Support to Primary Care from Derbyshire Substance Misuse Service for prescribed / OTC drug dependence SUMMARY 1) Derbyshire Substance misuse service provides Psycho-social treatment interventions for ALL substances of misuse (excluding primary alcohol and nicotine) with access to 1:1 keyworker 2) For prescribed medication dependence, the interventions would largely be through psychosocial interventions. Prescribing guidance will be provided to the appropriate practice through the consultant addiction psychiatrist in liaison with the client s individual keyworker. 3) In specific situations-considerations may be given to transfer onto more appropriate substitute medications with these being managed through the specialist prescribing. 4) Where patients of the practice have developed a dependence to illicitly obtained opioid analgesia or benzodiazepines, you are guided against commencing supportive prescribing without specific expertise or specialist guidance as current guidance does not support the use of such medications outside of structured treatment services or in the absence of psychosocial support 5) Where patients of the practice present with dependence to combination analgesics (e.g cocodamol, ibuprofen/codeine) consider providing substitute opioid analgesics within BNF limits and consider further medical investigations-contingent on clients accessing specialist drug services for further management 6) Where patients are involved in substance misuse services, please contact the services prior to commencement of other opioids, benzodiazepines/hypnotics, gabapentin or pregabalin. However, manage analgesic needs as appropriate to conditions where patients on substitute medications present with pain conditions 7) Do not provide continuation or replacement substitute medication when involved in out of hours/emergency work outside of the treatment system 8) Lead practitioners should consider systems to reduce the risk of replacement prescriptions being generated and signed for opioid analgesics, benzodiazepines and z-hypnotics, regular reviews and weekly-fortnightly prescriptions to reduce the risk of tolerance and dependence developing or continuing. 9) Be aware of current and any updated guidance in accordance with nice etc for prescribed opioid analgesic use and review and that of benzodiazepines and z-hypnotics 1
Support to Primary Care from Derbyshire Substance Misuse Service for prescribed / OTC drug dependence Derbyshire substance misuse services is commissioned to provide interventions to clients who either self present or are referred by other routes into service for all substances of abuse. In terms of prescribing interventions, these would normally be restricted to illicit opioid/opiate dependence with pharmaceutical costs being provided for the use of opiate substitute medications and symptomatic community detoxification support. For patients in general practices who have an identified dependence to prescribed medication which has been either prescribed from the practice or inherited from previous practices, these clients can access assessment and psychosocial support through regular structured keywork to support from the community drug team. Where guidance is required for supported reductions, the drug worker will liaise closely with the practice to advise on contact, progress and guidance on dose reductions with support from the addiction consultant who will be happy to provide advice and information to GPs. Opioid Analgesic Dependence With respect to opiate analgesic dependence, where doses are exceptionally high, there are significant risk associations and there have been attempts to withdraw such clients in the community without success; consideration would be given for management of opiate dependence through substitute medication. This would be agreed only following keyworker assessment and further discussion with the consultant and medical review appointment. If such clients are referred by GPs to the service, GPs will need to confirm with their patient: 1) That there is evidence of physical dependence 2) That their ongoing dependence on opiates is primarily one of dependence and not serving a physiological or psychological analgesic function for an ongoing physical health condition (in which case initial involvement should be through the community pain management services). 3) That the patient accepts the reasons for their referral to services and is motivated to address their analgesic physical dependence. 4) That the patient is aware that the purpose would be to reduce and stop their opioid dependence 5) That the patient is aware that there would be no guarantee of opioid prescribing from services 6) That patients would be made aware that if medication is provided it would be an opiate substitute medication which if commenced would include daily supervised consumption. Where patients have a longstanding dependence secondary to analgesic needs which have since resolved, provided the patient has a motivation to reduce and stop there analgesics, reduction can be reasonably straight forward provided patients are given some ownership of the rate of reduction and reductions are made gradually at a rate of roughly 10% of overall dose at an agreed schedule which should be no more frequent than fortnightly. Ordinarily this should be done on the preparation that they are dependant on but switching to a longer acting preparation may be considered at equivalency doses, as per BNF, if reduction on short half life preparations is proving problematic. Clear structure should be placed on prescription management and systems in place within the practice to ensure that all practice prescribers adhere to the principles. Prescriptions for opioid analgesics as part of a reduction schedule should not be given more frequently than weekly to fortnightly. Where possible, patients with analgesic difficulties or undergoing reduction schedules should be seen by the same practitioner. Under no circumstances should replacement prescriptions be provided for lost prescriptions or lost medications and this should be made explicit to patients prior to any commencement of opioid analgesics but particularly prior to reduction schedules. 2
Once a schedule is agreed, this should be followed, but opportunities should be given to the patient to identify risk times etc where reductions may be problematic and call time. It should be made clear from the outset, that once a reduction schedule is commenced, doses will not go up but patients should be given the opportunity to modify the amount doses are reduced, the frequency of reductions or temporary suspensions of a schedule with an agreed resumption date. All these strategies are preferable to attempts to reduce at rates that have not been negotiated as this increases the risk of illicit use, more problematic opiates(heroin) and the likelihood of additional use of combination analgesics (where there are higher risks associated with paracetamol toxicity or NSAID toxicity complications) or use of class A opiates, benzodiazepines or alcohol excess. In the case of over the counter combination analgesics the higher risks are associated with the non opioid component as these are likely to be consumed at toxic levels for sufficient opioid effect to be achieved ( normally between 8-12mg codeine per tablet). Where this is presents to general practice, screens for paracetamol or NSAID toxicity should be performed, if there is any evidence of this being symptomatic, strong considerations should be given to further medical and surgical management. There would be benefits in considering provision of codeine at BNF doses with the clear understanding that this would be until investigations of physical health stability and that further prescriptions would be contingent on engagement with physical health interventions, addressing the problem either through primary care or the specialist drug services. This may include provision of substitute prescribing if the drug problem is problematic or could be managed through the practice if not. Diversion should always be a consideration of any patient on opiate analgesics of any age group. Particular vigilance should be given to prescribing to vulnerable socially isolated older adults who may potentially be manipulated (or knowingly) divert there medication to those with dependence problems either for money or more often for help and assistance. Where this is suspected a vulnerable adults referral via social services should be considered. Benzodiazepine Dependence Where patients have benzodiazepine dependence, this should be managed with more care due to the physical risks associated with withdrawal which can be potentially fatal. Again, psychosocial support around withdrawal regimes can be offered through the community drug team with advice around prescribing reductions being provided through the keyworker and consultant addiction psychiatrist. Temporary management of benzodiazepines would be considered if:- 1) The patient is on doses of 40mg or more diazepam equivalency 2) There is clear demonstrable evidence of dependence 3) There is concurrent risks associated with other sedative taking (particularly alcohol with evidence 4) The patient is involved with prescribing elements of substance misuse treatment services. 5) There is an agreement with the patient that the purposes for engagement with any prescribing would be to reduce down there benzodiazepines to a negotiated level. 6) That they would be transferred to diazepam as part of the process if this is not their benzodiazepine of dependence 7) That there is an awareness on the part of the patient that any transfer of prescribing would involve a period of instalment prescribing which could include daily dispense collection of medications 8) That referral into services would not be a guarantee of provision of medication. From a prescribing perspective, as the services are primarily commissioned for the management of opiate dependence and substitute medications, as well as the fact that services are now 3
commissioned with the expectations of aiming to exit the majority of clients substance and prescribed medication free, there is not provision within the service to manage the longer term prescribing of benzodiazepines due to the length of time a reduction of these could potentially take and especially, as this can be managed within the competencies of general practitioners. Where prescribing interventions are agreed, this will be based on an agreement that at a negotiated level and stability, that it will be returned to general practice to implement ongoing reduction strategies which had been agreed and negotiate with the client prior to return of prescribing with primary care. This would normally occur when the patient has reduced down to BNF limits of prescribed diazepam but may be lower if there are significant risks including concurrent prescribing of opiate medications through substance misuse services. In certain circumstances, where clients are on maintenance opiate substitution prescribing, high substance misuse/mental health related overdose risks, and involvement with consultant community psychiatrist, consideration may be given to manage benzodiazepine prescribing through substance misuse services. This will be taken over on the understanding that should the client either successfully detox from substitute medication or fail to continue appropriate engagement, then this prescribing responsibility would return to primary care on exit from substance misuse services. Prescription Management Principles of script management within primary care should be the same as above for opioid analgesics, with any repeat prescriptions ideally being provided on a weekly basis with regular reviews by the same GP where practical and clear systems in place at the practice and agreement from the patient that under no circumstances will replacement prescriptions or additional doses provided for over consumption, loss of prescriptions or medication. When reduction strategies are agreed, benzodiazepine should be converted to the diazepam equivalency as per the BNF table. These should generally be reduced at a rate of 10% of overall dose between fortnightly to monthly. Benzodiazepines have a high risk of diversion and are increasingly popular amongst illicit drug takers. Due to the influx of illicit benzodiazepines from overseas, where quality is variable, diazepam that can be evidenced as being prescribed are bought illegally at a premium ( 1/10mg diazepam vs. 0.60/10mg tablet for foreign imports). Where urine testing for drugs is available in practice it would be advisable to gain agreement from patients for random testing if diversion is suspected. Diversion risks can also be reduced by prescribing preparations of lower strength tablets (5mg or 2 mg) and strict management of non replacements-gps should be vigilant that diversion is not restricted to younger patients with drug taking problems or histories. Where older adults who may be vulnerable are prescribed, particular vigilance should be placed on establishing social circumstances, particularly when older adults live alone or are socially isolated- social services may need to be considered from an adult protection perspective. Where practice patients disclose dependence to benzodiazepines and request legitimate prescribing or support around this, this should not be routinely undertaken without some experience, No prescriptions for this purpose should be presented or generated on first presentation. Where possible a corroborative history should be collected. Patients should be asked to provide a diary of their usage, evidence of physical dependence and high risk withdrawal states should ideally be present and testing be carried out. Where this is not done/available, patients should be advised on harm reduction and withdrawal risks and to present to Accident and emergency services if they are experiencing acute physical withdrawal and have no means of obtaining illicit medication to contain this. They should also be advised to attend for psychosocial support should they wish to access this, but again should be given no false expectations or hope that prescribing will be done through the drug services. 4
Out of Hours All GPs working out of hours are advised of the high risk of medication provision out of hours for any substance misuse related matters as a service we would not recommend any provision of replacement medication for substance misuse as there is inadequate methods to corroborate requirements and high risks of accidental overdose. Further more, a large amount of the boundaried aspects around treatment including the need for clients of the drug service to manage there medication queries or misses through the team are part of the structured approach to treatment. This aspect of treatment is severely undermined if clients of service find ways to obtain medications outside of the treatment process. Preventive Measures It should be remembered that problematic higher dose dependency is largely a chronic problem and develop over a period of time. Though iatrogenic legacy cases require appropriate management, there are many things that can be done to reduce the risk of future problems. Firstly, never begin prescribing medications of dependence without a clear indication, and minimum doses for an agreed time limited period and only where all other options have been considered. This should be made clear to the patient from the outset-if necessary through a signed agreement. Secondly, ensure there are clear systems in the practice to alert all doctors including locums and sessional GPs about not replacing prescriptions which have been either lost or where patients are reporting lost medications. Consider having an alert system if patients are regularly trying to do this with different prescribers or have a tendency to request replacements whilst their main GP is away. This may be an early sign of developing problems. Thirdly, ideally ensure all prescriptions for benzodiazepines or opiates where there is a suspicion of dependence are of 7 days duration, have a start date of the prescription in the body of the script and to a named pharmacy. Fourthly, have a plan within practice to manage patients who are likely to be disruptive or ensure that such clients are seen by doctors who have the most experience or confidence at managing such patients in a boundaried way. Finally, never feel obliged to save a patient who has got themselves into psychosocial adversity. Where a patient has developed problematic substance misuse to the point of dependence they are likely to have had this problem for sometime and are reasonably resourced to support themselves in maintaining their behaviours, the longer this pattern of behaviour is perpetuated, the longer it will take for them reach a stage of motivation to actively change. Though patients may not be appreciative initially, they generally respect the fact that there is a boundaried approach to such requests/demands of crisis provision of medications so are less likely to repeat the behaviours at future points of crisis. Opiate/ opioid withdrawal is not in itself fatal. Benzodiazepine withdrawal has more severe potentially fatal consequences if there are high levels of physical dependence so may better be managed through acute hospital observation and review. Risk: Benefits Though it is never ideal to keep patients on medication they no longer need, if there are patients of the practice who are on medications of dependence for many years, are otherwise well and stable, show no significant evidence problematic medication use or diversion, it is always helpful to consider what the benefits of any reduction schedules or plans for detox are. When taken appropriately and in the absence of other significant risk factors, doses even above BNF limits for those who have had such medications prescribed for decades remain safer than the physical and psychosocial destabilisation associated with an enforced reduction plan because there is no need for them to be on them. Always ensure there is a clinical rational to any proposed reduction schedule. Where medications are above BNF limits, it may be appropriate to plan a reduction to BNF levels. Patients are generally very 5
understanding of our limitations in terms of medico legal aspects and are generally prepared to accept this particularly if a good therapeutic rapport has been established. Always consider new and emerging drug trends. A number of patients in recent times have been moved from opiate analgesics to Pregabalin and gabapentin. This was seen as a safer way to manage pain than historic opiates from a dependence point of view. It is increasingly clear now (as had been predicted) that these drugs would become drugs of abuse. Where patients are otherwise stable on medications which have historically been seen as not advisable in longer term use, may, in relative terms be safer because the effects are known to both patients and clinicians and the methods of treating problems are established. Pregabalin in particular has been associated with increased risk of accidental overdose and has an established withdrawal reaction which potentially requires medicated supportive management-codeine, oxycodone/contin and other opioid analgesics do not. Contact details: North Derbyshire Dr D J Sirur Bayheath House Tel: 01246 293280 Fax: 01246 554679 South Derbyshire Dr S Sarkar Ripley Tel. 01773 744594, fax 01773 744607, Ilkeston Tel. 01159 309442, fax 01159 304156, Swadlincote Tel. 01283 817352, fax 01283 222438 Caroline Jones (specialist pharmacist) caroline.jones@derbyshcft.nhs.uk Mobile: 07920290233 References: Action on addiction (2013) The Management of Pain in People with a Past or Current History of Addiction; www.actiononaddiction.org.uk BNF - British National Formulary 6