Transcript Prescription Opiate Abuse

Dr Nigel Hawkins - UWS

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

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

Is a simple but effective way for GPs to
managed their own patients who have
become addicted to opiates

It is not the same as prescribing
methadone or burprenorphine/naloxone
which involve a higher level of
supervision

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
Definition
 Incidence
 Recognition
 Assessment
 Management
 Case presentation
 Discussion

 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

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
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If the patient runs out of their medications
more frequently than expected
If the patient is seeing other doctors for their
medication
If the patient is using other addictive drugs
If the patient’s 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
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


Does the patient have a
genuine cause of pain or is the
patient simply addicted?

How many times the recommended
therapeutic dose (for pain) is the patient
consuming
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History
Records
Doctor shoppers
Real time services
Alcohol
Tobacco
Cannabis
Speed
Valium
Heroin
Cocaine
Working?
 Homeless?
 Transportation?
 Social supports or
liabilities?
 Criminal record

Diabetes
 Ischemic heart disease
 Cirrhosis
 Renal impairment
 Cancer
 Back injury
 Arthritis

Depression
 Anxiety
 PTSD
 Schizophrenia
 Personality disorders
 Cognitive impairment

Patches
 Tablets
 Syrups
 Films
 Opiate / naloxone
preparations
 Over the counter preparations


Is the patient visiting multiple
doctors at different surgeries or
do they stick to one doctor or
one surgery?

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
Is the patient 
disolving and injecting their medication?

smoking their medication

ingesting the medication
If the patient is injecting their medication consider ORT

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

Dependents must be taken into account

Report any children at risk
Signs of opiate withdrawal
 Signs of opiate intoxication
 Track marks
 General appearance and hygeine
 Signs of liver disease
 Is the patient in pain

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
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?

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


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

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


From the patient point of view:
› It is better than nothing
› It requires more effort to get the medication
› It is harder to take more medicine than
prescribed
› It “puts the breaks on”
› It prevents the patient running out of
medication early

From the doctors point of view:
› It requires a little more communication with
›
›
›
›
the pharmacist
It ensures that the patient will not 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

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
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?

Staged
Supply
ORT
Rational
IVDU
Reliable
Very high
quantities
Prescription
abuse
Illicit / street
use
Doctor
More
frequent
pickups
Risk
Desperation
Patient

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
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
