Controlled substance prescriptions during public health emergencies

When a public health emergency unfolds in Australia, the rhythm of community pharmacy changes overnight. Whether the trigger is a pandemic, a prolonged bushfire season across New South Wales, or the kind of flooding that has repeatedly cut off towns in northern Queensland, pharmacists quickly find themselves navigating an unfamiliar balance between access and safety. Controlled substance prescriptions sit at the sharpest end of that balance. A patient who relies on opioid analgesia for cancer pain, a person stabilised on methadone, or someone recovering from a stimulant use disorder each rely on scripts that, in calmer times, are processed with predictable workflows. In an emergency, those workflows can be disrupted by staff shortages, supply interruptions, sudden regulatory changes, and a surge of new patients seeking help.

The tension between continuity of care and the risk of diversion is not new to Australian pharmacists, but emergencies amplify it. Schedule 8 permits, real-time prescription monitoring, and state-based regulatory frameworks were designed for steady-state conditions. Add a crisis on top, and the decisions made at the dispensary counter carry greater clinical and legal weight. Pharmacists in Melbourne, Sydney, Brisbane, Perth, and regional centres have all had to interpret evolving advice in real time, often with little more than an email from the Chief Health Officer and a queue forming at the front of the shop.

This article walks through the practical considerations that shape controlled substance prescribing during a public health emergency in Australia. It looks at the monitoring systems now operating across most jurisdictions, the scheduling framework that underpins clinical decisions, and the day-to-day judgement calls pharmacists make when supply is tight and demand is rising. It also considers how to communicate clearly with prescribers and patients when usual channels are strained.

Real-time prescription monitoring across Australian states

Australia has spent the past decade rolling out real-time prescription monitoring (RTPM) systems, and most jurisdictions now have a working platform. Victoria's SafeScript, Queensland's QScript, and the Australian Capital Territory's DORA allow pharmacists and prescribers to view a patient's recent dispensing history for monitored medicines before a script is handed over. Western Australia has implemented its own platform, while New South Wales has moved toward a national approach through the Electronic Recording and Reporting of Controlled Drugs framework. Tasmania and the Northern Territory are progressively adopting the national Real-Time Prescription Monitoring platform.

These systems were built to reduce the harms associated with high-risk medicines, particularly opioids and benzodiazepines, and they shine during emergencies. When a flood forces the closure of a regular pharmacy in Lismore, a relief pharmacist in Ballina can use RTPM to verify a patient's history before supplying an interim prescription issued by a substitute prescriber. The data also flags doctor shopping and helps identify patients who may be using multiple pharmacies during a crisis because their usual dispensary is closed. Pharmacists working in disaster-affected areas have reported that RTPM provides a critical safety net at exactly the moment when face-to-face handover of care is disrupted.

However, the systems are not yet fully harmonised. Cross-border patients moving between states during an emergency may find that not every pharmacist can view the same record, and privacy consent processes vary. Pharmacists working in border regions such as Albury-Wodonga or Tweed Heads often need to check which state system is active and may have to phone a colleague across the border for clarification. A helpful resource for pharmacists reflecting on the broader clinical context of prescribing is this neurosurgeon clinical guide, which highlights how controlled substances fit within multimodal treatment plans.

TGA scheduling and PBS considerations for controlled drugs

The Therapeutic Goods Administration (TGA) classifies controlled substances into Schedule 8 (Drugs of Addiction) and Schedule 4 (Prescription Only Medicine), with selected benzodiazepines sitting in Schedule 4 at the stricter end. State and territory health authorities add their own permit requirements on top, so the legal status of a script can vary between Sydney and Adelaide even when the medicine itself is identical. The Pharmaceutical Benefits Scheme (PBS) determines whether a subsidy applies, and during emergencies the Department of Health and Aged Care can issue amendments that temporarily alter authority requirements, streamline repeats, or approve pharmacist-initiated supplies in defined circumstances.

Pharmacists who treat the PBS as a purely reimbursement mechanism miss its clinical role. PBS listings carry restrictions designed to ensure high-risk medicines are used appropriately, and authority-required items often demand a clear treatment plan. During emergencies, when prescribers are stretched, pharmacists may need to support patients whose authority approvals are about to lapse or whose circumstances have changed. Calling the prescriber, confirming the indication, and documenting the conversation carefully are core elements of defensible practice. The PBS Safety Net also continues to operate during emergencies, and pharmacists in towns such as Broome and Mount Gambier have supported patients through the paperwork when their regular GP is unavailable.

Codeine was rescheduled in 2018 and is no longer available over the counter, a change that has reshaped how pharmacists triage acute pain presentations. Tramadol has also been progressively rescheduled, and pharmacists now routinely counsel patients whose prescriptions switch between products. These scheduling changes interact with emergency planning in subtle ways, because patients who lose access to their usual prescriber may present expecting older regimens. Clear documentation and respectful conversation help avoid misunderstandings at the counter.

Clinical decision-making when supply chains are disrupted

Supply chain disruption is one of the most predictable consequences of a public health emergency, and controlled substances are often among the first affected. Manufacturing issues, transport bottlenecks during floods, and export restrictions in source countries can all tighten availability of morphine, oxycodone, methylphenidate, and certain benzodiazepines. The Therapeutic Goods Administration publishes shortage notifications, and pharmacists are expected to check these registers regularly. When a listed shortage is confirmed, professional judgement comes into play: whether to substitute a therapeutically equivalent product, to contact the prescriber for a new script, or to provide a smaller quantity with documented advice to the patient.

Substitution is rarely straightforward. Switching a stable patient from one brand of methadone mixture to another can alter plasma levels, and changes to long-acting opioid formulations can destabilise pain control. Pharmacists working in palliative care, including in aged care facilities around Melbourne and regional Victoria, often need to liaise closely with the prescriber, the patient, and the patient's family before any change is made. Where a direct substitution is unsafe, pharmacists may need to ration supply, contact alternative wholesalers, or, in exceptional circumstances, prepare an extemporaneous product. Each of these decisions should be documented in the patient's record with the clinical reasoning clearly stated.

Emergencies also prompt the rapid uptake of digital health tools. Electronic prescribing, which became mainstream during the COVID-19 response, allows scripts to be transmitted securely to a pharmacy of the patient's choice, including when the prescriber is consulting from a different city. Pharmacists have embraced these workflows but must remain alert to the small but real risk of fraudulent electronic tokens circulating during a crisis, particularly for high-value or high-risk medicines. Verifying the prescription through the prescribing system and confirming patient identity with photo identification remain essential steps.

Opioid stewardship and harm minimisation in crisis settings

Opioid stewardship has moved to the centre of Australian pharmacy practice, and emergencies test how well those systems hold. Pharmacists are encouraged to review the indication, dose, duration, and concomitant medicines for every opioid prescription, and to flag concerning patterns to the prescriber. During a public health emergency, the usual rhythm of medication review can be disrupted. Outreach services may be cancelled, hospital outpatient appointments postponed, and patients who would normally attend a multidisciplinary pain clinic may present at the community pharmacy with nowhere else to turn.

Harm minimisation extends beyond opioids. Take-home naloxone programs have expanded across Australia, and pharmacists in every state can now supply naloxone without a prescription in defined circumstances. During emergencies, when overdose risk may rise due to changes in drug supply, isolation, or interrupted treatment, naloxone supply becomes an even more important intervention. Pharmacists in inner Sydney and in towns such as Bunbury have both reported increased demand for take-home naloxone following bushfire and flood events. Brief intervention, a respectful conversation about overdose risk, and clear instructions on administration can save lives in the days and weeks that follow a major disruption.

The Opioid Pharmacotherapy Program, which provides methadone and buprenorphine for opioid dependence, is particularly vulnerable during emergencies. Dosing points may close, transport routes may be cut, and takeaway doses may need to be authorised for patients who would not normally receive them. State authorities can issue temporary authorities for increased takeaways, and pharmacists are central to implementing these safely. Communication with the prescriber, careful documentation, and secure storage of takeaway doses all form part of the stewardship role.

Interstate prescribing and telehealth complexities

Telehealth has become a routine part of Australian healthcare, and controlled substance prescribing via telehealth is permitted under specific conditions. During the COVID-19 pandemic, temporary arrangements allowed prescribers to issue S8 prescriptions via telehealth for patients they had an established clinical relationship with. Many of those arrangements have been refined rather than fully reversed, and pharmacists now regularly receive electronic prescriptions issued by a prescriber in one state for a patient physically located in another. The prescriber must hold registration with Ahpra and, in most cases, comply with the drugs and poisons legislation of the state where the patient is located at the time of supply.

This creates practical challenges. A prescriber in Brisbane can lawfully issue a script for a patient holidaying in Cairns, but the pharmacist in Cairns must apply Queensland rules when dispensing. The same script, presented in Sydney, triggers NSW requirements. Pharmacists in tourism hotspots such as the Gold Coast or Hobart regularly work through these scenarios, often calling the prescriber to clarify authority numbers and indications. Good documentation protects both the patient and the pharmacist when audits occur.

Telehealth also changes how pharmacists collaborate with prescribers. A quick phone call or secure message can confirm a treatment plan, request a corrected script, or arrange an interim supply. Pharmacists have found these channels particularly valuable during emergencies when face-to-face meetings are impractical. UK pharmacy reflections on the digital transformation of community pharmacy offer useful parallels for Australian practice, particularly around the ethical boundaries of pharmacist-initiated supplies.

Communicating with prescribers and patients in stressful times

Clear, calm communication is the pharmacist's strongest clinical tool during a public health emergency. Patients who arrive at the dispensary distressed by evacuation, illness, or the loss of a regular pharmacy need reassurance as much as they need medication. A brief, private conversation away from the front counter can clarify concerns, identify adherence problems, and reduce the risk of conflict. Pharmacists who lead with empathy and provide clear, jargon-free explanations of any change in medication or supply tend to see better outcomes than those who focus solely on the technicalities of the prescription.

Communicating with prescribers requires a different tone. Pharmacists should be specific about the clinical concern, the action they are considering, and the documentation they intend to keep. A well-written intervention note that names the patient, the prescription details, the clinical issue, and the recommended next step is far more effective than a hurried phone call. Many Australian pharmacists now use templates within their dispensing software to standardise these notes, and several professional bodies publish example wording. The Pharmaceutical Society of Australia and the Pharmacy Guild of Australia both offer guidance on documentation during emergencies, and pharmacists are encouraged to revisit these resources at the start of any major event.

Pharmacists should look after their own wellbeing and that of their team. Sustained emergency response can lead to burnout, and the cumulative trauma of repeated disasters has prompted renewed attention to peer support and professional supervision. Taking scheduled breaks, debriefing after difficult encounters, and accessing employee assistance programs are all part of sustainable practice. A pharmacy team that is supported, informed, and rested is far better placed to deliver safe care to the Australians who rely on controlled substance prescriptions during the most difficult periods of their lives.