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PRESCRIPTION DRUG PROBLEMS IN PRESCRIPTION DRUG PROBLEMS IN TASMANIA, AUSTRALIATASMANIA, AUSTRALIA
APSAD ConferenceAPSAD Conference14 November 201114 November 2011
Clinical Director, Alcohol & Drug Services, TasmaniaDr Adrian Reynolds
Too Much or Too Little?Too Much or Too Little?
Although the optimal use of opioids in the management of CNMP is still debated it is clear that opioids are sometimes used excessively & at other times too sparingly
T.O.R. for the Tasmanian Opioid ReviewT.O.R. for the Tasmanian Opioid Review
DHHS Tasmania commissioned our NDARC to conduct a
staged review to develop prioritised recommendations &
an implementation plan in relation to ‘evidence-informed’
prescribing of opioid medication for: Pain management, generally
Pain management, specifically in the context of drug addiction or risk of
addiction
Safe prescribing of Schedule 8 opioids and other drugs of dependence, in a
manner that takes into account patient & community safety & the
requirements of best practice chronic pain medicine & addiction medicine
Increasing Opioid PrescribingIncreasing Opioid Prescribing
While opioid analgesics have a well-established place in the treatment of acute pain & cancer-related pain, their role in the management of persistent non-cancer pain is less clear With several reviews finding limited evidence for their
effectiveness in the long term Evidence of range of risks & harms
Falls, accidents, OIH, chemical coping while under-utilising or rejecting non-drug interventions, endocrine & immune system problems…
Furlan, et al., 2006; Kalso, et al., 2004; Manchikanti, et al., 2011; Noble, et al., 2010; Trescot, et al., 2008; Ballantyne, 2003
Risk of Problems…Risk of Problems…
Until recent times, it was common to hear pain medicine specialists & others say that aberrant behaviour& addiction are rare events in patients treated appropriately with opioids for moderate to severe pain In my experience, this was significantly influenced by
the lack of training of doctors in knowing what to look for & often, less than careful clinical history taking & examination
Faculty of Pain Medicine…Faculty of Pain Medicine…
“Chronic pain is usually incompletely assessed & managed & this incomplete assessment can result in numerous failed treatments” Faculty of Pain Medicine, 2010
Misuse of Prescribed OpioidsMisuse of Prescribed Opioids
Precise extent of problem unknown in Australia US study suggested ~3% of chronic pain patients
using opioid analgesics for extended periods develop opioid abuse or dependence problem ~12% exhibited aberrant drug-related behaviours
Fishbain, Cole, Lewis, Rosomoff, &Rosomoff, 2008
So this study suggests ~1 in 8 patients engaging in risky drug use, which is significant from a clinical & public health perspective
Misuse of Prescribed OpioidsMisuse of Prescribed Opioids
However, drug problems arising from opioid prescription for pain management may be even more common than this
Misuse of Prescribed OpioidsMisuse of Prescribed Opioids
Prospective cohort study found 32% of opioid-treated patients with chronic pain misused their opioids, when misuse was defined as: Negative urine screen for prescribed opioids Positive urine screen for opioids or controlled substances
not prescribed Evidence of procurement of opioids from multiple providers Diversion of opioids, prescription forgery, or Stimulants found in urine screens
Ives, Chelminski, Hammett-Stabler, Malone, Perhac, Potisek, Shilliday, DeWalt, &Pignone, 2006
Diversion for Illicit UseDiversion for Illicit Use
Then we have Tasmanian review data & analysis… Estimates, although uncertain, suggest IDUs in
Tasmania may be consuming an increasing large proportion of total amount of morphine prescribed per annum Perhaps as much as 30% in 2010
Diversion to Illicit MarketDiversion to Illicit Market
IDUs in Tasmania are also estimated to consume around 10% of prescribed physeptone
Across all jurisdictions, IDUs are estimated to consume less than 5% of prescribed oxycodone
The proportion of oxycodoneconsumption in Tasmania is estimated at 8% of total consumption
Multimodal TreatmentMultimodal Treatment
Pain specialists have for some time now advocated a multimodal approach to managing chronic pain where physical & psychological therapies are emphasised &opioid analgesics are considered as a second or third line treatment
High Doses = High Risk of DeathHigh Doses = High Risk of Death
Growing awareness of need for agreed “ceiling dose” which alerts prescribers to need for a review of patient management
Higher doses found to result in 3-4X overdose risk Patients with PNMP prescribed ≥100mg/ day
morphine had 7x likelihood of fatal OD c.f. ≤20mg Bohnert, et al., 2011
Tasmania has many patients on doses 4-8x higher & on multiple drugs that pose sig. risk
Dangerous Drug CombinationsDangerous Drug Combinations
Further concern is patients who are prescribed multiple medications: opioid analgesics, sedatives, anti-psychotics, & anti-
depressants Combination of CNS depressants particularly
dangerous (including alcohol)
Rapid Increase in PrescribingRapid Increase in Prescribing
Rapid & largely unexplained sudden upturn in opioid prescribing for PNCP in Tasmania in 2006-07 after gradual increases in preceding years Paralleled by increase in authority applications
Doctors must seek an authority to prescribe S8 medications beyond 2 months continuously
S8 Authorities per Annum in Tasmania: 1989-2010S8 Authorities per Annum in Tasmania: 1989-2010
Total number of morphine, oxycodone and buprenorphine prescriptions per annum in Tasmania,
DAPIS, 1996-2010
Opioid Prescribing is EscalatingOpioid Prescribing is Escalating
Illicit Use of Morphine IDRS SampleIllicit Use of Morphine IDRS Sample
6 month use of morphine by IDRS participants (%) Tasmania &National 2000-2010
Illicit Use of Oxycodone (IDRS)Illicit Use of Oxycodone (IDRS)
6 month use of oxycodone by IDRS participants (%) Tasmania & National 2000-2010
Diversion of Methadone TabletsDiversion of Methadone Tablets
6 month use of physeptone by IDRS participants (%), Tasmania and National 2000-2010
Source of Prescription Opioids used for Pain by IDRS Source of Prescription Opioids used for Pain by IDRS Participants in Tasmania & Nationally (2010)Participants in Tasmania & Nationally (2010)
Non-Fatal OverdoseNon-Fatal Overdose
Percentage reporting a non-fatal overdose by drug type in the past 12 months (2010)
OpioidRelated DeathsOpioidRelated Deaths
Tasmania has the highest or second highest rate of accidental deaths due to opioids per million among those aged 15-54 years in Australia 53.7 deaths per million persons in 2005
NDARC, 2007
Number of Opioid&Opioid Plus BZD-related Number of Opioid&Opioid Plus BZD-related Deaths in Tasmania per AnnumDeaths in Tasmania per Annum
Oxycodone Deaths in AUSOxycodone Deaths in AUS
Rates of death associated with oxycodone in years 2000-2009
Clinical OutcomesClinical Outcomes
Opioid prescribing for CNMP in isolation from a broader Rx plan is often associated with apparently poor clinical outcomes
Medicalisation of Human Medicalisation of Human ProblemsProblems
Caution: the (over)medicalisation of human problems & ‘acopia’ is a serious issue Seeing this with increased & inappropriate prescribing
of a range of other drugs like the BZDs, anti-depressants, mood stabilsiers& anti-psychotics Selling many patients short on their life opportunities?
Often defended as ‘harm reduction’ but it may not be
The Strong Desire to Cure…The Strong Desire to Cure…
A strong desire to cure/relieve pain on the part of the doctor But not alone in this highly aspirational if not
sometimes unrealistic & potentially counterproductive way of thinking…
Doctors Under Pressure to PrescribeDoctors Under Pressure to Prescribe
Doctors, patient advocates, health complaints offices & lawyers are now unwittingly & counterproductively becoming intricately caught up in the web of chemical coping & black or grey market forces Acting on behalf of the patient who may be demanding or at least
placing great pressure on the doctor to prescribe unsafely or inappropriately
Defending decisions designed to safeguard patient & community is placing an increasing drain on time & resources which the healthcare sector does not have available to use unwisely
Also doing great harm to involved health professionals, which is hardly a moral good: do we demand justice for all or just for some?
Doctors Under Pressure to PrescribeDoctors Under Pressure to Prescribe
Doctors are largely unprepared in their undergraduate & post graduate medical training to manage these pressures Don’t always know how or don’t necessarily have the
confidence to appropriately manage these pressures to prescribe & to offer alternative treatments (or in some, just explanation & practical advice) that may be more appropriate
Changing Clinical PracticeChanging Clinical Practice
Need to equip doctors to provide appropriate Rx Such change in practice will require:
Educating prescribers in clinical reasoning Removing barriers to the use of some non-drug
therapies (such as financial cost) Accessibility to alternative methods& treatments to
deal with pain Addressing perverse disincentives to do the right thing
Structural Reforms to Improve CareStructural Reforms to Improve Care
Tasmania will look to further enhance our regulatory-clinical interface to provide education & structural incentives to prescribers through the authority application process e.g. by ensuring that the application process forms
part of the doctor’s assessment of the patient’s suitability for an opioid prescription & their treatment plan
Building Clinical RelationshipsBuilding Clinical Relationships
We will work to further develop the working relationship between Pain & Addiction Medicine in teaching, in collaborative service delivery & in consultation liaison support of the hospital & primary care sectors
Clarity Regarding Role of OpioidsClarity Regarding Role of Opioids
We will adopt a systems approach to ensure patients clearly understand that: Opioid pharmacotherapy for PNMP may be one component
of a multi-modal Rx plan & when prescribed, is an ongoing trial;
That there is an implied contract in continued treatment with opioids that agreed goals of therapy will be maintained; &…
That there will be an ongoing review of benefit, risk & harm Important to recognise that in the absence of adherence, there is no
therapeutic alliance
Universal Precautions a Key ElementUniversal Precautions a Key Element
Teaching & supporting the Universal Precautions approach which includes the 5A’s + 2A’s Analgesia Activity Adverse events Aberrant behaviours Affect Adherence Accurate medical records
Opioid Review – Blueprint for the FutureOpioid Review – Blueprint for the Future
Our Tasmanian Opioid Review – Blueprint for the Future will soon be finalised& handed to our Minister, who has been very supportive in our endeavours to research, better understand & respond to the challenges We look forward to sharing the report & findings &
recommendations with our colleagues across the nation & beyond
AuthorsAuthors Dr Adrian Reynolds, Clinical Director, Alcohol and Drug Services,
Department of Health and Human Services, Tasmania, Australia Prof Richard Mattick, National Drug and Alcohol Research Centre, UNSW,
Sydney, New South Wales, Australia Ms Mary Sharpe, Chief Pharmacist, Pharmaceutical Services Branch,
Department of Health and Human Services, Tasmania, Australia Dr Fiona Shand, National Drug and Alcohol Research Centre, UNSW,
Sydney, New South Wales, Australia Plus long list of other people with specialist knowledge & skills!
No conflict-of-interest regarding this study which was funded by the government of Tasmania
