Clinician Perspectives on Prescribing Restrictions and Opioid Pain Management in Australian Podiatric Practice: A...

Australian-endorsed general podiatrists and podiatric surgeons (EGPs and EPSs, respectively) operate under a fixed prescribing formulary, the National Podiatry Scheduled Medicines List (NPSML), that restricts access to opioid analgesics including tramadol and tapentadol, despite emerging evidence questioning the efficacy of available alternatives such as codeine. The impact of these restrictions on clinical practice has not been qualitatively examined.

A qualitative descriptive study using semi-structured interviews was conducted with thirty-one clinicians: ten pharmacists, seven dentists, five EGPs and nine EPSs practising across metropolitan, regional and rural Australia. Profession-specific interview guides explored prescribing practices, analgesic strategies, experiences with formulary limitations and perceived impacts on patients and care systems. Interviews were audio-recorded, transcribed verbatim and analysed using comparative thematic analysis with inductive coding. This study was reported in accordance with the COREQ checklist.

Three themes were identified: (1) Inadequacy of fixed prescribing formularies: All professional groups, including pharmacists and dentists not directly constrained by the NPSML, critiqued the static, list-based prescribing model as structurally misaligned with contemporary evidence and practice. (2) Codeine as an unreliable ceiling for moderate to severe pain: Codeine was widely regarded as an unreliable analgesic because of variable metabolism, with clinicians describing cases of treatment failure necessitating emergency department referral. (3) Fragmented care pathways and cascading patient impact: Prescribing restrictions were perceived to generate disjointed care pathways, delayed pain relief, increased healthcare utilisation and disproportionately affected patients in rural settings.

Australia's NPSML is perceived by clinicians to be structurally misaligned with current pharmacological evidence, professional competencies and equitable care principles. These findings support the transition to a dynamic, scope-of-practice-based prescribing model that can respond to emerging evidence and meet the analgesic needs of diverse patient populations.