Public Health Association of Australia: Policy-at-a-glance Pharmaceutical Drug Misuse Policy

Transcription

1 Public Health Association of Australia: Policy-at-a-glance Pharmaceutical Drug Misuse Policy Key message: Summary: Audience: Responsibility: 1. Pharmaceutical drugs, when used as intended as part of quality medical care, make a positive contribution to the health and wellbeing of many members of the community. Strategies to reduce pharmaceutical misuse must balance the need to preserve the community benefits of these drugs against the requirement to protect the community from harm associated with misuse. 2. A public health approach to reducing pharmaceutical misuse and associated harms must be comprehensive and focus primarily on preventing or delaying the onset of drug misuse, and minimising harm associated with misuse. A combination of prevention strategies addressing the broader community, plus targeting at-risk groups and existing users is required. Policy responses to pharmaceutical misuse should emphasise alterations to the structural environment to make healthy lifestyle choices easier, rather than shifting the responsibility for behaviour change solely to the individual. PHAA believes that policy and programs should be designed and implemented to: raise awareness; restrict supply; improve monitoring; reduce demand; and reduce harm. This policy seeks to outline a series of principles and tangible actions designed to achieve these goals. Australian, State and Territory Governments, policy makers and program managers. PHAA s Health Promotion Special Interest Group (SIG) Date policy adopted: September 2013 Contact: Co-Convenors: Dr Justine Leavy j.leavy@curtin.edu.au, Dr Emma Croager ecroager@cancerwa.asn.au 1

2 Pharmaceutical Drug Misuse Policy The Public Health Association of Australia (PHAA) notes the following: Pharmaceutical drug misuse refers to any use of pharmaceutical drugs that is inconsistent with the intended use or directions 1. This may include: a. Overuse, where a therapeutic drug is being used at higher doses or for a longer duration than prescribed or directed. b. Intentional misuse, where pharmaceutical drugs are used, often in large doses, for their intoxicating effects, or to enhance the intoxicating effects of other substances (also referred to as non-medical use). c. Diversion, where prescribed pharmaceutical drugs are transferred from the original user to others through on-sale via illegal markets for profit. Pharmaceutical drug misuse in Australia is common and ranks highly among other forms of illicit drug misuse. The 2010 National Drug Strategy Household Survey found that 4.2% of Australians aged 14 years or older had used pharmaceuticals including analgesics, tranquillisers, steroids, methadone/buprenorphine or other opiates for non-medical purposes in the previous 12 months 2. Recent use of pharmaceuticals for non-medical purposes increased between 2007 to 2010 from 3.7% to 4.2% of people in Australia aged 14 years and over (from 640,000 people to 770,000 people) 3. The pharmaceuticals most likely to have been used in the previous 12 months were pain-killers/analgesics, and, of those who had recently used painkillers/ analgesics, the majority used over-the-counter (72.7%) pain-killers as their main type rather than prescription analgesics (27.3%). Misuse of analgesics (3.0%) was the second most common form of illicit drug use, behind marijuana/cannabis (10.3%), equal with ecstasy (3.0%), and ahead of more readily identified drugs of misuse such as meth/amphetamines (2.1%), cocaine (2.1%) and heroin (0.2%) 4. Individuals misusing analgesics were approximately three times more likely to misuse over-the-counter analgesics (72.7% of people misusing analgesics) than prescription analgesics (27.3% of people misusing analgesics). Misuse of tranquilisers and sleeping pills was reported by 1.5% of the population 5. In 2010, 2.7% of the population aged 12 years or older engaged in recent (last month) non medical us of prescription psychotherapeutic drugs, the second most common illicit drug use. This exceeded the prevalence of misuse of all illicit drugs except cannabis 6. 2

3 Globally, pharmaceutical misuse is increasing, particularly in developed countries and in some, misuse of and trafficking in prescription drugs exceeds illicit drugs 7. In the United States an epidemic of prescription drug related deaths has been declared 8. Overdose deaths caused by the abuse of prescription opioids have quadrupled since 1999 and since 2003 have exceeded deaths attributable to cocaine and heroin combined 9. The greater availability of prescription opioids including oxycodone and hydrocodone has contributed to increased misuse and addiction 10. This may point to future trends in Australia. In 2011 in the US there were 5.1 million drug related emergency department (ED) visits; about half (49%) were attributed to drug misuse or abuse, and the number of these visits increased from visits in 2004 to 1,428,145 in The most commonly involved drugs were antianxiety and insomnia medications, and narcotic pain relievers (160.9 and visits per 100,000 population respectively 11. From 1999 to 2010, the number of U.S. drug poisoning deaths involving any opioid analgesic (e.g., oxycodone, methadone, or hydrocodone) more than quadrupled, from 4,030 to 16,651. In 2010 there were twice as many poisoning deaths involving these drugs than the combined number of deaths involving the illicit drugs cocaine and heroin 12. Opioid analgesics and benzodiazepines are among the most widely and increasingly available classes of pharmaceutical drugs in Australia 13,14, however it is unclear whether increasing supply is consistent with best practice use of these medicines. Increasing supply of oxycodone and alprazolam has found to be significantly associated with increased drug-related deaths 15,16. The risks associated with the use and misuse of pharmaceutical drugs is poorly recognised within the community. Many people perceive opioid analgesics and benzodiazepines to be low risk because they are therapeutically indicated by a health professional, safer than illicit drugs, and do not recognise them as drugs for potential misuse 17. Pharmaceutical drug misuse can lead to dependence, poisoning, serious morbidity and death. Pharmaceutical drug misusers may also experience difficulties with their relationships, poor outcomes in education or employment, and legal problems. Harms associated with pharmaceutical misuse reach beyond the individual to impact on family, workplaces and the community. Pharmaceutical misuse places a burden on the health system and is associated with both crime to obtain and divert, and crime under the influence of drugs 18. Pharmaceutical drug misusers are a heterogeneous population. Some may choose to misuse drugs for their intoxicating effect. For others dependence is iatrogenic and consumers may misuse or become dependent on their medications without perceiving that they have a substance use disorder. The latter are described as a hidden population not easily identified by health professionals, and not attracted into treatment settings designed for illicit drug users. Pathways to misuse of pharmaceuticals include the unwitting development of physical and psychological dependence during medical treatment; prolonged and increasing self-medication for pain, anxiety, and other disabling symptoms; and substitution for other illicit drugs. It is also worth noting that people may be harmed by using their medications as prescribed, for example unintentional overdose and sleep apnoea 19. Use of pharmaceuticals by people who inject drugs (PWID) may be related to cost and availability of other illicit drugs; it is likely that the decrease in availability of heroin in some areas of Australia during the early 2000s contributed to increasing pharmaceutical opioid and benzodiazepine misuse by PWIDs 20. Findings from the 2012 national Illicit Drug Reporting 3

4 System indicate that recent misuse of pharmaceutical drugs among people who regularly inject is very common 21. Public health strategies to reduce pharmaceutical misuse and minimise associated harms should be complementary to broader approaches towards illicit drug misuse (refer to PHAA s Illicit Drug Misuse Policy). Persons who are dependent on alcohol, have chronic pain or a mental illness are especially vulnerable to misuse of pharmaceutical drugs. Since 1985, Australia s National Drug Strategy has consistently advocated a harm minimisation approach which balances supply reduction, demand reduction and harm reduction strategies. At the request of the Ministerial Council on Drug Strategy a National Pharmaceutical Drug Misuse Framework is in development to provide a systematic national response to pharmaceutical diversion and misuse, and address prevention, supply, harm reduction and improved access to quality treatment. The Public Health Association of Australia affirms the following principles: Pharmaceutical drugs, when used as intended as part of quality medical care, make a positive contribution to the health and wellbeing of many members of the community 22. Strategies to reduce pharmaceutical misuse must balance the need to preserve the community benefits of these drugs against the requirement to protect the community from harm associated with misuse. A public health approach to reducing pharmaceutical misuse and associated harms must be comprehensive and focus primarily on preventing or delaying the onset of drug misuse, and minimising harm associated with misuse. A combination of prevention strategies addressing the broader community, plus targeting at-risk groups and existing users is required. Policy responses to pharmaceutical misuse should ensure that pharmaceutical medications with dependence liability are only prescribed where there is evidence that they are the most effective treatment, and where safeguards such as ongoing monitoring of effectiveness and for evidence of adverse effects are in place to minimise harms. Appropriate strategies to prevent problems associated with prescription opioid use have been outlined by the Royal Australasian College of Physicians 23. The Public Health Association of Australia believes that the following steps should be undertaken: Raise awareness: a. Raise awareness of the community and health professionals to the risk of dependence, other harms and potential for misuse of pharmaceutical drugs. Restrict supply: a. Limit prescription duration and over-the-counter (OTC) packaging size for pharmaceuticals prone to misuse to short term use only, requiring patients and consumers to engage with a health professional to determine appropriateness of prolonged use. b. Advocate for the rescheduling of pharmaceuticals under the Standard for the Uniform Scheduling of Medicines and Poisons whenever it is evident that the threat to public 4

5 health exceeds the benefits of less restricted community access.(the interim decision to reschedule alprazolam to Schedule 8 is a recent example.) c. Develop/promote initiatives to encourage safe storage of potentially dangerous medicines, and for return of unwanted medications. Home medicine cabinets are a common source of pharmaceuticals that are used non-medically 24,25. Improve monitoring: a. Implement real-time electronic coordinated medication management systems to limit drug-seeking and enable prescribers, dispensers and regulators to make informed and timely decisions about safe supply of schedule 8, prescription opioids, over the counter codeine analgesics and any other pharmaceutical drugs prone to misuse at the time of prescribing or dispensing. b. Review monitoring interventions described above to determine effectiveness and unintended consequences of monitoring. Reduce demand: a. Increase health professional and consumer awareness and use of non-drug management options for conditions such as anxiety, insomnia and chronic pain. Reduce harm: a. Improve access to safe facilities and affordable clean equipment for injecting through Needle and Syringe Programs. This should include provision of filters which can significantly reduce harm from injection of particulate matter 26,27. b. At prescribing and dispensing occasions of pharmaceutical drugs prone to misuse, inform consumers of the risks associated with use, non-medical use, and provide information on ways to prevent harm and access support and treatment. c. Ensure people who use and misuse pharmaceutical drugs can receive treatment and care that is appropriate, accessible, affordable and informed by evidence. The Public Health Association of Australia resolves to undertake the following actions: The Board, Special Interest Groups and State and Territory Branches will advocate this policy to the Ministerial Council on Drug Strategy (MCDS), all levels of government and other relevant interested parties. PHAA will seek to assist in the development of the National Pharmaceutical Drug Misuse Framework. References 1 Nielsen S, Thompson N. Prevention of pharmaceutical drug misuse. West Melbourne: Drug Info Clearinghouse December Australian Institute of Health and Welfare National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW, Ibid. 5

6 4 Ibid. 5 Ibid. 6 Substance Abuse and Mental Health Services Administration, Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, International Narcotics Control Board. INCB Annual Report Press Release: Urgent action is needed against the growing problem of prescription drug abuse. Vienna: INCB; 2010 [cited October]; Available from: 8 White House Office of National Drug Control Policy. Epidemic: responding to America's prescription drug abuse crisis. Washington (DC): Executive Office of the President of the United States, Board INC. Report of the International Narcotics Control Board for New York: United Nations, Board INC. Report of the International Narcotics Control Board for New York: United Nations, Substance Abuse and Mental Health Services Administration, Center for Behavioural health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug related Emergency Department Visits. Rockville MD. 12 National Vital Statistics System. Mortality data. Available at Centers for Disease Control and Prevention. Number of Deaths From Poisoning, Drug Poisoning, and Drug Poisoning Involving Opioid Analgesics United States, MMWR 2013;62: Australian Department of Health and Ageing. Australian Statistics on Medicines Canberra: Drug Utilisation Sub-Committee, Pharmaceutical Benefits Advisory Committee, Department of Health and Ageing, Commonwealth of Australia Australian Institute of Health and Welfare. Drugs in Australia Tobacco, alcohol and other drugs. Drugs statistics series no.27 Cat. no. PHE 154. Canberra: AIHW, Rintoul AC, Dobbin MDH, Drummer OH, Ozanne-Smith J. Increasing deaths involving oxycodone, Victoria, Australia Injury Prevention. 2011;17(4): Rintoul AC, Dobbin MDH, Nielsen S, Degenhardt L, Drummer OH. Recent increase in detection of alprazolam in Victorian heroin-related deaths. Medical Journal of Australia. 2013;198(4): Drugs and Crime Prevention Committee. Inquiry into misuse/abuse of benzodiazepines and other pharmaceutical drugs. Melbourne: Parliament of Victoria Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. Societal Costs of Prescription Opioid Abuse, Dependence, and Misuse in the United States. Pain Medicine. 2011;12(4): Walker J, RJ F, Rhondeau S, Boyle K, Valentine K, Cloward T, et al. Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing. Journal of Clinical Sleep Medicine 2007 August ;3(5):455-61). 20 Degenhardt L, Day C, Hall W. The causes, course and consequences of the heroin shortage in Australia. Sydney: National Drug and Alcohol Research Centre, University of New South Wales

7 21 Stafford J, Burns L. Australian Drug Trends Findings from the Illicit Drug Reporting System (IDRS). Australian Drug Trend Series No. 91. Sydney: National Drug and Alcohol Research Centre, University of New South Wales, Drugs and Crime Prevention Committee. Inquiry into misuse/abuse of benzodiazepines and other pharmaceutical drugs. Melbourne: Parliament of Victoria The Royal Australasian College of Physicians (2009) Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use, (accessed 21/06/2013) 24 Inciardi JA, Surratt HL, Kurtz SP, Cicero TJ. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Medicine. 2007;8(2): Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. In: Office of Applied Studies NSH-, HHS Publication No. SMA , editor. Rockville, MD Patel P, Patel RP, Brandon S, McLean S. Bruno R, de Graaf B. Effects of Filtration on the Presence of Particulate and Oxycodone Content of Injections Prepared from Crushed Oxycontin Tablets. Current Drug Safety. 2012;7(3): McLean S, Bruno R, Brandon S, de Graaf B. Effect of filtration on morphine and particle content of injections prepared from slow-release oral morphine tablets. Harm Reduction Journal. 2009;6(37). 7

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