority of my patients are on less than 60 milligrams of morphine equivalent today and they do just as well as 15 years ago when I was happy for them to be on higher doses.

Jill Thistlethwaite:

Thank you. I think such important points to take away from this. And I'd like to thank you both for your time and thank everybody who's listening. Before we do go, I'd just like to mention our resources to help with tapering conversations, including conversation starters, and a series of communications videos. One of which is now available on our website and three are to be available shortly. If you would like to find out more about Opioids, Chronic Pain and the Bigger Picture program and find resources that can help you, we will put some links in the podcast description. Please send any questions or suggestions for future podcasts by NPS MedicineWise via Twitter or LinkedIn. So goodbye and thank you all for listening.

Voiceover:

For more information about the safe and wise use of medicines, visit the NPS MedicineWise website at www.nps.org.au