1. Prescription Opiate Abuse Managed by GPs with Authorized Staged Supply Dr Nigel Hawkins - UWS

2. 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

3. 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 are usually reserved for illicit - intravenous drug use and involves higher levels of supervision

4. 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

5. Outline  Definition  Incidence  Recognition  Assessment  Management  Case presentation  Discussion

6. 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

7. Incidence of dependence POINT Study Campbell et al Pain Medicine 2015

8. Incidence of tampering, doctor shopping and diverting POINT Study Campbell et al Pain Medicine 2015

9. Incidence of perceived dependence and side effects, lifetime OD and sharing POINT Study Campbell et al Pain Medicine 2015

10. Incidence of other drug use POINT Study Campbell et al Pain Medicine 2015

11. Incidence of moderate to severe depression and anxiety POINT Study Campbell et al Pain Medicine 2015

12. What is the cause of the patient’s pain?  Does the patient have a genuine cause of pain or is the patient simply addicted?

13. Recognising Opiate Abuse  If the patient runs out of their medications more frequently than expected  If asking for increased doses  If the patient is seeing other doctors  If the patient is using other addictive drugs  If 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

14. 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

15. 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

16. 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

17. What form of opiate is being used?  Patches  Tablets  Syrups  Films  Opiate / naloxone preparations  Over the counter preparations

18. 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

19. What other drugs are being used?  Alcohol  Tobacco  Cannabis  Speed  Valium  Heroin  Cocaine

20. What is the patient’s social setup?  Working?  Homeless?  Transportation?  Social supports or liabilities?  Criminal record

21. What co-morbidities exist?  Diabetes  Ischemic heart disease  Cirrhosis  Renal impairment  Cancer  Back injury  Arthritis  hepatitis

22. Are there any mental health conditions?  Depression  Anxiety  PTSD  Schizophrenia  Personality disorders  Cognitive impairment

23. How many doctors are involved?  Is the patient visiting multiple doctors at different surgeries or do they stick to one doctor or one surgery?

24. 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

25. Examination  Signs of opiate withdrawal  Signs of opiate intoxication  Track marks  General appearance and hygeine  Signs of liver disease  Is the patient in pain

26. 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

27. 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?

28. 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

29. 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

30. 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

31. How does Staged Supply help with Prescription Abuse?  From the patient point of view: › It is better than nothing › It is more restrictive than normal prescribing › It is less controlling than ORT › It “puts the breaks on” › It helps prevent the patient running out of medication early

32. Staged Supply and Prescription Opiate Abuse  From the doctors point of view: › It requires a little more communication with the pharmacist › It reduces the chance of 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

33. Which 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

34. Just write staged supply and the interval on the script

35. 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

36. Frequency of Pickups Risk Desperation Doctor Patient More frequent pickups

37. Staged supply of opiates Staged Supply ORT Illicit / street use Very high quantities IVDU Prescription abuse Reliable Rational

38. 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

39. ‘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

40. Children at Risk  Dependents must be taken into account  Report any children if they are at risk

41. 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? If the answer is “no” to all of the above then consider ORT

42. In Conclusion  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

43. Question Time

44. Case Presentation