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

 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  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 Illicit / street use Very high quantities IVDU Prescription abuse ReliableRational

Risk Desperation Doctor Patient More frequent pickups

 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