Transcript Prescription and Over-the-Counter (OTC) Drug Misuse © 2009 University of Sydney

Prescription and
Over-the-Counter (OTC)
Drug Misuse
© 2009 University of Sydney
Learning Objectives
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What is prescription drug misuse
Substances
Extent of problem
Recognising the problem
Managing the problem
Understanding medication regulations
What is prescription drug
misuse
• Variety of terms
- Prescription drug misuse: use of any drug in a
manner other than how it is indicated or
prescribed
- Aberrant drug related behaviours: behaviours
that suggest the presence of substance abuse
or addiction, implying that the behaviours are
pathologic
• Spectrum including excess ingestion,
diversion, injection, dependence
The Medications
• Sedating
• Stimulant
• Performance enhancing
Sedative
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Opioids-illicit, prescribed and OTC
Benzodiazepines
Non-benzodiazepine hypnotics
Antipsychotics (in some environments)
Ketamine
Barbiturates (rarely)
Performance Enhancing
include:
• Diuretics
• Anabolic Androgenic Steroids
• Hormones EPO, hGH, Insulin,
glucocorticoids
• B Agonists/ B blockers
• Steroid antagonists
• Stimulants
• Opioids
How do we
identify/monitor this?
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Anecdotal/case reports
Post marketing surveillance
WHO
National Drug Strategy Household
Survey
• Illicit Drug Reporting System
• DAWN (US)
• User sites
Stimulant misuse in the USA
• Rates of non-prescribed stimulant use
-0.5% past month use in age 12-17(1)
-0.8% adults >26 years report last year use(1)
-4.1% college students report last year use(2)
• Among college students
-whites, members of fraternities and sororities,
individuals with lower grade point averages, use of
immediate-release preparations, and individuals
who report ADHD symptoms at highest risk for
misusing and diverting stimulants(2)
(1) 2007National Survey on Drug Use and Health:National Findings at
http://oas.samhsa.gov
(2) McCabe SE. Knight JR. Teter CJ. Wechsler H. Non-medical use of prescription
stimulants among US college students: prevalence and correlates from a
national survey Addiction. 2005; 100(1): 96-106.
Australian prescription
Opioid Misuse
• 2.5% Australians report recent use of
pain-killers for non-medical purposes
• 4.45 report lifetime use
• 15.4% had opportunity to use painkillers for non-medical purposes
• Jurisdictional variations
2007 Australian National Drug Strategy Household survey
Australian Tranquiliser/
Sleeping Pill Misuse
• 2007 3.3% ever used nonmedically
• 2007 1.4% had used in the last
year-an increase from previous
surveys
2007 Australian National Drug Strategy Household survey
ED presentations in USA
relative to community opioid
prescribing
“Reprinted from Drug and Alcohol Dependence, 82(2), Dasgupta et al,
“Association between non-medical and prescriptive usage of opioids”,
135-142, 2006, with permission from Elsevier.
Australian opioid use
1992-2007
Leong, M., Murnion. B., Haber, P., 2009, Internal Medicine Journal; in press
Number of PBS opioid
preparations
Murnion, B., 2009, unpublished data
Over The Counter
• Regulation does not easily allow
monitoring
• Complex epidemiological methods
• Jurisdictional variability in misuse
• May vary with availability of illicits
• Consider pseudoephedrine story
• Is there a need for codeine containing
OTC analgesics?
Performance Enhancing
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2007- 223,898 tests undertaken by World Anti-Doping Agency
4,402 AAF (1.97%)
Anabolic agents
2,322
Stimulants
793
Cannabanoids
576
B2Agonists
399
Diuretics and other masking agents
359
Glucocorticoids
288
Hormones and related substances
41
B Blockers
27
Narcotics
21
Anti-oestrogens
18
Enhancement of oxygen transfer
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May include TUE’s
World Anti-Doping Agency, 2007 Adverse Analytical Findings
Recognising prescription
and OTC misuse
• Longitudinal observation
• Corroborative history from other health
care providers
• Frequent presentations with lost or
stolen scripts
• Consider identified risk factors
• Morbidity (e.g. Gastric erosions, CV
events )
• Routine screening (e.g. elite athletes)
Strategies to prevent
PDA
1. Patient
2. Drug
3. Prescriber
4. Governmental policy and legislation
5. Modification of the medication
1. Patient factors
• Prior or current substance abuse
disorder places in high risk category
• Environment (e.g. Prescribing
dexamphetamine to child whose
parent/carers have a substance use
disorder)
• Psychosocial setting may justify close
monitoring
Risk of opioid misuse in
chronic pain patients (CPPs)
Amongst 2000+ CPPs exposed to prescribed opiates:
• Adverse drug related behaviour (ADRB) in
11.5%
• Overt abuse/addiction in 3.27%
• If no prior/current history of abuse,
abuse/addiction in 0.19%
• Urine toxicology showed 20% had nonprescribed or nil drug in urine and 14% had
illicit drugs in urine
Structured Literature Review: Fishbain et al, 2008, Pain Med, 9
2. Drugs
• Drugs with abuse potential
- opioids
- hypnotics
- psychostimulants
- anticholinergics
- performance enhancing
3. Prescriber
• High index of suspicion when unknown
patients present requesting repeat scripts
for high risk drugs
• Screening tools
• May feel isolated/threatened
• Drs known to easily prescribe these
medications attract this clientele
• Should report aberrant prescribing
• Always ask about OTC and CAT use
• Identify colleagues and report
appropriately
Managing PDA
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Diagnosis
Consider need for ongoing pharmacotherapy
Consider cessation (gradual dose reduction)
Harm minimisation strategy
Patient contracts/UDS
Doctor Shopping Agreements
Frequent pharmacy dispensing
Supervised dosing
Consider need for other treatments for underlying
disorder (eg anxiety/pain)
• Consult senior colleague or specialist
4. Governmental and
legislative interventions
• “Rogue” prescribers may be deregistered
or have prescribing limits
• Urgent NSW Medical Board inquiries to
take action to protect the public rose from
22 in 2005/06 to 35 in 2006/2007
• Due in large part to increased referrals
about prescribing practices from PSB
• Twelve doctors suspended, 19 had
conditions imposed on registration, and
two doctors removed from the Register.
New NSW medical board
requirements (1/10/2008)
• Mandatory reporting to medical board if practises
medicine whilst intoxicated by drugs (whether
lawfully or unlawfully administered) or alcohol
• Medical Board recommends
-be vigilant in identifying doctors or other
colleagues whose health, conduct, behaviour or
performance may be a threat to the public;
-do your best to find out the facts, then if
necessary, notify an appropriate person such as the
hospital chief executive or the Medical Board. Your
comments about colleagues must be honest. If you
are not sure what to do, ask an experienced
colleague or contact the Medical Board or your
defence organisation for advice. The safety of
patients must come first at all times; and
-report adverse events which reflect on the
professional performance or conduct of colleagues
to a hospital Chief Executive or Medical Board.
NSW Medical Board, 2009
Impaired Colleagues
• If unable to deal with the matter yourself,
consult appropriate senior colleague.
• If you feel able to talk to the colleague
yourself, do not take on a treating role, but
– arrange to meet with them privately,
– let them know that you are concerned
and why,
– ask them to consult with an appropriate
practitioner, and provide them with
contact information
NSW Medical Board, 2009
Impaired Colleagues
• Follow up to make sure that they have
taken your advice. Be aware that your
colleague may tell you what they think you
want to hear, having taken no positive
steps.
• Consider the impact of their problem upon
their work. If you believe that patient safety
may be at risk, you should advise the
doctor accordingly and seek the advice of
the Medical Board
NSW Medical Board, 2009
Section 28 of the Poisons and
Therapeutic Goods Act 1966
The authority of the Department of Health is
required:
– to prescribe for or supply to a drug dependent person
any drug of addiction (Schedule 8), or
– to prescribe for or supply to any person any
preparation of dexamphetamine or methylphenidate, or
– to prescribe for or supply to any person other than a
drug dependent person, for therapeutic use by that
person continuously for more than two months, any of
the following drugs of addiction – buprenorphine
(excluding transdermal patches), flunitrazepam,
hydromorphone, methadone or any injectable drug of
addiction.
Governmental and
legislative requirements
• Vary between countries and states
• Concern internationally that rigid
legislative requirements limit access to
essential medications
• Separate from authority through PBS
(federal)
• Prescription of methadone liquid or
buprenorphine as Subutex/suboxone
through OTP requires a separate
authority
5. Modification of
medications
• Limit scheduling of combination OTC
products
• Limit to pack sizes and dose of opioid in OTC
product
• Limit DTC advertising
• Reschedule substance (e.g. Ketamine)
• Remove from market e.g. pseudoephedrine
• Introduction of “abuse deterrant”
formulations/combinations eg suboxone®
Case Study 1
• JS
• 22yr old man
• Presents with agitaion, lacrimation,
rhinorrhea, yawning, abdominal pain
and diarrhoea
• PMHx
– Crohns Disease Rxed with Azothioprine and
prednisolone
• Acknowledges 70+ Neurofen Plus daily
What are you going to do?
What are you going to do?
• Diagnosis
What are you going to do?
• Diagnosis
– opioid dependence
– question diagnosis of CD
What are you going to do?
• Diagnosis
– opioid dependence
– question diagnosis of CD
• Investigations
What are you going to do?
• Diagnosis
– opioid dependence
– question diagnosis of CD
• Investigations
• Treatment options
– withdrawal management
– maintenance therapy
Case Study 2
• Ms TD
• 52 yr old woman
• Presents frequently to ED with
migraine
• Seen neurologistprophylactics/tryptans ineffective
• ADRs to morphine and oxycodone
• Requests parenteral pethidine and has
letter form neurologist supporting this
What are you going to do?
What are you going to do?
• Diagnosis
What are you going to do?
• Diagnosis
– consider rebound headaches
What are you going to do?
• Diagnosis
– consider rebound headaches
• Corroborative history
What are you going to do?
• Diagnosis
– consider rebound headaches
• Corroborative history
• Very limited availability of pethidine in
public hospitals in NSW
• Refer to appropriate local speciality
– Non-opioid management
– Patient education
• Stabilise opioid use and wean
Author
Dr Bridin Murnion
Staff Specialist
Drug Health Services, RPAH
All images used with permission, where applicable