Prescription Opiate Abuse

Managed by GPs with

Authorized Staged Supply

Dr Nigel Hawkins - UWS

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

What makes patient’s angry

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

Staged supply

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

To minimize incidents with your addicted patients

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

Outline

Definition Incidence Recognition Assessment Management Case presentation Discussion

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

Incidence

Recognising Opiate Abuse

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

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

What is the cause of the patient’s pain?

Does the patient have a genuine cause of pain or is the patient simply addicted?

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

What other drugs are being used?

AlcoholTobaccoCannabis SpeedValiumHeroinCocaine

What is the patient’s social setup?

Working? Homeless? Transportation? Social supports or

liabilities? Criminal record

What co-morbidities exist?

Diabetes Ischemic heart disease Cirrhosis Renal impairment Cancer Back injury Arthritis

Are there any mental health conditions?

Depression Anxiety PTSD Schizophrenia Personality disorders Cognitive impairment

What form of opiate is being used?

Patches Tablets Syrups Films Opiate / naloxone

preparations Over the counter preparations

How many doctors are involved?

Is the patient visiting multiple doctors at different surgeries or do they stick to one doctor or one surgery?

Who is the principal doctor?

Who is going to manage the patient?

Communication between doctors is essentialSomebody needs to take responsibility for the patientThis should be documented in the patient’s record

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

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

Children at Risk

Dependents must be taken into account

Report any children at risk

Examination

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

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

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?

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

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

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

How does staged supply help with Addiction?

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

Staged Supply

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

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

Case Presentation

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?

Staged supply of opiates

Staged Supply ORT

Illicit / street use

Very high quantities

IVDU

Prescription abuse

Reliable

Rational

Frequency of Pickups

Risk

Desperation

Doctor

Patient

More frequent pickups

What form of 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

‘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

Question Time