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PRESCRIPTION DRUG PROBLEMS IN TASMANIA, AUSTRALIA APSAD Conference 14 November 2011 Clinical Director, Alcohol & Drug Services, Tasmania Dr Adrian Reynolds.

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Presentation on theme: "PRESCRIPTION DRUG PROBLEMS IN TASMANIA, AUSTRALIA APSAD Conference 14 November 2011 Clinical Director, Alcohol & Drug Services, Tasmania Dr Adrian Reynolds."— Presentation transcript:

1 PRESCRIPTION DRUG PROBLEMS IN TASMANIA, AUSTRALIA APSAD Conference 14 November 2011 Clinical Director, Alcohol & Drug Services, Tasmania Dr Adrian Reynolds

2 Too Much or Too Little?  Although the optimal use of opioids in the management of CNMP is still debated it is clear that opioids are sometimes used excessively & at other times too sparingly

3 T.O.R. for the Tasmanian Opioid Review  DHHS Tasmania commissioned our NDARC to conduct a staged review to develop prioritised recommendations & an implementation plan in relation to ‘evidence-informed’ prescribing of opioid medication for:  Pain management, generally  Pain management, specifically in the context of drug addiction or risk of addiction  Safe prescribing of Schedule 8 opioids and other drugs of dependence, in a manner that takes into account patient & community safety & the requirements of best practice chronic pain medicine & addiction medicine

4 Increasing Opioid Prescribing  While opioid analgesics have a well-established place in the treatment of acute pain & cancer- related pain, their role in the management of persistent non-cancer pain is less clear  With several reviews finding limited evidence for their effectiveness in the long term  Evidence of range of risks & harms Falls, accidents, OIH, chemical coping while under-utilising or rejecting non- drug interventions, endocrine & immune system problems…  Furlan, et al., 2006; Kalso, et al., 2004; Manchikanti, et al., 2011; Noble, et al., 2010; Trescot, et al., 2008; Ballantyne, 2003

5  Until recent times, it was common to hear pain medicine specialists & others say that aberrant behaviour& addiction are rare events in patients treated appropriately with opioids for moderate to severe pain  In my experience, this was significantly influenced by the lack of training of doctors in knowing what to look for & often, less than careful clinical history taking & examination

6 Faculty of Pain Medicine…  “Chronic pain is usually incompletely assessed & managed & this incomplete assessment can result in numerous failed treatments”  Faculty of Pain Medicine, 2010

7 Misuse of Prescribed OpioidsMisuse of Prescribed Opioids  Precise extent of problem unknown in Australia  US study suggested ~3% of chronic pain patients using opioid analgesics for extended periods develop opioid abuse or dependence problem  ~12% exhibited aberrant drug-related behaviours Fishbain, Cole, Lewis, Rosomoff, &Rosomoff, 2008  So this study suggests ~1 in 8 patients engaging in risky drug use, which is significant from a clinical & public health perspective

8 Misuse of Prescribed OpioidsMisuse of Prescribed Opioids  However, drug problems arising from opioid prescription for pain management may be even more common than this

9 Misuse of Prescribed OpioidsMisuse of Prescribed Opioids  Prospective cohort study found 32% of opioid- treated patients with chronic pain misused their opioids, when misuse was defined as:  Negative urine screen for prescribed opioids  Positive urine screen for opioids or controlled substances not prescribed  Evidence of procurement of opioids from multiple providers  Diversion of opioids, prescription forgery, or  Stimulants found in urine screens Ives, Chelminski, Hammett-Stabler, Malone, Perhac, Potisek, Shilliday, DeWalt, &Pignone, 2006

10 Diversion for Illicit Use  Then we have Tasmanian review data & analysis…  Estimates, although uncertain, suggest IDUs in Tasmania may be consuming an increasing large proportion of total amount of morphine prescribed per annum  Perhaps as much as 30% in 2010

11 Diversion to Illicit Market  IDUs in Tasmania are also estimated to consume around 10% of prescribed physeptone  Across all jurisdictions, IDUs are estimated to consume less than 5% of prescribed oxycodone  The proportion of oxycodoneconsumption in Tasmania is estimated at 8% of total consumption

12 Multimodal Treatment  Pain specialists have for some time now advocated a multimodal approach to managing chronic pain where physical & psychological therapies are emphasised &opioid analgesics are considered as a second or third line treatment

13 High Doses = High Risk of Death  Growing awareness of need for agreed “ceiling dose” which alerts prescribers to need for a review of patient management  Higher doses found to result in 3-4X  overdose risk  Patients with PNMP prescribed ≥100mg/ day morphine had 7x  likelihood of fatal OD c.f. ≤20mg  Bohnert, et al., 2011  Tasmania has many patients on doses 4-8x higher & on multiple drugs that pose sig. risk

14 Dangerous Drug Combinations  Further concern is patients who are prescribed multiple medications:  opioid analgesics, sedatives, anti-psychotics, & anti- depressants  Combination of CNS depressants particularly dangerous (including alcohol)

15 Rapid Increase in Prescribing  Rapid & largely unexplained sudden upturn in opioid prescribing for PNCP in Tasmania in after gradual increases in preceding years  Paralleled by increase in authority applications  Doctors must seek an authority to prescribe S8 medications beyond 2 months continuously

16 S8 Authorities per Annum in Tasmania:

17 Total number of morphine, oxycodone and buprenorphine prescriptions per annum in Tasmania, DAPIS, Opioid Prescribing is Escalating

18 Illicit Use of Morphine IDRS Sample 6 month use of morphine by IDRS participants (%) Tasmania &National

19 Illicit Use of Oxycodone (IDRS) 6 month use of oxycodone by IDRS participants (%) Tasmania & National

20 Diversion of Methadone Tablets 6 month use of physeptone by IDRS participants (%), Tasmania and National

21 Source of Prescription Opioids used for Pain by IDRS Participants in Tasmania & Nationally (2010)

22 Non-Fatal Overdose Percentage reporting a non-fatal overdose by drug type in the past 12 months (2010)

23 OpioidRelated Deaths  Tasmania has the highest or second highest rate of accidental deaths due to opioids per million among those aged years in Australia  53.7 deaths per million persons in 2005 NDARC, 2007

24 Number of Opioid&Opioid Plus BZD-related Deaths in Tasmania per Annum

25 Oxycodone Deaths in AUS Rates of death associated with oxycodone in years

26 Clinical Outcomes  Opioid prescribing for CNMP in isolation from a broader Rx plan is often associated with apparently poor clinical outcomes

27 Medicalisation of Human Problems  Caution: the (over)medicalisation of human problems & ‘acopia’ is a serious issue  Seeing this with increased & inappropriate prescribing of a range of other drugs like the BZDs, anti- depressants, mood stabilsiers& anti-psychotics Selling many patients short on their life opportunities?  Often defended as ‘harm reduction’ but it may not be

28 The Strong Desire to Cure…  A strong desire to cure/relieve pain on the part of the doctor  But not alone in this highly aspirational if not sometimes unrealistic & potentially counterproductive way of thinking…

29 Doctors Under Pressure to Prescribe  Doctors, patient advocates, health complaints offices & lawyers are now unwittingly & counterproductively becoming intricately caught up in the web of chemical coping & black or grey market forces  Acting on behalf of the patient who may be demanding or at least placing great pressure on the doctor to prescribe unsafely or inappropriately  Defending decisions designed to safeguard patient & community is placing an increasing drain on time & resources which the healthcare sector does not have available to use unwisely  Also doing great harm to involved health professionals, which is hardly a moral good: do we demand justice for all or just for some?

30 Doctors Under Pressure to Prescribe  Doctors are largely unprepared in their undergraduate & post graduate medical training to manage these pressures  Don’t always know how or don’t necessarily have the confidence to appropriately manage these pressures to prescribe & to offer alternative treatments (or in some, just explanation & practical advice) that may be more appropriate

31 Changing Clinical Practice  Need to equip doctors to provide appropriate Rx  Such change in practice will require:  Educating prescribers in clinical reasoning  Removing barriers to the use of some non-drug therapies (such as financial cost)  Accessibility to alternative methods& treatments to deal with pain  Addressing perverse disincentives to do the right thing

32 Structural Reforms to Improve Care  Tasmania will look to further enhance our regulatory-clinical interface to provide education & structural incentives to prescribers through the authority application process  e.g. by ensuring that the application process forms part of the doctor’s assessment of the patient’s suitability for an opioid prescription & their treatment plan

33 Building Clinical Relationships  We will work to further develop the working relationship between Pain & Addiction Medicine in teaching, in collaborative service delivery & in consultation liaison support of the hospital & primary care sectors

34 Clarity Regarding Role of Opioids  We will adopt a systems approach to ensure patients clearly understand that:  Opioid pharmacotherapy for PNMP may be one component of a multi-modal Rx plan & when prescribed, is an ongoing trial;  That there is an implied contract in continued treatment with opioids that agreed goals of therapy will be maintained; &…  That there will be an ongoing review of benefit, risk & harm  Important to recognise that in the absence of adherence, there is no therapeutic alliance

35 Universal Precautions a Key Element  Teaching & supporting the Universal Precautions approach which includes the 5A’s + 2A’s  Analgesia  Activity  Adverse events  Aberrant behaviours  Affect  Adherence  Accurate medical records

36 Opioid Review – Blueprint for the Future  Our Tasmanian Opioid Review – Blueprint for the Future will soon be finalised& handed to our Minister, who has been very supportive in our endeavours to research, better understand & respond to the challenges  We look forward to sharing the report & findings & recommendations with our colleagues across the nation & beyond

37 Authors  Dr Adrian Reynolds, Clinical Director, Alcohol and Drug Services, Department of Health and Human Services, Tasmania, Australia  Prof Richard Mattick, National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia  Ms Mary Sharpe, Chief Pharmacist, Pharmaceutical Services Branch, Department of Health and Human Services, Tasmania, Australia  Dr Fiona Shand, National Drug and Alcohol Research Centre, UNSW, Sydney, New South Wales, Australia  Plus long list of other people with specialist knowledge & skills!  No conflict-of-interest regarding this study which was funded by the government of Tasmania

38 Thank you

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