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Prescription Drug Addiction

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Mano Ariyasinghe

on 9 October 2012

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Transcript of Prescription Drug Addiction

Prescription Drug Abuse Why is it a problem..? Background 2.Poor chronic pain outcomes:

–‘Passivity’ of patient in pain management
–Opiate withdrawal in between short-acting opioids
–Opioid hyperalgesia (greater sensitivity to pain following COT)

3.Aberrant drug behaviours: in up to 30% COT patients:

–Taking medications in a manner not prescribed or authorised

–Aberrant drug behaviours are markers of dependence (loss of control over drug use) Concerns re: Chronic Opioid Treatment Contd 2.. 1.Adverse events:
–Intoxication: ODs (resp depression), driving accidents, falls, sedation

–Side effects: constipation, nausea, sleep disorders, impaired cognition, pruritis, myoclonus, decreased saliva/dental caries, neuroendocrine (hypotestosteronism, hyperprolactinaemia, hyperhidrosis, antidiuretic hormone changes, osteoporosis)

–AEs linked to combination drugs: ibuprofen, paracetamol

–Drug interactions, esp benzodiazepines, alcohol Concerns re: Chronic Opioid Treatment Contd..
1 .Adverse events

2 .Poor chronic pain outcomes

3 .Aberrant drug behaviours: in up to 30% COT patients What are the concerns re: Chronic Opioid Treatment (COT)? Anxiety disorder is a chronic condition where Benzodiazepines have a very limited role in treatment, due to adverse effcts, tolerance, withdrawal difficulties and serious harm from chronic use –eg: traffic accidents, suicidality from depression. Withdrawal Intoxication Anxiety
Tremor Sedation,
Poor co-ordination and balance
Impaired memory
General impairment of cognitive function

Benzodiazepine Abuse Famous Cases Australian opioid use Number of PBS opioid preparations 2007 Australian National Drug Strategy Household survey 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 pain-killers for non-medical purposes

Jurisdictional variations The Medications Opioids and other pain killers eg:Oxycontin
Anti-anxiety drugs eg: Alprazolam
Feel good drugs (antidepressants)
Look good drugs (steroids)
Feeling goofy drugs (psychedelics) What is prescription drug misuse Non-medical use of a drug for psychic effect, dependence, or suicide attempt or gesture

Injecting oral drugs, selling them on the street, or simply overusing the prescribed amount 2007 Australian National Drug Strategy Household survey Australian Tranquiliser/ Sleeping Pill Misuse 2007 3.3% ever used non-medically

2007 1.4% had used in the last year-an increase from previous surveys Recognising
PDA New patient, often ‘recently moved’
Walk in presentation with no appointment
Last minute presentation when the surgery is almost at closing time
Very knowledgable about condition and drugs requested, often requests drug by name
Previous doctor unavailable to corroborate story
Multiple ‘allergies’ or drug reactions to nonaddictive medications
Carries letters from other doctors confirming treatment which appear to have dubious rationale (eg. high dose opioids or benzodiazepines)
Other Warning Signs What predicts addiction?

Personal history of drug abuse
Family history of drug abuse
Current addiction to alcohol or cigarettes
History of problems with prescriptions
Co-morbid psychiatric disorders History Recognising the problem Managing the problem
•Withdrawal (detox): reduction & cessation of drug
–Usually a gradual reduction as outpatient over weeks-months.
–High dose buprenorphine safe and effective
- Monitor for siezures in Bdz withdrawal
–Need concomitant pain/anxiety management plan

•Opioid/Bdz substitution treatment
–Stabilise on long-acting opioids/bdz with lower abuse potential
–Buprenorphine / buprenorphine-naloxone, methadone for opiates and Diazepam for bdz.
–Do not prescribe other opioids/sedatives for maintenance of dependence Treatment options for opioid/benzodiazepine dependence Patient contracts/UDS

Doctor Shopping Agreements

Frequent pharmacy dispensing (One doctor and one pharmacy involved)

Supervised dosing

Consider need for other treatments for underlying disorder (eg anxiety/pain)

Consult senior colleague or an addiction medicine specialist Managing PDA, contd… Diagnosis
Consider need for ongoing pharmacotherapy
Consider Medico-legal issues: eg: permits
Consider cessation (gradual dose reduction)
Harm minimisation strategy
•Structured > prn regimens
•Longer acting > shorter acting opioids
•Interval dispensing
–Limit ‘duration’ of dispensed medications to reduce dose escalation & ‘running short’ (e.g. weekly or daily)
–Do not refill prescriptions early if patient runs out
Have ‘severe pain/anxiety plan’ Managing PDA Legislation DPR does not have access to Medicare Australia records

Pharmacy computers are not yet linked (RTR in Tasmania)

The main source of information for the DPR database is the permit and notification system Key legislation relating to prescribing Schedule 4 and Schedule 8 poisons in Victoria
(legislation often differs in other jurisdictions)

Drugs and Poisons Regulation (DPR)
DPR = www.health.vic.gov.au/dpu DPR = 1300 364 545 Forms to apply for permits & notify drug-dependence
 Various information documents
 Legislative requirements and case studies
 Pharmacotherapy policy and related information
 Links to other websites DACAS – 1800 812 804
 Drug and Alcohol Clinical Advisory Service Direct Line - 1800 888 236
 Patient counselling plus information about treatment services Important resources MANDATORY REQUIREMENT
When a medical practitioner has REASON TO BELIEVE a person is drug-dependent and the person is seeking a drug of dependence
Overrides privacy and confidentiality issues

Contribution of important information to DPR database
Notification of treatment
Coordination of treatment Notification of a drug-dependent person
Where a permit is held by a medical practitioner at the same clinic and the prescribing is in accordance with that permit
Patients not generally in a position to obtain prescription medications from multiple sources
• Prisoners treated in a prison
• Residents treated in an aged care service
• In-patients treated in a hospital (not including day surgery)
Treatment of specified medical conditions (i.e. cancer pain) provided a written notification is submitted (using the permit application form) – Note: this exception relates only to the 8-week rule Exceptions to permit requirements Required for private and PBS and any other subsidised prescriptions General practitioners MUST hold a PERMIT

(1) BEFORE prescribing to a drug-dependent person
(2) BEFORE prescribing three specified drugs - methadone (Physeptone®), dexamphetamine or methylphenidate (Ritalin®, Attenta®, Concerta®)
(3) To prescribe for more than 8 weeks duration of treatment in other circumstances – the 8 weeks could correspond to a single prescription; it does not relate to dates between consultations Permits for Schedule 8 poisons Controlled drugs (previously called drugs of addiction)
 are more strictly controlled than Schedule 4 poisons
 include morphine, pethidine, oxycodone, fentanyl, codeine phosphate, flunitrazepam, ketamine (and others)

Why have permits?
 to attempt to prevent a patient obtaining the drugs from medical practitioners at multiple clinics
 to attempt to minimise development of drug-dependency
 to treat drug-dependent persons in a safe and meaningful manner – e.g. opioid-replacement therapy Permits to prescribe Schedule 8 poisons Schedule 8 poisons plus SOME Schedule 4 poisons
 listed in Schedule 11 of the Drugs Poisons and Controlled Substances Act 1981 (primarily to enable police to prosecute traffickers)
 consist mostly of Schedule 8 poisons but include specified Schedule 4 poisons - benzodiazepines, dextropropoxyphene (Digesic®), Duromine®, anabolic steroids and pseudoephedrine

Additional responsibilities for prescribers
 Take all reasonable steps to confirm a patient’s identity
 Handwrite components of computer-generated prescriptions - to foil forgeries and to enable pharmacists to comply with regulations Drugs of dependence include … Prescription only medicines
 most prescription-only medicines – including antibiotics, diuretics, antihypertensive drugs, oral contraceptives, some stronger analgesics (including Panadeine Forte®)

Drugs requiring a Warrant to prescribe
 prostaglandins, ovulatory stimulants, oral retinoids, thalidomide
 only to be prescribed by specialists who hold a warrant in relation to the specific drug or by practitioners who have the endorsement of the warrant holder to prescribe for a specific patient
 prescriptions for these drugs must be endorsed with the relevant warrant number and the name of the warrant holder Schedule 4 poisons Take ALL REASONABLE STEPS to ensure there is a therapeutic need

Relatively easy for existing patients?
More difficult for new or unfamiliar patients?
More difficult during after-hours consultations?
Is it necessary to examine a patient?

Be wary of hard to check claims and dodgy documents
Be wary of drugs that are targeted by drug-seeking patients Before prescribing S4 or S8 poisons
Drugs Poisons and Controlled Substances Act 1981
Drugs Poisons and Controlled Substances Regulations 2006 WHY?

To enable access and minimise risks associated with the use of important but potentially toxic drugs and poisons in Victoria

 To control and monitor the possession and use of drugs and poisons according to a hierarchy of poisons schedules
– Schedule 4 and Schedule 8 poisons are ‘prescription-only medicines’ and ‘controlled drugs’

 State legislation deals with the legality of prescribing and supply of drugs

 The Commonwealth Pharmaceutical Benefits Scheme relates merely to whether Medicare Australia will subsidise the cost of a medication Victorian legislation Failure to comply with legislation renders a prescriber liable to prosecution

Have you thwarted the intent of the legislation?

Can you justify your non-compliance? Legislation, guidelines and policies Criminal intent
Incompetent / Negligent
•scripts on request / unfamiliar drugs / no genuine therapeutic need
Well intentioned but NAÏVE (head in the sand)
Serial stupidity (camel’s back)
Bloody-minded (or poorly advised)
Self-administration (VDHP)
prescribing that cannot be justified is often the key issue Prescribers who have been prosecuted
No real-time reporting or monitoring in Victoria (as yet)
Pharmacy computers are not linked
DPR does not have access to PBS records

Seven interventions per pharmacy (on cursory examination)

1 significant = unlawful & potentially harmful
2 major = unlawful and/or inappropriate
4 minor = unlawful but not inappropriate Prescription Shoppers
“Prescription-shoppers” outnumber GPs (3 : 2) Prescription monitoring issues
The collection, storage and disclosure of information by the DPR is governed by privacy legislation inc. the Health Records Act 2001 (Vic)
Information held by the DPR about any patient will only be released to a health practitioner who possesses a legitimate need to access information to treat the patient Information Privacy Act 2000 (Vic)
If a provision made by or under this Act is inconsistent with a provision made by or under any other Act that other provision prevails and the provision made by or under this Act is (to the extent of the inconsistency) of no force or effect
Where information relates to a third party, such as a patient, then this information must be made available to that third party Exceptions:
 There is a threat to life or health of the individual or another
 Where information is given in confidence Privacy legislation ***
Intended to enable a medical practitioner to initiate treatment for short-term relief of severe pain
The 8 week period now includes any preceding period of treatment, by other prescribers, which there is reason to believe has occurred - to address the following concerns:
•Prescribing by multiple practitioners at a clinic without any practitioner properly managing the patient
•Fraudulent claims by drug-seeking patients

Where a person claims to be transferring from another clinic or needing a prescription for continuity of ongoing treatment, a permit application should be submitted immediately even if there is no intention to prescribe further prescriptions
So that a genuine patient will not suffer an unnecessary delay, prescribing will not contravene the Act until the permit application is approved or refused The 8 week period
The practitioner who writes a prescription is the person who is responsible under the legislation

 The fact that another medical practitioner has previously prescribed a drug is insufficient justification for you to do so – an issue that is particular relevant to locums and registrars

 The fact that a specialist recommends or supports prescribing a particular drug (or dosage) does not obviate the responsibility of the person who actually prescribes it Prescribe only for the medical treatment of patients under your care (regulation 8) Writing prescriptions
1.Letters of advice
2.Multiple or repeated letters of advice
3.Please explain letters
4.Personal counselling
5.Formal interview > prosecution?

•Some first-time offenders are prosecuted due to the nature or extent of their contravention(s) Levels of intervention by DPR Date: August 16, 1977
Drugs: As many as 14 different drugs, including codeine and methaqualone, AKA Quaaludes Elvis Presley Date: August 5, 1962
Drugs: Pentobarbital (AKA Nembutal) and chloral hydrate Marilyn Monroe Date: February 11, 2012
Drugs: Cocaine ,marijuana, Benadryl, Flexeril, and Xanax use resulting in accidental drowning in a bath tub

Whitney Houston Date: February 6, 2008
Drugs: Six drugs: oxycodone and hydrocodone, temazepam and diazepam (AKA Valium), alprazolam (AKA Xanax) and doxylamine Heath Ledger Date: June 25, 2009
Drugs: propofol Michael Jackson By. Mano Ariyasinghe. GP Registrar Drug seeking behaviour Useful documents
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