Prescription Drug Addiction

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1 Prescription Drug Addiction Dr Gilbert Whitton FAChAM Clinical Director Drug & Alcohol Loddon Mallee Murray Medicare Local Deniliquin 14 th May 2014

2 Prescription Drug Addiction Overview History Benzodiazepines Data Assessment Withdrawal Other prescription drugs - Opiates Management Benzodiazepines Opiates

3 History pharmaceutical drug use in Australia Over the counter heroin common until 1910 s Amphetamines commonly prescribed until 1960 s Barbiturates Benzodiazepines:1960 s safe, non-addictive, mother s little helper Increasing use over past 40 years > 3 million scripts in Australia / year Concerns re: abuse & addiction emerged 1980 s SSRIs: 1990 s onwards Atypical antipsychotics: 2000 s onwards Opioids: 2000 s onwards

4 National Pharmaceutical Drug Misuse Strategy

5 Benzodiazepine use In general population: 6-10% of US adults used a hypnotic for sleep in of those using BZD, ~25 76% use long term (>3/12) Prevalence long-term BZD use in Australia: 2 7% Estimates high dose BZD dependence: % In medical practice 2 of top 20 drugs prescribed in Australia; 4% all scripts; 7% all patients; 84% GP patients using benzodiazepines still on them 6 months later. In substance users (eg. heroin users, opioid treatment program) ~ 2/3 rds report any BZD use past month; 1/3 rd report regular use 10-20% report regular high dose BZD use 4

6 Trends in benzodiazepine dispensing in Australia (a) DDD= (WHO) defined daily dose (b) number of prescriptions (blue) PBS/RPBS; (brown) private; (green ) under co-payment. Internal Medicine Journal Volume 44, Issue 1, pages 57-64, 23 JAN 2014 DOI: /imj

7 Trends in benzodiazepine dispensing in Australia Internal Medicine Journal Volume 44, Issue 1, pages 57-64, 23 JAN 2014 DOI: /imj

8 Benzodiazepine use Is it a problem? 7

9 BZD Use amongst Australian IDUs (IDRS-Illicit Drug Reporting System): % of cohort using in past 6 months 100% 90% 80% Extra-medical Only Both Prescribed only 70% 60% 50% 21% 18% 21% 22% 24% 20% 40% 30% 19% 19% 23% 18% 12% 26% 20% 10% 24% 24% 23% 25% 30% 18% Median Frequency 0%

10 Illicit Drug Reporting System: Australia Year % recent use alprazolam Most common injected diazepam diazepam diazepam diazepam alprazolam alprazolam alprazolam alprazolam alprazolam

11 ASSESSMENT??

12 ASSESSMENT History

13 A hierarchy of drugs to enquire about Cigarette smoking? Alcohol? Cannabis? Amphetamine type stimulants? Heroin & other illicit/iv drugs? OTC medications (eg. codeine) & prescribed drugs (eg. benzodiazepines)?

14 ASSESSMENT History Examination

15

16

17

18

19 Not only arms

20 Not only arms

21 ASSESSMENT History Examination Investigations

22 A substance use diagnosis? Low risk use Hazardous use Harmful use Dependence

23 Assessment: summary Screening for every patient seen incorporated into your own patient assessment protocol More detailed history as indicated Cigarette smoking? Alcohol? Cannabis? Amphetamine type stimulants? Heroin & other illicit/iv drugs? OTC medications (eg. codeine) & prescribed drugs (eg. benzodiazepines)? Physical examination & investigations Reach a diagnosis for each substance used Assessment as therapy

24 MANAGING WITHDRAWAL

25 Withdrawal states (NSW Health, Drug & Alcohol Withdrawal Clinical Practice Guidelines, 2007) Drug Onset Duration Features Nicotine Within several hours of the last cigarette Peaks hours & lasts 2-4 weeks Craving, irritability, restlessness, mood swings, increased appetite, insomnia, difficulty concentrating Alcohol Hours after last drink 3 7 days Agitation, anxiety, sweating, tremor, tachycardia, fever, disorientation, hallucinations, seizures Cannabis Within 24 hours 1 2 weeks Insomnia, shakiness, irritability, restlessness, anxiety, anger, aggression Amphetamines hours Several weeks Fatigue; followed by fluctuating mood & energy levels, cravings, disturbed sleep, poor concentration Opiates 6 24 hours Peaks 2 4 days & lasts 5-10 days Aches, cramps, sweating, lacrimation, rhinorrhoea, nausea, vomiting, diarrhoea, dilated pupils

26 Alcohol Withdrawal Chart - CIWA - AR

27 Alcohol withdrawal Withdrawal ranges from insomnia and morning tension, through to (far less commonly) delirium tremens NSW Clinical Withdrawal Guidelines, from Pead

28 Benzodiazepine Discontinuation Recurrence or rebound of symptoms for which medication initially taken Withdrawal syndrome: emergence of characteristic profile of withdrawal symptoms % of long-term benzodiazepine use at therapeutic doses are physically dependent & experience withdrawal symptoms (Ashton 1997)

29 NSW Health, Drug & Alcohol Withdrawal Clinical Practice Guidelines, 2007

30 Other Prescription Drugs

31

32 DOES IT MATTER? ED presentations in USA - relative to community opioid prescribing

33 CDC: Opioid Sales and Overdose Deaths

34 DOES IT MATTER?

35 December 2008 With thanks to Podiatry Camden Hospital

36 May 2009 With thanks to Podiatry Camden Hospital

37 Fentanyl Patches

38 Fentanyl person and script count, QLD, Persons Scripts

39 With thanks to Innes Clarke

40 With thanks to Innes Clarke

41 Over-the-counter (OTC) opiates Notable Cases: Nurofen Plus misuse: an emerging cause of perforated gastric ulcer (MJ Dutch; MJA 2008; 188 (1): 56-57) Over a 6-month period, two patients presented to a community hospital emergency department with perforated gastric ulcers as the result of recreational misuse of over-thecounter ibuprofen codeine preparations. Misuse of these medications appears to be an emerging cause of significant morbidity in patients with codeine addiction.

42 Managing benzodiazepine use: a framework for safer treatment (Lintzeris) 41

43 Is there a role for therapeutic use of BZDs as anxiolytics/hypnotics? Concerns Onset of tolerance within weeks limits their utility Risks of abuse / addiction especially in high-risk groups Consider alternative management strategies Sleep hygiene and relaxation techniques Address underlying anxiety/depression Address other substance use disorders If going to prescribe: Limit duration <2 weeks Regular interval dispensing Avoid highly abused BZDs 42

44 Are some BZDs safer than others? Amount of cognitive impairment / intoxication Onset & duration of action Slow onset & longer-acting drugs less abuse potential than fast onset & short acting drugs Potential for misuse Preparations can impact upon misuse (e.g. temazepam capsules) Prescribing & dispensing practices (200x 2mg clonazepam + 5 repeats!!)

45 Treat concomitant anxiety / depression & address social circumstances Depression and anxiety respond optimally with combined pharmacotherapy and psychosocial interventions SSRI, SNRIs, antipsychotic medications CBT, psychotherapy, self help Peer, family & community supports Employment, exercise Develop appropriate treatment networks 44

46 If you are going to prescribe BZDs.. Negotiate contract with patient re: treatment conditions BZDs contingent upon not getting BZDs from elsewhere, stable in treatment, attend appointments, not abusing other drugs One doctor to manage all BZDs & related medications Doctor shopping consent forms Consent to provide information to other health care providers Limit access to BZDs: staged (daily/weekly) dispensing Avoid BZDs associated with high abuse rates (e.g. flunitrazepam, midazolam, alprazolam) Agree how to assess & monitor 45

47 Monitoring treatment Monitoring Outcomes : The 4A s Anxiety / Affect / sleep: scales, diary Activities: functional outcomes Adverse events: side effects Aberrant behaviours:

48 BZD detox or maintenance? Research unable to inform practice at this time: few controlled long-term trials Some patients will successfully detox if prompted & supported most won t Poor success rates in low dose & high dose BZD detoxes 5 to 20% achieve long term abstinence If repeated attempts at detox do not work, then consider longer period of stabilisation & review Informed consent & need for monitoring safety concerns of long term BZD use (AEs, memory, cognition, sleep) No role for unconditional, never-ending BZD maintenance 47

49 Murrumbidgee LHD D&A Service Patients Benzodiazepines Opioids Amphetamines Cannabinoids Alcohol Nicotine 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Principal Drug of Concern

50 Managing opioid dependence 49

51 Treatment Approaches for Opiate Dependence 1. Abstinence preferred, if can be achieved. but, relapse is common & carries significant risks (eg. of overdose). 2. Substitution / Replacement for those who are unlikely to achieve abstinence. harm minimisation

52 Retention in Treatment NEPOD Study 2004

53 Methadone

54 Suboxone Sublingual Film Carton Sachet Film 2/05 mg Suboxone Film 8/2 mg Suboxone Film

55 Suboxone Film Administration Should be placed under the tongue close to the base on either side If the dose is 2 Suboxone Films, patients should place the other Film under the tongue on the opposite side at the same time. Patients should try to avoid letting the Suboxone Films touch as much as possible If more than two films are required, place Suboxone Film under the tongue on either side after the first 2 have dissolved Supervision time is dictated by the Australian Clinical Guidelines for the use of Suboxone Sublingual Film

56 Thank you Dr Gilbert Whitton health.nsw.gov.au

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