Transcript Prescription Opiate Abuse

Prescription Opiate
Abuse
Managed by GPs
with
Authorized Staged Supply
Dr Nigel Hawkins - UWS
Introduction

Prescription opiate abuse is something
that all GP’s are familiar with and so all
GPs need to know how to manage it

This talk is not about IVDU or ORT, it is
about treating and containing the abuse
of drugs that we all prescribe
Staged supply

Is a simple but effective way for GPs to
manage their own patients who have
become addicted to opiates

It is not the same as prescribing
methadone or buprenorphine/naloxone
which are usually reserved for illicit intravenous drug use and involves higher
levels of supervision
What upsets patients

We may not say these words but this is
what it often boils down to
› Go away
› Junkie
› No, we cannot help you
› We don’t want you here
Outline
Definition
 Incidence
 Recognition
 Assessment
 Management
 Case presentation
 Discussion

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
Incidence of dependence
18
16
14
Past 12 months
Life time
% of group
12
10
8
6
4
2
0
<20mg
21-90mg
91-99mg
Oral Morphine Equivalents
POINT Study Campbell et al Pain Medicine 2015
>200mg
Incidence of tampering, doctor
shopping and diverting
14
tampering
12
doctor shopping
% of group
10
re-routing
8
6
4
2
0
<20mg
21-90mg
91-99mg
>200mg
oral morphine equivalents
POINT Study Campbell et al Pain Medicine 2015
Incidence of perceived dependence and
side effects, lifetime OD and sharing
80
70
60
SE / dependence
% of group
50
OD lifetime
40
sharing
30
20
10
0
<20mg
21-90mg
91-99mg
>200mg
Oral Morphine Equivalents
POINT Study Campbell et al Pain Medicine 2015
Incidence of other drug use
60
benzodiazepines
50
illicit drugs
% of Group
40
risky drinking
30
20
10
0
<20mg
21-90mg
91-99mg
>200mg
Oral Morphine Equivalents
POINT Study Campbell et al Pain Medicine 2015
Incidence of moderate to
severe depression and anxiety
70
60
depression
anxiety
% of group
50
40
30
20
10
0
<20mg
21-90mg
91-99mg
Oral Morphine Equivalents
POINT Study Campbell et al Pain Medicine 2015
>200mg
What is the cause of the
patient’s pain?

Does the patient have a
genuine cause of pain or is the
patient simply addicted?
Recognising Opiate Abuse







If the patient runs out of their medications
more frequently than expected
If asking for increased doses
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
New patients
Care should be taken with new patients
 Very pesistent patients
 Asking for a specific drug that is prone to
abuse
 Look at the patients arms
 Consider doing a urine drug screen
(UDS)
 Talk to doctor shoppers

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 there is any doubt about this then the
patient will need to have at least a week
of supervised daily doses
**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?
Alcohol
Tobacco
Cannabis
Speed
Valium
Heroin
Cocaine
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?
Who is the principal doctor?

Who is going to manage the
patient?
Communication between doctors is essential
Somebody needs to take responsibility for the
patient
This should be documented in the patient’s
record
Examination
Signs of opiate withdrawal
 Signs of opiate intoxication
 Track marks
 General appearance and hygeine
 Signs of liver disease
 Is the patient in pain

Management of Prescription
Opiate Abuse
Single prescriber
 Authority to prescribe
 Staged supply
 Opiate Naloxone preparation
 Opiate replacement therapy**

** if very large quantities or intravenous drug use or if buying street
drugs
Are you the principal
doctor?
Is there another doctor who knows the
patient better?
 Is there another doctor who is authorized to
prescribe opiates?
 What is to stop you taking over the
management of the patient?

What is the point of getting
an authority to prescribe?

Getting an authority to prescribe after
two months would guard against
multiple prescribers if all doctors did this

Getting an authority shows the
authorities that you are taking
precautions to prevent doctor shopping
and it therefore confers some degree of
immunity against prosecution or
disciplinary action
What is Staged Supply?
Staged supply is when only part of the
script is dispensed to the patient in a set
interval and the remainder of the script is
retained by the pharmacy
 This must be done with the knowledge of
the prescriber and the permission of the
patient
 It may be initiated by the pharmacist,
the doctor who prescribes or by a carer /
case worker

Staged supply (continued)

Examples:
› 2 oxycontin tablets dispensed daily
› 4 targin tablets dispensed second daily
› One fentayl patch dispensed every 3 days
› One norspan patch dispensed weekly
› Seven suboxone films dispensed weekly
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 a little more communication with
›
›
›
›
the pharmacist
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
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 going elsewhere to get
opiates, then ORT will need to be
considered

Frequency of Pickups
Doctor
More
frequent
pickups
Risk
Desperation
Patient
Staged supply of opiates
Staged
Supply
ORT
Rational
IVDU
Reliable
Very high
quantities
Prescription
abuse
Illicit / street
use
Opiate Replacement
Therapy (ORT / OST)
Opiate replacement therapy only differs
from Staged Supply in the level of
supervision and the medicines used are
more tightly controlled
 Treatement usually begins with
supervised daily doses of methadone or
buprenorphine-naloxone
 The pharmacy must be acredited, the
doctor authorized and the patient
registered

‘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?
 Would obtaining an authority stop this
patient doctor shopping?
 Would staged supply put the breaks on
this patient’s opiate abuse?
 Would an opiate-naloxone preparation
be useful?

If the answer is “no” to all of the above then consider ORT
In Conclusion

All GPs should know about Staged
Supply and how to prescribe opiates
with a state authority

It would be good if at least one doctor in
the practice / suburb knew how to
prescribe ORT
Question Time
Case Presentation