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Prescription Opiate Abuse
Managed by GPswith
Authorized Staged Supply
Dr Nigel Hawkins - UWS
Admissions for prescription vs illicit opiate abuse
NATIONAL PHARMACEUTICAL DRUG MISUSE FRAMEWORK FOR ACTION (2012-2015)
Prescriptions for Opiates
Deaths related to oxycodone
Opiates are usually prescribed for severe disabling pain
Most commonly› Low back pain› Cervical nerve root irritation› Migraine› Musculoskeletal pain
Definitions Abuse is when a patient is not taking their
medications as prescribed by a single doctor
Dependence is when a patient cannot cope without their medication
Addiction is when a patient experiences tolerance and withdrawal and is physically and psychologically dependent on their medication
Disorder includes any or all of the above
The POINT study recruitedPatients using opiates > 6 weeks from Pharmacies all over Australia
Patients were screened for › Aberrant Behaviours› Dependence› Other drug use› Co-morbid conditions
POINT: Age Distribution
18-34 35-64 65+0%
10%
20%
30%
40%
50%
60%
70%
% Prescription Opiates Users > 6 weeks
N=1085
Female 55%
POINT : Dose Ranges
1-21mg
21-90mg
91-199mg
>200mg
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%
% Prescription Opiate Users > 6 weeksN=1085
OralMorphine
Equivalents
Incidence of dependence
POINT Study Campbell et al Pain Medicine 2015
<20mg 21-90mg 91-199mg >200mg0
2
4
6
8
10
12
14
16
18
Past 12 months Life time
Oral Morphine Equivalents
% o
f gro
up
Incidence of other drug use
POINT Study Campbell et al Pain Medicine 2015
<20mg 21-90mg 91-199mg >200mg0
10
20
30
40
50
60
benzodiazepines illicit drugs
risky drinking
Oral Morphine Equivalents
% o
f Gro
up
Incidence of moderate to severe depression and anxiety
POINT Study Campbell et al Pain Medicine 2015
<20mg 21-90mg 91-199mg >200mg0
10
20
30
40
50
60
70
depression anxiety
Oral Morphine Equivalents
% o
f gro
up
Incidence of tampering, doctor shopping and diverting
POINT Study Campbell et al Pain Medicine 2015
<20mg 21-90mg 91-199mg >200mg0
2
4
6
8
10
12
14
tampering doctor shopping
re-routing
oral morphine equivalents
% o
f gro
up
What’s the point of POINT
Patients tend to be more complicated the higher the dose of opiate that they take
Higher doses were associated with higher likelihood of dependence, depression, anxiety, use of benzodiazepines and other drug and aberrant behaviours such as doctor shopping, injecting and OD
The majority of patients were nevertheless not dependent according to ICD10 criteria
Only 4.7%** met criteria for dependence in the last 12 months
**this is probably an underestimate
Some Drug Seekers can be very persistent and annoying We may not say these words but this is
how it may come across› Go away› Junkie› No, we cannot help you› We don’t want you here
Even genuine patients can become upset or angry because of this
Staged supply
Is a simple but effective way for GPs to manage their own chronic pain patients who have become addicted to prescribed opiates
It does not involve prescribing methadone or buprenorphine/naloxone which are usually reserved for illicit - intravenous drug use
Staged supply
Is an established pharmacy procedure for patients who have difficulty taking their medications properly
It can be used for any drug but it is ideal for opiates & benzodiazepines
Pharmacies receive a rebate for dispensing the medications in stages (daily, second daily, third daily etc)
Quantity dispensed and frequency of pickups
Quantity dispensed at a
time
RiskAvailability
Desperation
General Practice
Normal prescribing Staged Supply Opiate Replacement Therapy
Specialist
Prescription Opiate Abuse
•Patients who take their medicine properly
Normal Prescribing
•Patients with opiate use disorder on moderately large doses
Staged supply
•Patients who inject or use very large dosesORT
Recognising Opiate Abuse
When patients want more than you feel is appropriate
If the patient runs out of their medications more frequently than expected
If the patient is seeing other doctors If the patient is using other addictive
drugs If pain persists for longer than two months If the patient looks drug affected or has
track marks If alerted by doctor shoppers or real time
services
Assessment of New patients
Care should be taken with new patients Very persistent patients Asking for a specific drug that is prone
to abuse Look at the patients arms Consider doing a urine drug screen Talk to previous doctors Talk to doctor shoppers
What is the cause of the patient’s pain?
Does the patient have a genuine cause of pain or is the patient simply addicted?
What is the quantity being consumed?
How many times the recommended therapeutic dose (for pain) is the patient consuming
History Records Doctor shoppers Real time services
Is it for personal use?
Is the patient selling** (diverting) their medication or is it for their own personal use?
If diversion or injection suspected then consider supervised doses or an opiate-naloxone preparation
**Patients who sell their medication should not be entertained
What form of opiate is being used?
Patches Tablets Syrups Films Opiate / naloxone
preparations Over the counter preparations
How is the patient using the drug?
Is the patient - disolving and injecting their
medication? smoking their medication ingesting the medication
If the patient is injecting their medication consider ORT
What other drugs are being used?
AlcoholTobaccoCannabisSpeedValiumHeroinCocaine
What is the patient’s social setup?
Working? Homeless? Transportation? Social supports or
liabilities? Criminal record
What co-morbidities exist?
Diabetes Ischemic heart disease Cirrhosis Renal impairment Cancer Back injury Arthritis hepatitis
Are there any mental health conditions?
Depression Anxiety PTSD Schizophrenia Personality disorders Cognitive impairment
How many doctors are involved?
Is the patient visiting multiple doctors at different surgeries or do they stick to one doctor or one surgery?
Examination
Signs of opiate withdrawal Signs of opiate intoxication Track marks General appearance and hygiene Signs of liver disease Is the patient in pain
Management of Prescription Opiate Abuse
Single prescriber Authority to prescribe Staged supply Specialist consultation Allied health referral Opiate Naloxone preparation Opiate replacement therapy**
** if very large quantities or intravenous drug use or if buying street drugs
Who is the principal doctor?
Who is going to manage the patient?
Communication between doctors is essentialSomebody needs to take responsibility for the patientThis should be documented in the patient’s record
Consideration of alternative treatments
Referral to surgeons / specialists Referral to multidisciplinary pain clinics Physiotherapists / chiropractors Psychologists Non opiate medications Non pharmacological strategies
Authority to prescribe Getting an authority to prescribe is a
legal requirement after 2 months It ensures that there is only one
legitimate prescriber A DD Application needs to be faxed to
the PSU The doctor then needs to speak to the
PSU to confirm that the authority has been accepted
Pharmacists should also check that doctors writing scripts hold an authority
How does Staged Supply help with Prescription Abuse?
From the patient point of view:› It is better than nothing› It is more restrictive than normal
prescribing› It is less controlling than ORT › It “puts the breaks on”› It helps prevent the patient running out of
medication early
Staged Supply and Prescription Opiate Abuse
From the doctors point of view:› It requires communication with the
pharmacist and PSU / PSB› It reduces the chance of overdose on the
medication prescribed› It tends to screen out people who sell their
medicine› It saves dumping the patient› It requires the doctor to convince the
patient that this is the best option for them
Staged supply
Examples:
› 2 oxycontin tablets dispensed daily› 4 targin tablets dispensed second daily› One fentanyl patch dispensed every 3 days› One norspan patch dispensed weekly› Seven suboxone films dispensed weekly
Which opiate?
If there is a risk of injection or diversion then an opiate-naloxone preparation such as targin or suboxone should be used
Otherwise staged supply with an authority could be used with any opiate
Just write staged supply and the interval on the script
Reviewing staged supply If patients are going well then the
frequency of pickup can be reduced If patients are not doing well and
running out of tablets too soon, then the frequency of pick up can be increased up to even daily
If patients are still doctor shopping then ORT will need to be considered
If patients choose to find another doctor then at least you have done your best to help the patient and to prescribe safely
Staged supply of opiates
Staged Supply ORT
Illicit / street use
Very high quantities
IVDU
Prescription abuse
Unreliable
Rational
Truthful
Modest doses
‘Over the counter’ Opiates
Staged supply will not work for ‘over the counter’ opiate abuse as the drugs are freely available and out of the doctors control
When severe enough, addiction to ‘over the counter’ preparations can be managed with opiate replacement therapy
Children at Risk
Dependents must be taken into account
Report any children if they are at risk
To prescribe or not to prescribe?
Is it reasonable to withhold the medication from the patient?
What is a safe quantity of opiate to be giving this patient at any one time
How can I make it easier for the patient Would an opiate-naloxone preparation
be useful?
In Conclusion The majority of patients prescribed less
than 200mg OME are not dependent on their medication and normal prescribing may be appropriate
Most patients who are dependent or addicted to prescription opiates could be managed with staged supply
ORT could be used for patients who are not controlled with staged supply or are injecting their medication
Question Time
