Addiction to Medicines Analgesia or Fix?

The Rise of Polypharmacy 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 Cultural Shifts Pi Drug-U-Like

The relentless rise in prescribed opiates

Opioid Analgesics

Geographic differences Opioid Analgesics

Interesting but... 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.

Evidence of Misuse in USA 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

1.Can be originally given for acute or chronic problem 2.Positive effect 3.Subsequent reinforcement

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

Potential harms 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

Who has problems with ATM? Patients: Older adults Adolescents Women Along with other illicit drugs Prison population Healthcare professionals: Doctors Nurses Pharmacists Dentists Anaesthetists Veterinary surgeons

“Get me 100mg of Pethedine and whilst your there get something for this guy”

Long–term prescribing 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.

Treatment Data 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

Service models and route of access

What Prescription Drugs Do People Misuse? 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 More than just opiates and benzos

What happens when go for help? 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

Why getting help difficult to get? ATM poorly recognised by clinicians and patients Misunderstood and hidden problem Lack training and guidance

Prevention & Monitoring Ask Careful use of repeats Make use of pharmacists (local & PCT) Surveillance (run regular in house reports)

Detection of Prescription Drug Problems indicate increasing problems and / or tolerance 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

Recommendations of APPDMG Concerning GPs 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”

they are needed 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 Governance

1.Assessment 2.Preparation 3.Psychological support 4.Prescribing 5.Wraparound / peer support / groups – local or internet based

1.Assessment 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

Dependence, treat like you would any other addiction Stabilisation (drug & psychosocial) Detoxification Aftercare

Support with…. Good therapeutic relationship Management of associated problems: Mental health issues Pain Wraparound support Psychological interventions Time and patience

Reduction/detox interventions 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?