Transcript Steve Brinksman - Addiction to medicines

Over the Counter,
Prescription only Medicines
and
Benzodiazepines
 Four out of five people aged over 75 years take at least
one medicine.
 36 per cent of this age group take at least four
medicines.
 The Audit Commission calculated ADRs cost the NHS
£0.5 billion each year in longer stays in hospital.
 “A Pill for every Ill”
 Rise of pharmaceutical giants
 R&D and marketing
 In 2007, 20% of all people in USA age 12 and up had used prescription drugs non-medically at least
once in their lives
 The number of people misusing pain relievers
climbed from about 0.1% of the population in the
mid-80’s to 13% in 2007
(US National Survey on Drug Use & Health, NSDUH)
 430% increase in the rate of treatment admissions
for the misuse of synthetic opioids from ‘99 to ‘09
 Addictive drugs:
 e.g. opiates (oxycodone, tramadol), codeine-based,
benzodiazepines
 Often with physical withdrawal syndrome
 Non-addictive drugs may still be abused:




for their effects e.g. tricyclics
for regular self-medication e.g. antihistamine for sleep
in a compulsive way e.g. laxatives
to enhance the effects of other drugs e.g. SSRI’s
 Gabapentin
 Pregabalin
 Amitriptyline
 SSRI’s
Opioid Analgesics
 Trend data tells us something about the use of these
medicines
 Levels of prescribing can identify areas where there
might need to be further focus (particularly at a practise
level.)
But:
 Higher levels of prescribing do not necessarily mean that
these drugs are not being used appropriately.
 In 2009/10 there were 32,510 people reporting
POM/OTC (16% of treatment population)
 11% of these (3,735) POM/OTC only
 Most local areas provide treatment
Variation at sub-national level with North East having the
highest proportion of POM/OTC in treatment
The vast majority are white.
POM/OTC + illegal drug user very similar to general drug
treatment population in terms of age and gender.
POM/OTC only are almost twice as likely to be female and over
40.
 Most common codeine containing with either
paracetamol or ibuprofen
 12.8mg per tablet codeine highest dose available
 7.46mg per tablet dihydrocodeine also available
 Other medications –laxatives, sedative antihistamines
 May present due to effects of co-ingredient
 May be suspected by pharmacist
 Difficult to identify
 Need to specifically ask about OTC meds and usage
1.Can be originally given for acute or chronic
problem
2.Positive effect
3.Subsequent reinforcement
• Longer-term prescribing increases the likelihood of
dependency.
• Does the prevalence of long-term prescribing give us an
indication of the prevalence of dependency?
• Dependency is not inevitable
• There are conditions where long term prescribing is advised

Can have dependency along with mental health problems

Physical co-morbidity common

Self-medication psychological or physical

Prevalence chronic pain is 30-50% in treated substance
users, compared with 10-15% of the general population
1.Psychological – shame
hidden problem, unable to get help
2.Effect dependency on self, family and others
e.g. depression, loss of work
3.Lapse into another addiction
e.g. alcohol, opioids
4.Physical consequences of active ingredient
e.g. codeine, constipation,
5.Physical consequences of another ingredient
e.g. paracetamol OD
Patients:
Older adults
Adolescents
Women
Along with other illicit
drugs
Prison population
Healthcare
professionals:
 Doctors
 Nurses
 Pharmacists
 Dentists
 Anaesthetists
 Veterinary surgeons
 Over Count Study
 those patients who approached there GPs saying that they
felt they had a problem didn’t get the help and support they
required
 ATM poorly recognised by clinicians and patients
 Misunderstood and hidden problem
 Lack training and guidance
That, when GPs prescribe drugs known to have the
potential to cause physical dependence or
addiction
they must:
 explain these potential risks to the patient
 set up procedures to monitor the patient. … The
practice of repeat prescription without review for
these drugs must end”
www.nta.nhs.uk/addiction-to-medicine.aspx
 Ask
 Careful use of repeats
 Make use of pharmacists (local & PCT)
 Surveillance (run regular in house reports)
 Monitor patients’ use of drugs that may indicate
increasing problems and / or tolerance :
 rapid increases in the amount of a medication
needed/frequent lost scripts
 Frequent requests for refills or running out before due
 Seeing different doctors in practice
 This physician-administered checklist evaluates a series
of behaviors that suggest or are consistent with
prescription opiate abuse rather than relying on answers
to specific questions. Patients meeting 3 or more of the
following criteria are considered prescription opiate
abusers
(a) overwhelming focus on opiate issues;
(b) pattern of 3 or more early refills or escalating drug use
without acute changes in their medical condition;
(c) multiple telephone calls or visits to request additional
opiates or early refills;
(d) pattern of prescription problems due to lost, spilled, or
stolen medications;
(e) supplemental sources of opiates from other providers or
illegal sources.

Prescribe if they are needed for good clinical reasons

Put on as acute medications and don’t slip into repeat without
discussion or intention

Discuss with colleagues and document
1.
Assessment
2.
Preparation
3.
Psychological support
4.
Prescribing
5.
Wraparound / peer support / groups – local or internet based
 Full assessment
 Ask all about drugs, including OTC and alcohol
 Drug history, alcohol, other drugs inc. BZ
 Aspects of dependency:
 Drug seeking behaviour
 Lack of interest in other activities
 Physical withdrawals
 Mental health assessment - underlying issues?
 Pain?
Information-Risk of OD, Risk of S/E’s
List benefits and adverse things that get from using
Keep drug diary of use for 1-2 weeks
Engage with support
Explain tolerance
 Address anxiety /depression
 IAPT
 Counselling / CBT / Motivational interviewing
 Behavioural change
 Buprenorphine
 Codeine
 Dihydrocodeine
 Methadone
 Morphine (MST, MXL)
 Support groups
 Codeine free me
 Narcotics Anonymous
 SMART
 Social Services
 Befriending
 Activity Groups
Stabilisation
(drug & psychosocial)
Detoxification
Aftercare
 Good therapeutic relationship
 Management of associated problems:
 Mental health issues
 Pain
 Wraparound support
 Psychological interventions
 Time and patience
Same drug
 Advantages
 familiar
 Potential problems:
 easy to use on
top
 no blockade
Substitute
 Advantages
 blockade with
buprenorphine
 longer acting
 supervision possible
 differentiable on
toxicology
 Problems
 conversion uncertain
 unfamiliar drug
 Stigma
 Withdrawal effects
 Under recognised problem, and increasing
 Evidence growing but scope for further research
 Little formal guidance and training
 But many things can do to help
 Don’t forget: assessment, psychological help, prescribing and group
support
 And detox is only part of the process not the end
 Important GPs ,Pharmacists and all health care professionals are
educated about this problem
 Need for more help and services for people who have problematic use,
how should these be delivered?
Case study - Carol
Carol, a 46 year old teacher comes to see you with
acute abdominal pain. She smokes a few cigarettes a
day, and does not drink alcohol.
She tells you that she is now taking Nurofen Plus daily;
having initially been given them after having some
extensive dental work done. When she took them, she
found that they helped the pain, and also made her ‘feel
better’ and improved her mood.
She has no history of substance misuse. She started
taking the tablets at the recommended doses, but after
a few months felt that they were less effective,
especially after a stressful event, so she took more.
After 6 months she is now on about 30+ a day.
Carol
Around this time her abdominal pain started.
When she stops taking the Nurofen, she feels
unwell. She has had to find more and more
pharmacies to buy from, plus she buys off the
internet. She becomes anxious when she
knows her supplies are running low. She now
desperately wants to stop and wants your help
with this.
NB: 12.8mg codeine (and 200 mg ibuprofen) in
x1 Nurofen Plus tablet, and are available in
packs of 12, 24 and 32
Carol
What else would your initial
assessment involve?
What are Carol’s risks?
What would be your treatment plan?
What are your prescribing options?
Who else would you involve?
Case study - Margaret
Margaret, a 58 year old librarian who has
been seeing your senior partner for several
years comes to see you as he has reduced
his hours and she couldn’t get an
appointment with him. She has been told she
has fibromyalgia and says the fentanyl 50
patches she has been on for the past 6
months only help so much and she needs to
take 6-8 tramadol a day on top and also has
20mg of temazepam at night. She had been
given a trial of gabapentin but stopped it as it
made her feel dizzy.
Margaret
She has lived alone since her 86 year old mother
died 5 years ago with breast cancer and had a short
course of fluoxetine following this although she
stopped it after 3 months as she felt ok.
She has previously had X-rays which showed
minimal osteoarthritis of her hips only. Blood tests
showed no evidence of inflammatory arthritis
She had no history of drug use and drinks less than
10 units of alcohol / week.
Margaret
What else would your initial
assessment involve?
What are Margaret’s risks?
What would be your treatment plan?
What are your prescribing options?
Who else would you involve?
Case study - Tim
Tim, a 52 year old electrician, first saw you about 3
years ago after he had acutely injured his back when
he slipped off a ladder. He had had gastritis
previously so you had given him an acute
prescription of co-codamol (30/500) for the back
pain. 6 months later he attended with low back pain
without any obvious trauma, he was again given cocodamol 30/500. He found them helpful so he
attended the emergency surgery - where he saw a
locum - to ask for more and he requested them to be
added to his repeat prescription, which they were.
The reception staff noticed he was overdue a
medication review and passed his request for more
co-codamol to you.
Tim
You realised Tim’s use had gone up and he was requesting
100 tablets at less than 2 weekly intervals so you asked to see
him. You knew he had always drunk above safe levels, but
from what he told you it had gone up to about 10 units a day
since his injury, as he was drinking more because it seemed to
help the pain.
He said that he was not only using at least 8 prescribed cocodamol a day but he was also buying Solpadeine on top. He
was markedly constipated but if he tried stopping the
medication developed diarrhoea and abdominal pain and was
irritable. Every time he tried to reduce his tablets his alcohol
intake went up. His mood was low and he had become
withdrawn and isolated, staying in bed till the afternoon in an
effort to control the amounts he was using.
Tim
He had lost his job a year ago and said he needed a sick note as the
benefits office didn’t think he was fit to look for work..
NB Solpadeine Plus is a combination of Codeine Phosphate (8mg)
Paracetamol (500mg) and Caffeine (30mg) and is available in packs
of 16 and 32
What else would your initial assessment involve?
What are Tim's risks?
What would be your treatment plan?
What are your prescribing options?
Who else would you involve?
53
What are the effects of benzodiazepines?
What clinical indications are they used in?
For how long?
55
Hypnotic / anxiolytic
Used in clinical practice for treatment of anxiety, panic, insomnia,
seizures, alcohol withdrawal, muscle spasticity
Prescription is only recommended for short term use (2 - 4 weeks)
Have become an extensive and significant problem in drug users,
and prescribing guidelines do not recognise the complexity of this
The drugs most frequently used in combination with opioids
May be the sole drug of abuse
Usually taken orally but the tablets can be crushed and injected
Addictive and lead to significant problems with withdrawal
Table 2: Primary therapeutic actions of benzodiazepines (BZ)
Clinical Use Short Term
(< 2-4 weeks)
Common Uses
(commonly initiated in primary
care)
Action

Anxiolytic


Hypnotic


Anticonvulsant
Myorelaxant

Acute insomnia, with brief
situational stress & definite

identifiable endpoint, e.g.
grief, acute pain
Predicted acute insomnia, e.g.
funeral, exams, journey
Re-establishing a better sleep
routine

Treatment resistant
persistent severe anxiety
disorders (see mental illness
section)
Anxiety due to medical
illness
Treatment resistant
persistent severe sleep
disorders, due to chronic
physical or psychiatric
disorders, e.g. chronic pain

Epilepsy resistant to
treatment with
anticonvulsant drugs
Seizure prophylaxis

Muscle spasms, e.g. due to
back pain

Spastic disorders

Premedication for operations,
sedation for minor surgical
procedures

None

Harm reduction in those with
severe alcohol damage
Amnesia
Alcohol
withdrawal
Clinical Use Longer Term
(> 4 weeks)
Very Rare Uses
(typically initiated by specialists)

Acute stress related reactions,
adjustment disorders, acute
stress reaction prophylaxis
Anxiety disorders

Acute seizures due to any
cause
56

Acute alcohol withdrawal
syndrome
57
1959, chlordiazepoxide (Librium) was the first of the
benzodiazepines to be marketed for insomnia and anxiety.
First introduced into clinical practice in the 1960´s
benzodiazepines were thought to have distinct advantages
over other hypnotics
It took less than 10 years for benzodiazepines to replace
over 90% of a market previously dominated by the
barbiturates, however it became generally accepted that they
had many problems of their own, greatly limiting their
usefulness.
59
Although they possessed a much lower primary toxicity than
barbiturates, it was soon known that tolerance, dependence
and withdrawals are common in those taking
benzodiazepines long-term.
1970’s – 1980’s the volume of benzodiazepine prescribing
increased dramatically, reaching a peak in 1979 and has
been falling ever since. Even today however there are around
0.5 –1.5 million long term-users, with females out numbering
men by a ratio of 2:1.
60
The number of people world-wide who are taking prescribed
benzodiazepines is enormous.
In US about 2 per cent of the adult population have used prescribed
benzodiazepine hypnotics or tranquillisers regularly for 5 to 10 years or
more.
Studies have shown that between 30-50 per cent of long-term users have
difficulties in stopping benzodiazepines because of withdrawal symptoms.
Somewhere between 0.5 and 1.5 million people are addicted to
benzodiazepines in the UK most of whom are addicted on prescribed
medication, and there are an estimated 200,000 illicit benzodiazepine users.
Dose conversion table for
equivalent doses of
benzodiazepines to diazepam
Benzodiazepine Dose equivalent to diazepam 5 mg
Chlordiazepoxide 15mg
Clonazepam
0.25mg
Lorazepam
0.5mg
Nitrazepam
5mg
Temazepam
10mg
64
Approximately 90% of drug users report using benzodiazepines at some point
The reasons why people use benzodiazepines may include:
To make them feel normal, or enable them to cope
To treat anxiety or low mood
To treat insomnia
To potentiate the euphoriant effect of opioids
To combat opiate withdrawal symptoms
To ‘come down’ from stimulants
To improve confidence
To decrease psychotic symptoms such as auditory hallucinations
To enjoy the effects of a binge
High doses or binges can lead to impulsive behaviour, amnesia, increased risky
behaviour and other problems
Long term benzodiazepine use can lead to emotional suppression
65
66
Tolerance to the different benzodiazepine effects such as anxiolytic,
sedation and pleasure, develops at different speed, and this speed varies
between individuals and can change in individuals over time.
Tolerance can develop rapidly and increased doses are required to
maintain the same effect, especially for certain types of effects.
Tolerance develops to the pleasurable, sedative and motor coordination
effects but only partially to the anticonvulsant effects.
Tolerance may not develop to the anxiolytic, anti-panic and anti-phobic
effects.
There is a high degree of cross tolerance between other sedatives/
hypnotics and alcohol.
67
68
The liability to abuse of different benzodiazepines
varies. The major factor increasing abuse liability
is speed of onset of the drug which is unrelated
to its elimination half-life.
Diazepam and flunitrazepam have rapid onset of
action despite very different half-lives. Oxazepam
has a short half life but slow onset so has lower
abuse potential. Clonazepam [long half life]
increasingly abused via both prison and internet.
69
The reason is that rapid onset drugs are
associated with “good” subjective effects, and
therefore result in psychological reinforcement
every time the drug is taken, which over time
strengthens the psychological component of any
addictive process. The second most important
factor related to abuse is the dose of
benzodiazepine, as a higher dose leads to better
buzz.
70
71
 Withdrawal of a benzodiazepine prescription needs to be done with care and
should be patient-specific. Two main areas should be considered:
 Dose reduction: This should be tailored to the individual. It may take weeks,
months or even years but there should be no hurry, as the person needs to
learn how to manage without drugs; hence it is better to handle dose reduction
mainly in the community, as inpatient measures can be too rapid. Going too
fast will cause the patient enormous difficulties and often leads to failure. It is
best to allow the patient control. If there are problems, reduce speed but try
not to go backwards.
 Psychological support: Provide as much or as little as the person requires,
ranging from simple measures to long-term interventions. Ongoing support
should always be offered, self-help should be encouraged, and, if appropriate,
alternative coping skills training, such as anxiety management and CBT, should
be arranged.
• Longer-term prescribing increases the likelihood of dependency.
• RCGP data looked an available sample of a large national cohort
also prescribed opiate substitution therapy
• Median length of prescription = 29 days
• 35.3% longer than 8 weeks
• 50% in subset with concurrent OST.
73
Complex, as there is little or no evidence that maintenance
prescribing of benzodiazepines reduces harm
In substance misuse, not licensed for maintenance prescribing,
only for detoxification from benzodiazepine dependence
Prescribing benzodiazepines in many people does not affect the
use of street drugs
Long term high dose benzodiazepines (above 30mg diazepam)
may cause harm
Should only prescribe if you feel the benefits of treatment will
outweigh the risks (diversion, overdose etc.)
Treat underlying cause (anxiety, insomnia) first
74
Need to establish physical dependence (rather than intermittent use)
Test urine to confirm benzodiazepine use
At least 2 positive urine screens
No negative benzodiazepine screen in the last 4 months
Use benzodiazepine withdrawal scales
Define and agree clear goals with the patient
Prescribe for structured detoxification only – no role for maintenance prescribing
Convert all to diazepam (see DH Guidance)
Keyworking and psychosocial support should be in place in conjunction with
prescription
Review frequently
Set boundaries and stick to them (e.g. no replacement or additional scripts,
agreed time limits etc.)
Be more reluctant to initiate a prescription of benzodiazepines than opioids
Case study - Stephen
Stephen aged 32 came to see you at the GP surgery. He is prescribed
methadone by one of the partners at the surgery and had a drug treatment
review last week. At this review it was reported that he was prescribed
65mg of methadone and disclosed no illicit drug use. He has a history of
heroin and crack cocaine use (for 5 years), but has not used either since
stabilising on methadone 9 months ago. He reported at this drug treatment
review that he felt the methadone was “holding him” – he reported no
withdrawal symptoms and felt that he needed no changes to his
methadone programme at that time.
He has a history of moderate depression, and is also prescribed
mirtazapine 30mg, which he has been taking for 6 months.
He has presented today to disclose that he has been buying illicit
diazepam. He did not mention this at the review last week, and reports
that he used to take diazepam “occasionally” when taking heroin, but has
been taking increasing amounts of diazepam over the preceding 3 or 4
months.
Stephen
What would your initial assessment involve? What other
information do you need?
What are Stephen’s risks?
What are the issues that you need to consider that influence
a decision to prescribe benzodiazepines?
What would be your treatment plan?
If you decide to prescribe, what would you prescribe and
what would be your ongoing plan with respect to this?
Who else would you involve?
Case study - Irene
Irene is a 54 year old female patient who has recently joined your practice
and presents to you saying, “I need my zopiclone”.
She had seen the GP Registrar the previous evening and they refused to
prescribe any zopiclone and told her it was “practice policy not to prescribe
sleepers”.
She is very distressed this morning, and presents tearful and anxious.
On questioning she reveals that she is prescribed 28 x 3.75mg tablets per
month (or so) and takes “1 or 2 each night” to help her sleep. She says she
has been told in the past that the zopiclone is “bad for you”, but she feels
that she “can’t cope” without them.
She says they were initially prescribed by her previous GP when her
husband left her 5 years earlier, and has been picking them up “without any
problem” ever since. She moved into your practice area recently to be nearer
to her daughter.
Irene
Would you continue her prescription?
What are the risks to Irene?
What other issues are there?
What would be your treatment plan?
What are your prescribing options?
Who else would you involve?
Case study - Mary
78 year old woman, comes to see you with her 43
year old daughter who lives 15 miles away. Family
concerned as several falls and ambulance had to
be called once when daughter away. Also says she
has been a bit forgetful lately but she blames her
age. Had a “nervous breakdown” in 1972 and was
started on lorazepam 1.5mg tds and temazepam
10mg at night
Case study - Mary
She is well dressed and good eye contact, she
repeatedly apologies for bothering you.
On exam she has a mild tremor and is slightly
unsteady when walking.
MMSE scores 26
Case study - Mary
What would your initial assessment involve?
What other information do you need?
What are her risks?
What would be your treatment plan?
Who else would you involve?