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Prescription and Over-the-Counter (OTC) Drug Misuse. © 2009 University of Sydney. Learning Objectives. What is prescription drug misuse Substances Extent of problem Recognising the problem Managing the problem Understanding medication regulations. What is prescription drug misuse.

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Prescription and Over-the-Counter (OTC) Drug Misuse

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Prescription and Over-the-Counter (OTC) Drug Misuse

© 2009 University of Sydney


Learning Objectives

What is prescription drug misuse

Substances

Extent of problem

Recognising the problem

Managing the problem

Understanding medication regulations


What is prescription drug misuse

Variety of terms

- Prescription drug misuse: use of any drug in a manner other than how it is indicated or prescribed

- Aberrant drug related behaviours: behaviours that suggest the presence of substance abuse or addiction, implying that the behaviours are pathologic

Spectrum including excess ingestion, diversion, injection, dependence


The Medications

Sedating

Stimulant

Performance enhancing


Sedative

Opioids-illicit, prescribed and OTC

Benzodiazepines

Non-benzodiazepine hypnotics

Antipsychotics (in some environments)

Ketamine

Barbiturates (rarely)


Performance Enhancing include:

Diuretics

Anabolic Androgenic Steroids

Hormones EPO, hGH, Insulin, glucocorticoids

B Agonists/ B blockers

Steroid antagonists

Stimulants

Opioids


How do we identify/monitor this?

Anecdotal/case reports

Post marketing surveillance

WHO

National Drug Strategy Household Survey

Illicit Drug Reporting System

DAWN (US)

User sites


Stimulant misuse in the USA

Rates of non-prescribed stimulant use

-0.5% past month use in age 12-17(1)

-0.8% adults >26 years report last year use(1)

-4.1% college students report last year use(2)

Among college students

-whites, members of fraternities and sororities, individuals with lower grade point averages, use of immediate-release preparations, and individuals who report ADHD symptoms at highest risk for misusing and diverting stimulants(2)

(1) 2007National Survey on Drug Use and Health:National Findings athttp://oas.samhsa.gov

(2) McCabe SE. Knight JR. Teter CJ. Wechsler H. Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey Addiction. 2005; 100(1): 96-106.


Australian prescription Opioid Misuse

2.5% Australians report recent use of pain-killers for non-medical purposes

4.45 report lifetime use

15.4% had opportunity to use pain-killers for non-medical purposes

Jurisdictional variations

2007 Australian National Drug Strategy Household survey


Australian Tranquiliser/ Sleeping Pill Misuse

2007 3.3% ever used non-medically

2007 1.4% had used in the last year-an increase from previous surveys

2007 Australian National Drug Strategy Household survey


ED presentations in USA relative to community opioid prescribing

“Reprinted from Drug and Alcohol Dependence, 82(2), Dasgupta et al,

“Association between non-medical and prescriptive usage of opioids”,

135-142, 2006, with permission from Elsevier.


Australian opioid use 1992-2007

Leong, M., Murnion. B., Haber, P., 2009, Internal Medicine Journal; in press


Number of PBS opioid preparations

Murnion, B., 2009, unpublished data


Over The Counter

Regulation does not easily allow monitoring

Complex epidemiological methods

Jurisdictional variability in misuse

May vary with availability of illicits

Consider pseudoephedrine story

Is there a need for codeine containing OTC analgesics?


Performance Enhancing

2007- 223,898 tests undertaken by World Anti-Doping Agency

4,402 AAF (1.97%)

Anabolic agents2,322

Stimulants 793

Cannabanoids576

B2Agonists399

Diuretics and other masking agents359

Glucocorticoids288

Hormones and related substances41

B Blockers27

Narcotics21

Anti-oestrogens18

Enhancement of oxygen transfer3

May include TUE’s

World Anti-Doping Agency, 2007 Adverse Analytical Findings


Recognising prescription and OTC misuse

Longitudinal observation

Corroborative history from other health care providers

Frequent presentations with lost or stolen scripts

Consider identified risk factors

Morbidity (e.g. Gastric erosions, CV events )

Routine screening (e.g. elite athletes)


Strategies to prevent PDA

Patient

Drug

Prescriber

Governmental policy and legislation

Modification of the medication


1. Patient factors

Prior or current substance abuse disorder places in high risk category

Environment (e.g. Prescribing dexamphetamine to child whose parent/carers have a substance use disorder)

Psychosocial setting may justify close monitoring


Risk of opioid misuse in chronic pain patients (CPPs)

Adverse drug related behaviour (ADRB) in 11.5%

Overt abuse/addiction in 3.27%

If no prior/current history of abuse, abuse/addiction in 0.19%

Urine toxicology showed 20% had non-prescribed or nil drug in urine and 14% had illicit drugs in urine

Amongst 2000+ CPPs exposed to prescribed opiates:

Structured Literature Review: Fishbain et al, 2008, Pain Med, 9


2. Drugs

Drugs with abuse potential

- opioids

- hypnotics

- psychostimulants

- anticholinergics

- performance enhancing


3. Prescriber

High index of suspicion when unknown patients present requesting repeat scripts for high risk drugs

Screening tools

May feel isolated/threatened

Drs known to easily prescribe these medications attract this clientele

Should report aberrant prescribing

Always ask about OTC and CAT use

Identify colleagues and report appropriately


Managing PDA

Diagnosis

Consider need for ongoing pharmacotherapy

Consider cessation (gradual dose reduction)

Harm minimisation strategy

Patient contracts/UDS

Doctor Shopping Agreements

Frequent pharmacy dispensing

Supervised dosing

Consider need for other treatments for underlying disorder (eg anxiety/pain)

Consult senior colleague or specialist


4. Governmental and legislative interventions

“Rogue” prescribers may be deregistered or have prescribing limits

Urgent NSW Medical Board inquiries to take action to protect the public rose from 22 in 2005/06 to 35 in 2006/2007

Due in large part to increased referrals about prescribing practices from PSB

Twelve doctors suspended, 19 had conditions imposed on registration, and two doctors removed from the Register.


New NSW medical board requirements (1/10/2008)

Mandatory reporting to medical board if practises medicine whilst intoxicated by drugs (whether lawfully or unlawfully administered) or alcohol

Medical Board recommends

-be vigilant in identifying doctors or other colleagues whose health, conduct, behaviour or performance may be a threat to the public;

-do your best to find out the facts, then if necessary, notify an appropriate person such as the hospital chief executive or the Medical Board. Your comments about colleagues must be honest. If you are not sure what to do, ask an experienced colleague or contact the Medical Board or your defence organisation for advice. The safety of patients must come first at all times; and

-report adverse events which reflect on the professional performance or conduct of colleagues to a hospital Chief Executive or Medical Board.

NSW Medical Board, 2009


Impaired Colleagues

If unable to deal with the matter yourself, consult appropriate senior colleague.

If you feel able to talk to the colleague yourself, do not take on a treating role, but

arrange to meet with them privately,

let them know that you are concerned and why,

ask them to consult with an appropriate practitioner, and provide them with contact information

NSW Medical Board, 2009


Impaired Colleagues

Follow up to make sure that they have taken your advice. Be aware that your colleague may tell you what they think you want to hear, having taken no positive steps.

Consider the impact of their problem upon their work. If you believe that patient safety may be at risk, you should advise the doctor accordingly and seek the adviceof the Medical Board

NSW Medical Board, 2009


Section 28 of the Poisons and Therapeutic Goods Act 1966

The authority of the Department of Health is required:

to prescribe for or supply to a drug dependent person any drug of addiction (Schedule 8), or

to prescribe for or supply to any person any preparation of dexamphetamine or methylphenidate, or

to prescribe for or supply to any person other than a drug dependent person, for therapeutic use by that person continuously for more than two months, any of the following drugs of addiction – buprenorphine (excluding transdermal patches), flunitrazepam, hydromorphone, methadone or any injectable drug of addiction.


Governmental and legislative requirements

Vary between countries and states

Concern internationally that rigid legislative requirements limit access to essential medications

Separate from authority through PBS (federal)

Prescription of methadone liquid or buprenorphine as Subutex/suboxone through OTP requires a separate authority


5. Modification of medications

Limit scheduling of combination OTC products

Limit to pack sizes and dose of opioid in OTC product

Limit DTC advertising

Reschedule substance (e.g. Ketamine)

Remove from market e.g. pseudoephedrine

Introduction of “abuse deterrant” formulations/combinations eg suboxone®


Case Study 1

JS

22yr old man

Presents with agitaion, lacrimation, rhinorrhea, yawning, abdominal pain and diarrhoea

PMHx

Crohns Disease Rxed with Azothioprine and prednisolone

Acknowledges 70+ Neurofen Plus daily


What are you going to do?


What are you going to do?

Diagnosis


What are you going to do?

Diagnosis

opioid dependence

question diagnosis of CD


What are you going to do?

Diagnosis

opioid dependence

question diagnosis of CD

Investigations


What are you going to do?

Diagnosis

opioid dependence

question diagnosis of CD

Investigations

Treatment options

withdrawal management

maintenance therapy


Case Study 2

Ms TD

52 yr old woman

Presents frequently to ED with migraine

Seen neurologist-prophylactics/tryptans ineffective

ADRs to morphine and oxycodone

Requests parenteral pethidine and has letter form neurologist supporting this


What are you going to do?


What are you going to do?

Diagnosis


What are you going to do?

Diagnosis

consider rebound headaches


What are you going to do?

Diagnosis

consider rebound headaches

Corroborative history


What are you going to do?

Diagnosis

consider rebound headaches

Corroborative history

Very limited availability of pethidine in public hospitals in NSW

Refer to appropriate local speciality

Non-opioid management

Patient education

Stabilise opioid use and wean


Author

Dr Bridin Murnion

Staff Specialist

Drug Health Services, RPAH

All images used with permission, where applicable


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