Dr Gilbert Whitton FAChAM

Clinical Director Drug & Alcohol

Loddon Mallee Murray Medicare Local

Deniliquin

14th May 2014

Prescription Drug Addiction

Prescription Drug Addiction Overview

History

Benzodiazepines

– Data

Assessment

Withdrawal

Other prescription drugs - Opiates

Management

– Benzodiazepines

– Opiates

History pharmaceutical drug use in Australia

‘Over the counter’ heroin common until 1910’s

Amphetamines commonly prescribed until 1960’s

Barbiturates

Benzodiazepines:1960’s

– “safe”, “non-addictive”, “mother’s little helper”

– Increasing use over past 40 years

– > 3 million scripts in Australia / year

– Concerns re: abuse & ‘addiction’ emerged 1980’s

SSRIs: 1990’s onwards

Atypical antipsychotics: 2000’s onwards

Opioids: 2000’s onwards

National Pharmaceutical Drug

Misuse Strategy

Benzodiazepine use In general population:

– 6-10% of US adults used a hypnotic for sleep in 2010 - of those

using BZD, ~25–76% use long term (>3/12)

– Prevalence long-term BZD use in Australia: 2 – 7%

– Estimates ‘high dose’ BZD dependence: 0.1 - 0.2%

In medical practice

– 2 of top 20 drugs prescribed in Australia; 4% all scripts; 7% all

patients; 84% GP patients using benzodiazepines still on them 6

months later.

In substance users (eg. heroin users, opioid treatment program)

– ~ 2/3rds report any BZD use past month; 1/3rd report regular use

– 10-20% report regular high dose BZD use

4

Trends in

benzodiazepine

dispensing in Australia (a) DDD= (WHO) defined daily dose

(b)

number of prescriptions

(blue) PBS/RPBS;

(brown) private;

(green ) under co-payment.

Internal Medicine Journal Volume 44, Issue 1, pages 57-64, 23 JAN 2014 DOI: 10.1111/imj.12315 http://onlinelibrary.wiley.com/doi/10.1111/imj.12315/full#imj12315-fig-0001

Internal Medicine Journal Volume 44, Issue 1, pages 57-64, 23 JAN 2014 DOI: 10.1111/imj.12315 http://onlinelibrary.wiley.com/doi/10.1111/imj.12315/full#imj12315-fig-0001

Trends in

benzodiazepine

dispensing in

Australia

Benzodiazepine use

Is it a problem?

7

BZD Use amongst Australian IDUs (IDRS-Illicit Drug Reporting

System): % of cohort using in past 6 months

24% 24% 23% 25%30%

18%

19% 19% 23% 18% 12%26%

21% 18%21% 22% 24% 20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2002 2003 2004 2005 2006 2007

Extra-medical Only

Both

Prescribed only

Median

Frequency

24 24 30 30 48 48

Illicit Drug Reporting System: Australia

Year % recent use alprazolam Most common

injected

2003 3 diazepam

2004 4 diazepam

2005 5 diazepam

2006 6 diazepam

2007 11 alprazolam

2008 14 alprazolam

2009 17 alprazolam

2010 21 alprazolam

2011 46 alprazolam

ASSESSMENT

??

ASSESSMENT

History

A hierarchy of drugs to

enquire about

Cigarette smoking?

Alcohol?

– Cannabis?

– Amphetamine – type stimulants?

– Heroin & other illicit/iv drugs?

– OTC medications (eg. codeine) & prescribed

drugs (eg. benzodiazepines)?

ASSESSMENT

History

Examination

Not only arms

Not only arms

ASSESSMENT

History

Examination

Investigations

A substance use diagnosis?

Low risk use

Hazardous use

Harmful use

Dependence

Assessment: summary

Screening for every patient seen – incorporated into your own patient assessment protocol

More detailed history as indicated

– Cigarette smoking?

– Alcohol?

– Cannabis?

– Amphetamine – type stimulants?

– Heroin & other illicit/iv drugs?

– OTC medications (eg. codeine) & prescribed drugs (eg. benzodiazepines)?

Physical examination & investigations

Reach a diagnosis for each substance used

Assessment as therapy

MANAGING WITHDRAWAL

Withdrawal states (NSW Health, Drug & Alcohol Withdrawal Clinical Practice Guidelines, 2007)

Drug Onset Duration Features

Nicotine Within several hours of the

last cigarette

Peaks 24-72 hours &

lasts 2-4 weeks

Craving, irritability, restlessness, mood

swings, increased appetite, insomnia,

difficulty concentrating

Alcohol Hours after last drink 3 – 7 days Agitation, anxiety, sweating, tremor,

tachycardia, fever, disorientation,

hallucinations, seizures

Cannabis Within 24 hours 1 – 2 weeks Insomnia, shakiness, irritability, restlessness,

anxiety, anger, aggression

Amphetamines 12 – 24 hours Several weeks Fatigue; followed by fluctuating mood &

energy levels, cravings, disturbed sleep, poor

concentration

Opiates 6 – 24 hours Peaks 2–4 days &

lasts 5-10 days

Aches, cramps, sweating, lacrimation,

rhinorrhoea, nausea, vomiting, diarrhoea,

dilated pupils

Alcohol Withdrawal Chart - CIWA - AR

Alcohol withdrawal

NSW Clinical Withdrawal Guidelines, from Pead

Withdrawal ranges from insomnia and morning tension, through to (far less commonly) delirium tremens

Benzodiazepine Discontinuation

Recurrence or rebound of symptoms for which medication initially

taken

Withdrawal syndrome: emergence of characteristic profile of

withdrawal symptoms

– 20–100% of long-term benzodiazepine use at therapeutic doses

are physically dependent & experience withdrawal symptoms (Ashton 1997)

NSW Health, Drug

& Alcohol

Withdrawal

Clinical Practice

Guidelines, 2007

Other Prescription Drugs

DOES IT MATTER? ED presentations in USA - relative to community opioid prescribing

CDC: Opioid Sales and Overdose Deaths

DOES IT MATTER?

December 2008

With thanks to

Podiatry

Camden

Hospital

May 2009

With thanks to Podiatry

Camden Hospital

Fentanyl Patches

Fentanyl person and script count, QLD, 1999-2009

0

20000

40000

60000

80000

100000

120000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Persons

Scripts

With thanks to

Innes Clarke

With thanks to

Innes Clarke

Over-the-counter (OTC) opiates

Notable Cases: Nurofen Plus misuse: an emerging cause of perforated gastric ulcer (MJ Dutch; MJA 2008; 188 (1): 56-57)

Over a 6-month period, two patients presented to a community hospital emergency department with perforated gastric ulcers as the result of recreational misuse of over-the-counter ibuprofen–codeine preparations.

Misuse of these medications appears to be an emerging cause of significant morbidity in patients with codeine addiction.

Managing benzodiazepine use: a

framework for safer treatment

(Lintzeris)

41

42

Is there a role for therapeutic use of BZDs as anxiolytics/hypnotics?

Concerns

– Onset of tolerance within weeks limits their utility

– Risks of abuse / addiction especially in high-risk groups

Consider alternative management strategies

– Sleep hygiene and relaxation techniques

– Address underlying anxiety/depression

– Address other substance use disorders

If going to prescribe:

– Limit duration <2 weeks

– Regular interval dispensing

– Avoid highly abused BZDs

Are some BZDs safer than others?

Amount of cognitive impairment / intoxication

Onset & duration of action

– Slow onset & longer-acting drugs less abuse potential than

fast onset & short acting drugs

Potential for misuse

– Preparations can impact upon misuse (e.g. temazepam

capsules)

– Prescribing & dispensing practices

(200x 2mg clonazepam + 5 repeats!!)

Treat concomitant anxiety /

depression & address social

circumstances

Depression and anxiety respond optimally with combined

pharmacotherapy and psychosocial interventions

– SSRI, SNRIs, antipsychotic medications

– CBT, psychotherapy, self help

– Peer, family & community supports

– Employment, exercise

Develop appropriate treatment networks

44

45

If you are going to prescribe BZDs..

Negotiate contract with patient re: treatment conditions

– BZDs contingent upon not getting BZDs from elsewhere, stable in

treatment, attend appointments, not abusing other drugs

One doctor to manage all BZDs & related medications

– Doctor shopping consent forms

– Consent to provide information to other health care providers

Limit access to BZDs: staged (daily/weekly) dispensing

Avoid BZDs associated with high abuse rates

– (e.g. flunitrazepam, midazolam, alprazolam)

Agree how to assess & monitor

Monitoring treatment

Monitoring Outcomes : The 4A’s

– Anxiety / Affect / sleep: scales, diary

– Activities: functional outcomes

– Adverse events: side effects

– Aberrant behaviours:

47

BZD detox or maintenance?

Research unable to inform practice at this time: few controlled long-term trials

Some patients will successfully detox if prompted & supported… most won’t

– Poor success rates in low dose & high dose BZD detoxes

– 5 to 20% achieve long term abstinence

If repeated attempts at detox do not work, then consider longer period of stabilisation & review

Informed consent & need for monitoring safety concerns of long term BZD use (AEs, memory, cognition, sleep)

No role for ‘unconditional, never-ending BZD maintenance’

Murrumbidgee LHD D&A Service Patients

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Nicotine

Alcohol

Cannabinoids

Amphetamines

Opioids

Benzodiazepines

Principal Drug of Concern

Managing opioid dependence

49

Treatment Approaches for Opiate

Dependence

1. Abstinence

– preferred, if can be achieved.

– but, relapse is common & carries significant risks (eg.

of overdose).

2. Substitution / Replacement

– for those who are unlikely to achieve abstinence.

– “harm minimisation”

Retention in Treatment

NEPOD Study 2004

Methadone

Suboxone® Sublingual Film

Carton Sachet Film

2/05 mg Suboxone Film

8/2 mg Suboxone Film

Suboxone® Film Administration

• Should be placed under the tongue close to the base on either side

• If the dose is 2 Suboxone Films, patients should place the other Film under the tongue on the opposite side at the same time. Patients should try to avoid letting the Suboxone Films touch as much as possible

• If more than two films are required, place Suboxone Film under the tongue on either side after the first 2 have dissolved

• Supervision time is dictated by the Australian Clinical Guidelines for the use of Suboxone Sublingual Film

Thank you

Dr Gilbert Whitton

Gilbert.Whitton@gsahs.

health.nsw.gov.au

0402 011 888