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 heroin, it is about containing the abuse of drugs that we all prescribe

3. Opiates are usually prescribed for severe disabling pain  Most patients who attend regularly requesting opiate medication profess to have some sort of chronic pain  Most commonly › Low back pain › Cervical nerve root irritation › Migraine

4. Drug Seekers are not all the same  A lot of these patients have genuine pain and take their medication properly  Some of these patients have become dependent or addicted to opiates and are not taking their medication properly  Some patients are simply not genuine and are selling their medication or abusing it somehow

5. Some Drug Seekers can be very persistent and annoying  We may not say these words but this is how it comes across › Go away › Junkie › No, we cannot help you › We don’t want you here  Even genuine patients can become upset or angry because of this

6. Staged supply  Is a simple but effective way for GPs to manage their own chronic pain patients who have become addicted to prescribed opiates  It does not involve prescribing methadone or buprenorphine/naloxone which are usually reserved for illicit - intravenous drug use

7. Staged supply  Is an established pharmacy procedure for patients who have difficulty taking their medications properly  Pharmacies receive a rebate for dispensing the medications in stages (daily, second daily, third daily etc)

8. Quantity dispensed and frequency of dosing Frequency of dosing RiskAvailabilityDesperation

9. General Practice Normal prescribing Staged Supply Opiate Replacement Therapy Specialist

10. 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  Disorder includes all of the above

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

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

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

14. 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

15. 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

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

17. 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

18. 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

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

20. 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

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

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

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

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

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

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

27. Management of Prescription Opiate Abuse  Single prescriber  Specialist consultation  Authority to prescribe  Staged supply  Opiate Naloxone preparation  Opiate replacement therapy** ** if very large quantities or intravenous drug use or if buying street drugs

28. 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

29. Assessment and consideration of alternative treatments  Referral to surgeons / specialists  Referral to multidisciplinary pain clinics  Physiotherapists / chiropractors  Psychologists  Non opiate medications

30. Getting an authority to prescribe?  Getting an authority to prescribe after two months would guard against multiple prescribers  A DD Application needs to be faxed to the PSU  The doctor needs to then speak to the PSU to confirm that the authority has been accepted  There can only be one doctor with the authority at a time

31. 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  Staged supply can be done with any medication but it is particularly useful for opiates and benzodiazepines  Getting an authority and changing to an opiate/naloxone preparation provides additional safeguards

32. Staged supply  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

33. 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

34. Staged Supply and Prescription Opiate Abuse  From the doctors point of view: › It requires communication with the pharmacist and PSU / PSB › 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

35. 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

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

37. 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

38. Staged supply of opiates Staged Supply ORT Illicit / street use Very high quantities IVDU Prescription abuse Unreliable Rational Truthful Modest doses

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

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

46. NATIONAL PHARMACEUTICAL DRUG MISUSE FRAMEWORK FOR ACTION (2012-2015) Back