Opiate Abusers What can the GP do? Office Based management of Opiate Addiction Dr Nigel Hawkins 1
Managing opiate abuse in General Practice The extent of Opiate Abuse in Australia What treatment options are available? What is Opiate Maintenance Therapy? The pros and cons of the new vs older drugs Why should GPs prescribe it How you can incorporate OMT into your General Practice How can OMT be applied to doctor shoppers 2
Patients who do not take opiates as prescribed by a doctor are said to be abusing them Patients who are unable to stop using opiates even when it is in their best interests to do so are said to be dependent Patients who are physically addicted experience tolerance and withdrawal symptoms 3
Opiate Addiction Opiates are pain killers. They may be long or short acting They can be smoked, injected, taken orally, transdermally or snorted. They may be illicit or prescribed by doctors People who like them usually have some sort of pain in their life 4
Why Treat Opiate Addiction? Study Crude mortality rates 2% per year (all causes) Standardized mortality rate - 15 times higher than healthy norms Treatment reduces mortality by 2.4 times (all modalities combined) 5
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Doctor Shoppers Illicit Opiates oral/iv/smoked crime risk of dying high risk of HIV/HCV & other medical probs homeless unemployed mental health issues crisis and traumas DOCS issues dental / hygiene issues legal issues / jail multiple drug abuse common Prescribed Opiates May be selling it on street May be for own personal use eg Chronic Pain Patients May be illicit IVDU unable to get treated or looking for a cheap heroin alternative 8
Factors Contributing to Addiction Mental Illness Family Friends Occupation Housing Traumas General Health Upbringing Self Esteem Genetics Addiction Crime 9
Understanding the patient Functioning in Society Mental Health Physical Health Addiction 10
Food for thought There are 300 heroin addicts for every 100 GPs in Sydney Prescription opiate abuse is increasing and there are now more deaths from prescription opiates than heroin Less than 3% of GPs prescribe OMT There are not enough OMT prescribers to treat heroin addicts, let alone doctor shoppers 11
Australian Statistics Accidental Opioid related Deaths in Australia http://www.drugpolicy.org/library/freer2.cfm http://www.abs.gov.au/ausstats/abs@.nsf/mf/3321.0.55.001 12
Opiate related deaths in Australia 800 700 40000 Patient are treated on Opioid Maintenance in Australia each year 600 500 400 300 Heroin / Opium Methadone Other Opiates 200 100 Go to USA Stats 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 Australian Bureau of Statistics http://www.drugfree.org.au/fileadmin/media/reference/dfa_drugrelatedstats.pdf 13
Australian Statistics: Victoria Go to USA Stats http://injuryprevention.bmj.com/content/early/2011/01/07/ip.2010.029611.full 14
Prevention is better than cure This seminar is not about patients who are taking opiates as prescribed for appropriate reasons. GPs need to be very judicious in the way they prescribe opiates. There should be a single prescriber (or practice) who monitors what the patient is taking. Doctor shopping could be reduced if all opiates and benzodiazepines were made authority only medications. 15
Treatments for Opiate Addiction Naltrexone tablets & implants Needle Exchange & Injecting Rooms Inpatient / Outpatient Detoxification - Abstinence Programs Opiate Maintenance Therapy Opiate Maintenance Therapy is the only treatment that works and is practical and safe for GPs to administer in an office setting 16
Who can prescribe OMT? Psychiatrist D&A Specialist GP 18
Why should GPs prescribe OMT? Access to OMT in most parts of Australia is poor The new OMT drugs are safer and more practical for GPs to prescribe in an office setting OMT enables GPs to have a satisfying therapeutic relationship with addicts and opens the door to address other issues in their lives Supervised OMT could also be used for prescription opiate abuse More doctors treating fewer patients is better 19
What is Opioid Maintenance Therapy? Harm minimization philosophy It is replacing short acting, illegal, unsafe and unregulated opiates for long acting prescribed, supervised and controlled opiates as part of a holistic care approach that take the patient FORWARDS Acronyms OMT/ ORT / OST / OTP 20
Opioid Maintenance Therapy Buprenorphine Sublingual tablet Methadone Syrup Buprenorphine/Naloxone Sublingual tablet Buprenorphine/Naloxone Film 21
Supervised administration until stable and reliable First at a Clinic Then at a Pharmacy Then at Home 22
Dose Equiv Drugs are like keys Diagram Heroin Methadone Codeine Oxycodone Hydrocodone Some get in the lock and open it all the way but can be easily displaced Buprenorphine Some bind tightly to the lock and open it most of the way Naloxone** Naltrexone Some bind tightly to the lock but don t open it at all ** Naloxone is not active orally or sublingually 23
Maintenance OR Detoxification Study Heroin Opioid Maintenance Therapy Methadone Buprenorphine Buprenorphine/Naloxone Slow Weaning OR Rapid Detoxification Methadone Buprenorphine Buprenorphine/Naloxone Nothing Abstinence Naltrexone Coupled to Rehabilitation / Support and Holistic Care 24
Stages of Maintenance Treatment REDUCE RISK: Prevent Death, Stop Injecting, Stop doing crime, Stop using street drugs, Stop spreading HIV/HCV, start to get life in order, find accommodation, stabilize mental and physical health 80% IMPROVE QUALITY OF LIFE / FUNCTIONING: Stable Housing, Stable Job, Stable Friends, Stable Family, Stable Health, Resolve DOCS and Legal issues WEAN: Gradually reduce dependence on opiates 5-10% 25
Buprenorphine Maintenance Pros Cons Regimes Ideal for use in an office / pharmacy setting - especially the film Selected patients may be able to start in a pharmacy 26
Methadone Maintenance Pros Cons How to Start QTc Reserve for the more severe patients consider ECG initiate in a clinic 27
Moving Forwards Methadone or buprenorphine at a clinic Move to pharmacy when stable and well behaved Introduce more convenient dosing eg Take away doses 28
Using a holistic approach OMT Dental Social supports Bad influences Relationships Hepatitis / HIV Vaccination Needle Sharing Other medical problems Addiction Physical Health Social Mental Health Legal problems Current Crime Docs Housing / Licence Occupation Anxiety & Depression Borderline PD & PTSD Bipolar disorder Schizophrenia Childhood Abuse 29
Reviewing the Patient Assess compliance and stability Monitor Progress Try to move forwards Adjust dose and Take Aways 30
Prescribing Take Away Doses No TA doses TA doses 31
Examine the patient Identification & Authorisation Informed Consent Treatment Agreements Drug Screens Investigations Inform DOCS if children are at risk but keep looking after the patient Care plans Locum Arrangements 32
Beware multiple drug abuse Severe alcohol abuse refer to clinic specialist Concurrent Benzodiazepine abuse refer to specialist do not prescribe benzos to addicts Cannabis / Nicotine address once opiate abuse is under control Amphetamines address when opiate abuse is under control Cocaine refer to clinic specialist Always do a drug screen before starting treatment 33
Difficult Patients Transfer or Refer back to the clinic if problems Get advice from a specialist if unsure Cancel take aways if diverting Cancel take aways if unstable or using other addictive drugs Drug Screens Notify DOCS if there is a child at risk Get them to sign the voluntary doctor shopper privacy release form for the PBS Consider calling the police and banning from practice if abusive, persistent or will not leave 34
GPs Learning to Prescribe OMT 35
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OMT for Doctor Shoppers Patients must have : 1. Insight and indicate a willingness to stop doctor shopping 2. A doctor who is willing to prescribe them OMT 3. A Clinic or Pharmacy who will dispense it Significant Prescribed Oral or IV Opiate Abuse Buprenorphine Buprenorphine /Naloxone Very low dose Buprenorphine Nothing 37
What will need to happen before OMT can be used for doctor shoppers Doctors need to be able to check to see how many opiates and benzodiazepines are being prescribed and when they were last dispensed and / or Patients should be able to be restricted to obtaining addictive medications from one specialist and one GP who hold an authority If a patient is identified by Medicare as a doctor shopper then The principal doctor should consider buprenorphine or methadone OMT The other doctors should be informed by the Medicare The patient should be informed by the Medicare that they must stick to one prescriber There will need to be arrangements to commence in a clinic when It is necessary to ensure the patient is not diverting It is necessary to establish boundaries where there is difficult behaviour Methadone is required for very severe abuse 38
Summary Opiate abuse is a big problem in Australia Supervised OMT reduces the morbidity and mortality associated with illicit opiate abuse There are not enough OMT prescribers in Australia OMT is satisfying and rewarding to prescribe OMT can safely be prescribed by trained GPs OMT gives GPs an opportunity to address other issues in addicts lives OMT could help GPs manage doctor shoppers 39
Acknowledgements Reckitt- Benckiser for sponsoring this seminar Dr Gilbert Whitton MBBS FAChAM Senior Staff Specialist, Drug Health South Western Sydney Local Health Network Dr Mark Hardy MBBS FAChAM FRACGP Fellow in Addiction Medicine Northern Sydney LHN Dr Andrew Byrne MBBS FAChAM Redfern Clinic Dr Nicolas Lintzeris MBBS FAChAM PhD Phillip Bannon Director of the Langton Centre SESLHN Senior Advisor - Pharmaceutical Services Unit Clinical Safety Quality and Governance Branch My patients & colleagues at Ingleburn and Rouse Hill Medical Centres 40
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Back Similar trends in the USA http://www.cdc.gov/homeandrecreationalsafety/pdf/poison-issue-brief.pdf There are 250,000 patients on methadone OTP and 720,000 patients who receive methadone for chronic pain in the USA. Reference 42
Back hydrocodone oxycodone Non illicit Opiate related deaths in the state of Washington, USA 13.9 22.9 More studies are required to determine the relative importance of cardiac arrhythmias which are potentially preventable by QTc screening Methadone 64 0 50 100 % Deaths from prescribed opiates in the USA 3/4 of Methadone prescribed in the USA is for pain and dosing is not supervised as with OMT http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5842a1.htm 43
Back 35 Welfare vs Non-Welfare in Washington USA Deaths per 100,000 from non illicit opiate abuse 30 25 20 15 Deaths per 100,000 10 5 0 Welfare Non-Welfare Approximately 20% of the 25,000,000 residents are on Welfare (Medicaid) The relative risk is 5.7 44
How to Prescribe methadone safely in 2011 Methadone can prolong the QTc in some patients with genetic mutations of K+ channels*** Prolongation of the QTc occurs mostly with doses of methadone >120mg ### in as many as 23% of patients in some series!!! 2% of patients in some series had a QTc>500 ~~~ Back The average prolongation by methadone was 10msec in one series +++ The R isomer of methadone causes less QT prolongation *** There no consensus about QTc Screening on methadone Px Consider doing ECGs for patients starting methadone for the first time particularly when they reach their maintenance dose and it is over 100mg Stats Methadone should be ceased if the QTc >500 ~~~ Inform Patients if their QTc is 450-500 and monitor and consider changing treatment QTc normal ranges Avoid using multiple long term drugs that prolong the QTc or lower K + ### Addiction 2007;102(2):289-300 +++ Am J Cardiology 2005;95:915-918!!! Archives Internal Medicine 2007; 167 (22) 2469-2475 ~~~ QTc interval screening in methadone Treatment *** Archive of Internal Medicine 2010; 170(6):529-536 www.qtdrugs.org Polymorphic VT Torsades de Pointes
Prevalence of QTc Prolongation in patients on methadone and buprenorphine Methadone Dose dependent QTc prolongation 4.6% QTc>500ms (all on doses>120mg) 15% QTc> 470ms 28% QTc>450ms Mortality attributed to prolonged QTc 0.06 per 100 patient years Buprenorphine All patients had QTc <450ms http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2009.02549.x/full 46
Back Methadone Initiation Start LOW (20-40mg) Go SLOW - Increase the dose slowly by 5-10mg every 3-4 days until the patient is comfortable. Start in a clinic with experienced staff Deaths in the first week of methadone treatment are associated with high starting doses >50mg and multiple drug use.*** Transfer to a pharmacy when stable for several months if well behaved and not diverting. *** Addiction. 2000 Jan;95(1):77-84. Zador and Sunjic Deaths in methadone maintenance treatment in New South Wales, Australia 1990-1995. 47
Back Buprenorphine Regimes Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 A Methadone Transfer B Heroin Transfer C Detox 4 + 4 + 4 16** 16** 16 16 16 16 8 16** 24** 24 24 24 24 4 + 4 8 8 6 4 2 0 Beware precipitating withdrawal (especially for methadone transfers) Ensure the patient has not used in the last 12-24hrs ** Regimes can be tailored to suit the patient Ref - Nicholas Lintzeris
Back Dose Equivalents 49
Back Partial Agonists 50
Back Maintenance treatment with 8mg buprenorphine VS naltrexone tablets VS placebo RCT Malaysia 126 heroin addicts randomised to BPN (8mg) + counselling NTX (50mg) + counselling Placebo + counselling BPN associated with greater treatment retention & less heroin use The Lancet, Volume 371, Issue 9631, Pages 2192-2200 R. Schottenfeld et al 51
Back Naltrexone implants Patients require a lot of support and must be detoxified first
Back The French Experience No restrictions to prescribing buprenorphine 10-14 times more patients on buprenorphine *** Mortality 6-10 times less on buprenorphine *** 20% of doctors prescribe for 150000 addicts ^^^ 79% reduction in overdose deaths since 1995 when buprenorphine introduced ^^^ Daily supervised doses in pharmacy for 6 months results in better retention and less heroin use ^^^ Less opiate withdrawal in neonates whose mothers were treated with buprenorphine ^^^ *** ^^^ http://jama.ama-assn.org/content/285/1/45.full http://onlinelibrary.wiley.com/doi/10.1080/10550490490440780/full 53
Table. Deaths Attributable to Methadone vs Buprenorphine in France, 1994-1998. Auriacombe, M. et al. JAMA 2001;285:45-45
RCT 16mg BPN Maintenance vs Detox Back Maintenace 40 subjects randomised to 1 week detox / 1 yr maintenance all provided counselling for 1 year Heroin use Detox = all relapsed Maintenance=75% Opiate (-)ve UDS Mortality (p=0.015) Detox 4/20 (20%) Maintenance 0/20 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial Kakko et al The Lancet, Volume 361, Issue 9358, Pages 662-668, 22 February 2003 55
Mortality rates in Opiate Addicts Fifty-eight prospective studies reported mortality rates from opioid-dependent samples. Pooled all-cause CMR was 2.09 per 100 person-years (PY; 95% CI; 1.93, 2.26) Pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out-of-treatment periods had higher mortality risk than in-treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). (all treatment modalities combined) http://www.ncbi.nlm.nih.gov/pubmed/21054613 Back 56