Presentation is loading. Please wait.

Presentation is loading. Please wait.

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

Similar presentations


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


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

Similar presentations


Ads by Google