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Dr Alistair DunnLead Clinician
Northland Health Community Mental Health &
Addictions
Northland DHB
Whangarei
8:30 - 9:25 WS #147: The Bottom Line; Tackling the Problem of Prescribed Drug Addiction
9:35 - 10:30 WS #157: 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 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 Methylphenidate
Class C Cannabis plant , BZP
Rx Buprenorphine , codeine , DHC , ketamine , BENZOS Rx Cannabis ( THC /CBD)
Controlled Drugs ?
Tramadol ?
Controlled Drugs ?
Tramadol ? NOT YET
Controlled Drugs ?
Tramadol ? NOT YET
Zopiclone ?
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
Chronic Pain
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
Dr Mike Evans “advice for taking opioid medication” video
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