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