Dr Alistair DunnLead Clinician

Northland Health Community Mental Health &

Addictions

Northland DHB

Whangarei

16:30 - 17:25 WS #91: The Bottom Line: Tackling the Problem of Prescribed Drug Addiction

17:35 - 18:30 WS #103: The Bottom Line: Tackling the Problem of Prescribed Drug Addiction

(Repeated)

The Bottom Line :

Prescribed Controlled Drug

Addiction

Dr Alistair Dunn

Controlled Drugs ?

Controlled Drugs ?

◼ Class A : very high risk

◼ Class B : high risk

◼ Class C : moderate risk

Controlled Drugs

◼ Class A

◼ Cocaine, LSD , Heroin Methamphetamine , Mescaline

Controlled Drugs

◼ Class A◼ Cocaine, LSD , Methamphetamine ◼ Rx Heroin

◼ Class B ◼ Hashish , MDMA , opium , GHB

◼ Rx CD PAD ◼ morphine , fentanyl , methadone ◼ Methylphenidate

Controlled Drugs

◼ Class A◼ Cocaine, LSD , Methamphetamine ◼ Rx Heroin

◼ Class B ◼ Hashish , MDMA , opium , GHB ◼ Rx CD PAD◼ morphine , fentanyl , methadone , oxycodone ◼ Methylphenidate

◼ Class C ◼ Cannabis plant , BZP

◼ Rx Buprenorphine , codeine , DHC , ketamine , BENZOS ◼ Rx Cannabis ( THC /CBD)

Controlled Drugs

◼ Class A◼ Cocaine, LSD , Methamphetamine ◼ Rx Heroin

◼ Class B ◼ Hashish , MDMA , opium , GHB ◼ Rx CD PAD◼ morphine , fentanyl , methadone , oxycodone◼ Methylphenidate

◼ Class C ◼ Cannabis plant , BZP

◼ Rx Buprenorphine , codeine , DHC , ketamine , BENZOS ◼ Rx Cannabis ( THC /CBD)

Controlled Drugs ?

What is missing ??????????????

morphine , fentanyl , methadone , oxycodone

Buprenorphine , codeine , DHC

◼ BENZOS

Controlled Drugs ?

Tramadol ? NOT YET

Controlled Drugs ?

Tramadol ? NOT YET

Zopiclone ? NOT YET

M.O.D.A.

M.O.D.A.

◼ The Misuse Of Drugs Act

Says what ?

M.O.D.A.

Section 24

◼ of the Act prohibits prescribing a controlled drug to a person whom the prescriber believes to be dependent on that or any controlled drug, unless that prescriber:

◼ is a gazetted practitioner; or

◼ is working in a gazetted agency; or

◼ has an authority to prescribe for a particular patient.

M.O.D.A.

◼ Case #1 :morphine 50 mg bi d

◼ Case #2 : diazepam 5mg tds

Prescribed Controlled Drugs

◼ Opiates & Benzodiazepines

Prescription Opiates

Prescription Opiates

◼ Morphine , Methadone , Fentanyl ,

◼ Oxycodone ( @#$%^& !!!!!!!)

◼ Codeine,DHC,panadeine,nurofen plus

◼ Buprenorphine (Suboxone , Norspan)

Plus

Tramadol you betcha

OPIATE Dependence

◼ All prescribed opiates can be addictive so TAKE CARE

OPIATE Dependence

Tolerance & Withdrawal

what else ?

DSM criteria :

OPIATE Dependence

Tolerance & Withdrawal

Dyscontrol

Salience

Craving

Continued use despite adverse consequences

Opiates are prescribed for PAIN

YEAH …….NAH

Opiates are prescribed for PAIN

◼ Acute & short term : YEAH

◼ Longer term : NAH

◼ “There are no longitudinal RCTs on the long term effectiveness & consequences of opioid use in chronic non malignant pain”

◼ ( Prescription Opioid Policy , RACP / RACGP / RANZP . 2009 )

Opiates for chronic pain : risks ?

Opiates for chronic pain : risks

◼ Tolerance/hyperalgesia

◼ Mortality/overdoses

◼ No gains in pain/function

BOTTOM LINE

◼ Opiates are a dumb choice to treat chronic non malignant pain

Opiates are a dumb choice to treat chronic non malignant pain

Chronic Pain Management

Counselling / Education

◼ acceptance of pain , adjust & adapt thru self-management

◼

◼ “Incurable” - like diabetes

◼ Change goal & expectation from being pain-free to “taking the edge off it” and promoting function / goals

Counselling / Education

◼ patient must address resentment and rejection of their damaged / new self

◼ Stress, anxiety, depression , guilt , frustration

Counselling / Education

◼ Illness Beliefs

◼ - I can't stand it / can't cope

◼ - No one believes me

◼ - I must be a bad person / punished

◼ - Im useless

Counselling / Education

◼ Cognitive Errors

◼ Catastrophising : interpret pain as damage / bad sign

◼ Nothing helps / no-one cares

◼ Fear Avoidance : stay at home in pain vs go out and watch a movie in pain

◼ Black and White thinking : one thing or opposite

Counselling / Education

◼ Passive recipient of relief-'bystanders' in own treatment

◼ vs active participant in pain management

Counselling / Education

◼ Support team

◼ Pacing ( boom/bust)

◼ Relaxation/distraction

◼ Activity/exercise

Counselling / Education

◼ Multidisciplinary Pain Team

◼ - DHB – yeah right

◼ - ACC – ref Habit Rehab / short Orebro questionnaire

Oh well , if you must prescribe

opiates …remember..

◼ Look before you leap

◼ Easy to start HARD TO STOP

Red Flags

3 Red Flags

◼ 1- past hx A&D

3 Red Flags

◼ 1- past hx A&D

◼ 2- fam hx A&D

3 Red Flags

◼ 1- past hx A&D

◼ 2- fam hx A&D

◼ 3- “aberrant behaviour”

3 Red Flags

◼ 1- past hx A&D

◼ 2- fam hx A&D

◼ 3- “aberrant” behaviour

◼ Plus – Hep C = IVU

“Universal Precautions”

◼ When was this concept created ?

◼ What does it mean ?

“Universal Precautions”

◼ Not all risks are apparent

◼ Diversion of medication to users

◼ ( family members ,resale , theft )

Not the “usual suspects”

◼ No prior A&D

◼ Prescribed Rx only

◼ High functioning

7 Prescribing Tips

7 Volunteers to recall 1 each please

7 Prescribing Tips

◼ 1.Dispensing

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date / timeframe /exit plan

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – limit ? Mg daily morphine

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

◼ 5.Contract / consent

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

◼ 5.Contract / consent

◼ 6.Testing – urine drug screen

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

◼ 5.Contract / consent

◼ 6.Testing – urine drug screen

7 Prescribing Tips

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

◼ 5.Contract / consent

◼ 6.Testing – urine drug screen

◼ 7.Restriction Notice

◼ 1.Dispensing

◼ 2.Restriction Notice

DRDOCTR

“Doctor , Doctor “

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

◼ 5.Contract / consent

◼ 6.Testing – urine drug screen

◼ 7.Restriction Notice

Benzodiazepines

◼ The “pams”

◼ PLUS Zopiclone / “Imovane”

BENZO Dependence

◼ All prescribed benzos can be addictive so TAKE CARE

BENZO Dependence

◼ All prescribed benzos can be addictive so TAKE CARE

◼ Long term use 1) Hypnosedative Rx

2) Anxiolytic Rx

BENZOS as hypnosedative

◼ The “blue rinse brigade”

BENZOS as hypnosedative :risks?

BENZOS as hypnosedative

◼ Risk of falls

◼ Cognitive impairment

◼ Sedation

◼ polypharmacy

Benzos as anxiolytic ?

◼ YEAH , NAH

Benzos as anxiolytic

◼ Acute & short term : YEAH

◼ Longer term : NAH

Benzos as anxiolytic

◼ Acute & short term : YEAH

◼ Longer term : NAH

◼ > memory loss / cog impairment

◼ > sedation / driving / overdose

◼ > addiction

Management of Anxiety

Try SSRI first for anxiety NOT a benzo

Oh well , if you must …..

Look before you leap

Easy to start > Hard to stop

Name 3 Red Flags

◼ 1.Past hx A&D

◼ 2.Fam hx A&D

◼ 3.Aberrant behaviour / early pick ups

7 Prescribing Tips ???

DRDOCTR

DRDOCTR

◼ 1.Dispensing

◼ 2.Review date

◼ 3.Dose – set limit

◼ 4.Outcome measures functional goal

◼ 5.Contract / consent

◼ 6.Testing – urine drug screen

◼ 7.Restriction Notice

SUMMARY

◼ Take care when prescribing opiates and benzos because of their addictive potential

◼ These drugs are easy to start but hard to stop

◼ Pharmacotherapy is only one part of management of chronic pain or anxiety

And remember ….

Opiates are …

Opiates are a dumb choice to treat chronic non malignant pain

Try SSRI first for anxiety NOT a benzo

Handy Resources

◼

◼ Enter “opioid/opiate meds”

Dr Mike Evans “advice for taking opioid medication” video

◼ Enter “chronic pain”

Handy Resources

Audit of Medical Practice Resources

Controlled Drug Prescribing – Clinical Audit 2018

Handy Resources

◼ Identifying and managing addiction to opioids - BPJ 64 ... - bpac NZ

◼ https://bpac.org.nz/BPJ/2014/October/opioid-addiction.

THANKYOU