Dr Alistair Dunn. Lead Clinician Northland Health Community Mental Health & Addictions Northland DHB Whangarei
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1 Dr Alistair Dunn Lead Clinician Northland Health Community Mental Health & Addictions Northland DHB Whangarei 8:30-9:25 WS #147: The Bottom Line; Tackling the Problem of Prescribed Drug Addiction 9:35-10:30 WS #157: The Bottom Line: Tackling the Problem of Prescribed Drug Addiction (Repeated)
2 The Bottom Line : Prescribed Controlled Drug Addiction Dr Alistair Dunn
3 Controlled Drugs?
4 Controlled Drugs? Class A : very high risk Class B : high risk Class C : moderate risk
5 Controlled Drugs Class A Cocaine, LSD, Heroin Methamphetamine, Mescaline
6 Controlled Drugs Class A Cocaine, LSD, Methamphetamine Rx Heroin Class B Hashish, MDMA, opium, GHB Rx CD PAD morphine, fentanyl, methadone Methylphenidate
7 Controlled Drugs Class A Cocaine, LSD, Methamphetamine Rx Heroin Class B Hashish, MDMA, opium, GHB Rx CD PAD morphine, fentanyl, methadone Methylphenidate Class C Cannabis plant, BZP Rx Buprenorphine, codeine, DHC, ketamine, BENZOS Rx Cannabis ( THC /CBD)
8 Controlled Drugs Class A Cocaine, LSD, Methamphetamine Rx Heroin Class B Hashish, MDMA, opium, GHB Rx CD PAD morphine, fentanyl, methadone Methylphenidate Class C Cannabis plant, BZP Rx Buprenorphine, codeine, DHC, ketamine, BENZOS Rx Cannabis ( THC /CBD)
9 Tramadol? Controlled Drugs?
10 Controlled Drugs? Tramadol? NOT YET
11 Controlled Drugs? Tramadol? NOT YET Zopiclone?
12 Controlled Drugs? Tramadol? NOT YET Zopiclone? NOT YET
13 M.O.D.A.
14 M.O.D.A. The Misuse Of Drugs Act Says what?
15 M.O.D.A. Section 24 of the Act prohibits prescribing a controlled drug to a person whom the prescriber believes to be dependent on that or any controlled drug, unless that prescriber: is a gazetted practitioner; or is working in a gazetted agency; or has an authority to prescribe for a particular patient.
16 M.O.D.A. Case #1 :morphine 50 mg bi d Case #2 : diazepam 5mg tds
17 Prescribed Controlled Drugs Opiates & Benzodiazepines
18 Prescription Opiates
19 Prescription Opiates Morphine, Methadone, Fentanyl, Oxycodone Codeine,DHC,panadeine,nurofen plus Buprenorphine (Suboxone, Norspan) Plus Tramadol you betcha
20 OPIATE Dependence All prescribed opiates can be addictive so TAKE CARE
21 OPIATE Dependence Tolerance & Withdrawal what else? DSM criteria :
22 OPIATE Dependence Tolerance & Withdrawal Dyscontrol Salience Craving Continued use despite adverse consequences
23 Opiates are prescribed for PAIN YEAH.NAH
24 Opiates are prescribed for PAIN Acute & short term : YEAH Longer term : NAH There are no longitudinal RCTs on the long term effectiveness & consequences of opioid use in chronic non malignant pain ( Prescription Opioid Policy, RACP / RACGP / RANZP )
25 Opiates for chronic pain : risks?
26 Opiates for chronic pain : risks Tolerance/hyperalgesia Mortality/overdoses No gains in pain/function
27 BOTTOM LINE Opiates are a dumb choice to treat chronic non malignant pain
28 Opiates are a dumb choice to treat chronic non malignant pain
29 Chronic Pain Management
30 Counselling / Education acceptance of pain, adjust & adapt thru self-management Incurable - like diabetes Change goal & expectation from being pain-free to taking the edge off it and promoting function / goals
31 Counselling / Education patient must address resentment and rejection of their damaged / new self Stress, anxiety, depression, guilt, frustration
32 Counselling / Education Illness Beliefs - I can't stand it / can't cope - No one believes me - I must be a bad person / punished - Im useless
33 Counselling / Education Cognitive Errors Catastrophising : interpret pain as damage / bad sign Nothing helps / no-one cares Fear Avoidance : stay at home in pain vs go out and watch a movie in pain Black and White thinking : one thing or opposite
34 Counselling / Education Passive recipient of relief- 'bystanders' in own treatment vs active participant in pain management
35 Counselling / Education Support team Pacing ( boom/bust) Relaxation/distraction Activity/exercise
36 Counselling / Education Chronic Pain
37 Oh well, if you must prescribe opiates remember.. Look before you leap Easy to start HARD TO STOP
38 Red Flags
39 1- past hx A&D 3 Red Flags
40 1- past hx A&D 2- fam hx A&D 3 Red Flags
41 3 Red Flags 1- past hx A&D 2- fam hx A&D 3- aberrant behaviour
42 3 Red Flags 1- past hx A&D 2- fam hx A&D 3- aberrant behaviour Plus Hep C = IVU
43 Universal Precautions When was this concept created? What does it mean?
44 Universal Precautions Not all risks are apparent Diversion of medication to users ( family members,resale, theft )
45 Not the usual suspects
46
47 No prior A&D Prescribed Rx only High functioning
48 7 Prescribing Tips 7 Volunteers to recall 1 each please
49 1.Dispensing 7 Prescribing Tips
50 7 Prescribing Tips 1.Dispensing 2.Review date / timeframe /exit plan
51 7 Prescribing Tips 1.Dispensing 2.Review date 3.Dose limit? Mg daily morphine
52 7 Prescribing Tips 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal
53 7 Prescribing Tips 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal 5.Contract / consent
54 7 Prescribing Tips 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal 5.Contract / consent 6.Testing urine drug screen
55 7 Prescribing Tips 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal 5.Contract / consent 6.Testing urine drug screen
56 7 Prescribing Tips 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal 5.Contract / consent 6.Testing urine drug screen 7.Restriction Notice
57 1.Dispensing 2.Restriction Notice
58 DRDOCTR Doctor, Doctor 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal 5.Contract / consent 6.Testing urine drug screen 7.Restriction Notice
59 Benzodiazepines The pams PLUS Zopiclone / Imovane
60 BENZO Dependence All prescribed benzos can be addictive so TAKE CARE
61 BENZO Dependence All prescribed benzos can be addictive so TAKE CARE Long term use 1) Hypnosedative Rx 2) Anxiolytic Rx
62 BENZOS as hypnosedative The blue rinse brigade
63 BENZOS as hypnosedative :risks?
64 BENZOS as hypnosedative Risk of falls Cognitive impairment Sedation polypharmacy
65 Benzos as anxiolytic? YEAH, NAH
66 Benzos as anxiolytic Acute & short term : YEAH Longer term : NAH
67 Benzos as anxiolytic Acute & short term : YEAH Longer term : NAH > memory loss / cog impairment > sedation / driving / overdose > addiction
68 Management of Anxiety
69 Try SSRI first for anxiety NOT a benzo
70 Oh well, if you must.. Look before you leap Easy to start > Hard to stop
71 Name 3 Red Flags
72 1.Past hx A&D 2.Fam hx A&D 3.Aberrant behaviour / early pick ups
73 7 Prescribing Tips???
74 DRDOCTR
75 DRDOCTR 1.Dispensing 2.Review date 3.Dose set limit 4.Outcome measures functional goal 5.Contract / consent 6.Testing urine drug screen 7.Restriction Notice
76 SUMMARY Take care when prescribing opiates and benzos because of their addictive potential These drugs are easy to start but hard to stop Pharmacotherapy is only one part of management of chronic pain or anxiety
77 And remember. Opiates are
78 Opiates are a dumb choice to treat chronic non malignant pain
79
80 Try SSRI first for anxiety NOT a benzo
81 Handy Resources Enter opioid/opiate Dr Mike Evans advice for taking opioid medication video
82 Handy Resources Audit of Medical Practice Resources Controlled Drug Prescribing Clinical Audit 2018
83 Handy Resources Identifying and managing addiction to opioids - BPJ bpac NZ ber/opioid-addiction.
84 THANKYOU
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