Prescription Opiate Abuse
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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
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
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 involve higher levels of supervision
To minimize incidents with
your addicted patients
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
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 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
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 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
Are there any mental health
conditions?
Depression
Anxiety
PTSD
Schizophrenia
Personality disorders
Cognitive impairment
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
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
Children at Risk
Dependents must be taken into account
Report any children at risk
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
How does staged supply
help with Addiction?
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
Staged Supply
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
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
Handwritten scripts
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
What form of 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
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
Case Presentation
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?
Question Time