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

2. Admissions for prescription vs illicit opiate abuse

3. NATIONAL PHARMACEUTICAL DRUG MISUSE FRAMEWORK FOR ACTION (2012-2015) Prescriptions for Opiates

4. Deaths related to oxycodone

5. Opiates are usually prescribed for severe disabling pain  Most commonly › Low back pain › Cervical nerve root irritation › Migraine › Musculoskeletal pain

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  Disorder includes any or all of the above

7. The POINT study recruited Patients using opiates > 6 weeks from Pharmacies all over Australia  Patients were screened for › Aberrant Behaviours › Dependence › Other drug use › Co-morbid conditions

8. POINT: Age Distribution Female 55%

9. POINT : Dose Ranges Oral Morphine Equivalents

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

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

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

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

14. What’s the point of POINT  Patients tend to be more complicated the higher the dose of opiate that they take  Higher doses were associated with higher likelihood of dependence, depression, anxiety, use of benzodiazepines and other drug and aberrant behaviours such as doctor shopping, injecting and OD  The majority of patients were nevertheless not dependent according to ICD10 criteria  Only 4.7%** met criteria for dependence in the last 12 months **this is probably an underestimate

15. Some Drug Seekers can be very persistent and annoying  We may not say these words but this is how it may come 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

16. 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

17. Staged supply  Is an established pharmacy procedure for patients who have difficulty taking their medications properly  It can be used for any drug but it is ideal for opiates & benzodiazepines  Pharmacies receive a rebate for dispensing the medications in stages (daily, second daily, third daily etc)

18. Quantity dispensed and frequency of pickups Quantity dispensed at a time RiskAvailabilityDesperation

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

20. Prescription Opiate Abuse Patients who take their medicine properly Normal Prescribing Patients with opiate use disorder on moderately large doses Staged supply Patients who inject or use very large doses ORT

21. Recognising Opiate Abuse  When patients want more than you feel is appropriate  If the patient runs out of their medications more frequently than expected  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

22. Assessment of New patients  Care should be taken with new patients  Very persistent patients  Asking for a specific drug that is prone to abuse  Look at the patients arms  Consider doing a urine drug screen  Talk to previous doctors  Talk to doctor shoppers

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

24. 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

25. Is it for personal use?  Is the patient selling** (diverting) their medication or is it for their own personal use?  If diversion or injection suspected then consider supervised doses or an opiate- naloxone preparation **Patients who sell their medication should not be entertained

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

27. 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

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

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

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

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

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

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

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

35. 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

36. Consideration of alternative treatments  Referral to surgeons / specialists  Referral to multidisciplinary pain clinics  Physiotherapists / chiropractors  Psychologists  Non opiate medications  Non pharmacological strategies

37. Authority to prescribe  Getting an authority to prescribe is a legal requirement after 2 months  It ensures that there is only one legitimate prescriber  A DD Application needs to be faxed to the PSU  The doctor then needs to speak to the PSU to confirm that the authority has been accepted  Pharmacists should also check that doctors writing scripts hold an authority

38. 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

39. 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

40. Staged supply  Examples: › 2 oxycontin tablets dispensed daily › 4 targin tablets dispensed second daily › One fentanyl patch dispensed every 3 days › One norspan patch dispensed weekly › Seven suboxone films dispensed weekly

41. 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

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

43. 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 still doctor shopping then ORT will need to be considered  If patients choose to find another doctor then at least you have done your best to help the patient and to prescribe safely

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

45. ‘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

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

47. To prescribe or not to prescribe?  Is it reasonable to withhold the medication from the patient?  What is a safe quantity of opiate to be giving this patient at any one time  How can I make it easier for the patient  Would an opiate-naloxone preparation be useful?

48. In Conclusion  The majority of patients prescribed less than 200mg OME are not dependent on their medication and normal prescribing may be appropriate  Most patients who are dependent or addicted to prescription opiates could be managed with staged supply  ORT could be used for patients who are not controlled with staged supply or are injecting their medication

49. Question Time