Oxycodone. Dr Alistair Dunn Addiction Medicine Specialist & General Practitioner

Transcription

1 Oxycodone Dr Alistair Dunn Addiction Medicine Specialist & General Practitioner Whangarei, Northland.

2 Oxycodone Dr Alistair Dunn Addiction Medicine Specialist Whangarei, Northland. CRUSADER!

3 Oxycodone Pharmacology : Powerful synthetic opioid agonist

4 Oxycodone vs Morphine Approx half mg dose required Same side effect profile Safer in renal impairment ( GFR < 30 )

5 Oxycodone vs Morphine Cont'd Greater Abuse Potential : More euphoria More easily injected Easily smoked

6 Oxycodone what's the problem?

7 Oxycodone what's the problem?

8 USA Experience Marked rise in Oxycodone prescribed

9 USA Experience Marked rise in Oxycodone prescribed Subsequent increase in ED presentations with overdose related to prescribed opioid analgesics

10 USA Experience Marked rise in Oxycodone prescribed Subsequent increase in ED presentations & overdose related to prescribed opioid analgesics Number of deaths from pr rescribed opiates now exceeds deaths due to cocaine & heroin

11 Opioid supply: USA grams (mi illions) codeine oxycodone pethidine (Vicodin ) hydrocodone morphine methadone Source: ARCOS Automated Reports and Consolidated Orders. DEA, US DoJ.

12 Emergency Department visits: USA ED visits (1000's) hydrocodone oxycodone DAWN non-medical use : estimate.,data collection method changed

13 Canada

14 OxyContin sales and oxycodone deaths: Ontario sales ($Cmil llion) No. death hs 0 03-'04 04-'05 05-'06 06-'07 07-'08 0 sales (C$million) oxycodone deaths Ontario Ministry of Health and Long Term Care, Ontario Centre of Forensic Sciences

15 Australia

16 Opioid base supply: Australia, base Kg pethidine morphine methadone codeine

17 Opioid base supply: Australia, base Kg morphine oxycodone pethidine methadone codeine

18 PBS oxycodone supply & NCIS oxycodone-detdet tected deaths: Victoria, PBS scripts (' '000) PBS oxy scripts ('000) deaths Deaths

19 PBS oxycodone supply & NCIS oxycodone-detdet tected deaths: Victoria, DRAFT

20 New Zealand?

21 New Zealand Number of oxycodone prescriptions in NZ ( Pharmaceutical Wharehouse data )

22 New Zealand

23 Don't Ignore the Early Warning!

24 The Men From the Ministry... MINISTRY OF HEALTH Dr Adrian Gray, Medicines Control Here in NZ Oxycodone is a relative newcomer, but in 2008 oxycodone prescribing was already on a par with DHC and diazepam. This dramatic increase is difficult to explain on any grounds other than successful marketing by the drug companies. It has no clinical advantage over other agents already available in NZ.

25 The Men From the Ministry... MINISTRY OF HEALTH Dr Adrian Gray, Medicines Control Oxycodone should be co onsidered a second line potent analgesic, for use only when morphine is not tolerated. The abuse potential is high : oxycodone is a potent analgesic with high dependence potential and is easily extracted from the long-acting formulation for intravenous use

26 BPAC 2009 Oxycodone use has been steadily increasing over the last three to four years.

27 BPAC 2009 Oxycodone use has been steadily increasing over the last three to four years This trend is similar to patterns observed in other countries such as the UK and Australia and corresponds with a prominent marketing campai ign suggesting that oxycodone should be the preferred opioid analgesic for the treatment of moderate to severe persistent pain.

28 BPAC 2009 Oxycodone use has been steadily increasing over the last three to four years This trend is similar to patterns observed in other countries such as the UK and Australia and corresponds with a prominent marketing campaig gn suggesting that oxycodone should be the preferred opioid analgesic for the treatment of moderate to severe persistent pain. Oxycodone is more expensive than morphine, has a similar side effect profile and there is no clinical evidence to support its use first-line.

29 BPAC 2009 Morphine remains the first-linoxycodone should be reserved for specific situations strong opioid and Oxycodone can be considered if morphine is poorly tolerated

30 Local experience - Whangarei

31 Local experience - Whangarei patients discharged from hospital Rx Oxycodone Patients arriving from Australia on high doses Oxycodone Hosp Rheum : try simple analgesics such as tramadol / oxynorm / oxycontin

32 Local experience - Whangarei

33 Why is this happening?

34 Why is this happening? 1) Honeymoon phase of new medication Newer = better Long term effects less clear ( Selegiline, HRT, Calciu um ) Keeping up to date

35 Why is this happening? 1) Honeymoon phase 2) Effective marketing - perceived advantages - appeals to doctor's des sire to alleviate suffering Target group ; yrs Osteoarthritis ( ref case examples Australia )

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38 Osteoarthritis?

39 Osteoarthritis? Dr Terry Macedo, Rheumatologist

40 Osteoarthritis? Dr Terry Macedo, Rheumatologist Dear Alistair I agree that it is not desirable to use the opioids for chronic management of osteoarthritis or chronic non-malignant musculoskeletal pain. It is fairly likely that tolerance will develop.it is worrying to hear of ED admissions with overdose, both intentional but also unintentional. I much prefer to keep to simple analgesia, NSAIDs short term tramadol, and low dose amitriptyline for chronic pain. Regards Terry

41 Chronic non malignant pain?

42 Chronic non malignant pain? There are no longitudinal RCTs on the long term effectiveness & consequences of opioid use in chronic non malignant pain ( Prescription Opioid Policy, Improving management of chronic non malignant pain and prevention of problems associated with prescription opioid use. RACP / RACGP / RANZP )

43 Chronic non malignant pain? Dr Bob Large, Pain Specialist, TARPS

44 Chronic non malignant pain? Dr Bob Large, Pain Specialist, TARPS I am convinced that it is best to avoid opioids as a treatment option for chronic non-cancer pain

45 Why is this happening? 1)Honeymoon phase 2)Effective marketing 3)Lack of resources / alternatives - multidisciplinary pain service - access to psychologistss, physio, O/T

46 Why is this happening? 1)Honeymoon phase 2)Effective marketing 3)Lack of resources / alternatives 4)More appealing than morphine it's morphine vs it's oxycodone

47 And another thing...

48 And another thing...

49 LA Morphine 160 mg = $1.57 Main Title Row 2 LA Morph LA Morph 160mg

50 M Eslon 160mg = $1.49 Main Title Row 2 LA Morph 160mg M Eslon 160mg

51 Oxycontin 80 mg = $2.49 st for 160mg morphine / 80 mg Oxycod LA Morph M Eslon Oxycodone 80 mg Row 2

52 Annual Expenditure Total expenditure on Oxycodone increased between 2009 to 2010 by more than 1 MILLION DOLLARS

53 Annual Expenditure Total expenditure on Oxycodone increased between 2009 to 2010 by more than 1 MILLION DOLLARS Morphine 2010 $ 3,235,862

54 Annual Expenditure Total expenditure on Oxycodone increased between 2009 to 2010 by more than 1 MILLION DOLLARS Morphine 2010 $ Oxycodone 2010 $ 3,235,862 5,167,500

55 Stop and think What to do?

56 Have I Exhausted Alternatives? Non pharmacological measures Activity Referrals pain clinic / specialist Counselling / Education

57 Alternative Medication Paracetamol, NSAID, Tramadol, Codeine Amitriptyline, Gabapentin

58 - past hx A&D - fam hx A&D - Hep C aberrant behaviour Red Flags

59 If you must...

60 Universal Precautions Not all risks are apparent ( not the usual suspects ) Diversion of medication to users ( family members, resal le, theft )

61 Seek Advice Second opinion - multidisciplinary pain service - musculoskeletal specialist - addiction specialist - peers

62 Full Discussion Check patient expectations ( no cure for chronic pain, goal is management and restoration of QOL / functional goals )

63 Clarify Plan Formalise contract - dose - dispensing - time-frame - exit criteria - urine drug screen tests

64 Consider other opiates Transdermal Buprenorphine ( not subsidised )

65 Rx Morphine Prescribe Morphine Unless GFR < 30 Unless not tolerated

66 If you do prescribe Oxycodone Don't advise the patient it's like morphine

67 If you do prescribe Oxycodone Say

68 If you do prescribe Oxycodone Say it's like heroin