Prescription and Over-the-Counter (OTC) Drug Misuse

1. Prescription and Over-the-Counter (OTC) Drug Misuse © 2009 University of Sydney

2. Learning Objectives What is prescription drug misuse Substances Extent of problem Recognising the problem Managing the problem Understanding medication regulations

3. What is prescription drug misuse Variety of terms - Prescription drug misuse: use of any drug in a manner other than how it is indicated or prescribed - Aberrant drug related behaviours: behaviours that suggest the presence of substance abuse or addiction, implying that the behaviours are pathologic Spectrum including excess ingestion, diversion, injection, dependence

4. The Medications Sedating Stimulant Performance enhancing

5. Sedative Opioids-illicit, prescribed and OTC Benzodiazepines Non-benzodiazepine hypnotics Antipsychotics (in some environments) Ketamine Barbiturates (rarely)

6. Performance Enhancing include: Diuretics Anabolic Androgenic Steroids Hormones EPO, hGH, Insulin, glucocorticoids B Agonists/ B blockers Steroid antagonists Stimulants Opioids

7. How do we identify/monitor this? Anecdotal/case reports Post marketing surveillance WHO National Drug Strategy Household Survey Illicit Drug Reporting System DAWN (US) User sites

8. Stimulant misuse in the USA Rates of non-prescribed stimulant use -0.5% past month use in age 12-17(1) -0.8% adults >26 years report last year use(1) -4.1% college students report last year use(2) Among college students -whites, members of fraternities and sororities, individuals with lower grade point averages, use of immediate-release preparations, and individuals who report ADHD symptoms at highest risk for misusing and diverting stimulants(2) (1) 2007National Survey on Drug Use and Health:National Findings athttp://oas.samhsa.gov (2) McCabe SE. Knight JR. Teter CJ. Wechsler H. Non-medical use of prescription stimulants among US college students: prevalence and correlates from a national survey Addiction. 2005; 100(1): 96-106.

9. Australian prescription Opioid Misuse 2.5% Australians report recent use of pain-killers for non-medical purposes 4.45 report lifetime use 15.4% had opportunity to use pain-killers for non-medical purposes Jurisdictional variations 2007 Australian National Drug Strategy Household survey

10. Australian Tranquiliser/ Sleeping Pill Misuse 2007 3.3% ever used non-medically 2007 1.4% had used in the last year-an increase from previous surveys 2007 Australian National Drug Strategy Household survey

11. ED presentations in USA relative to community opioid prescribing “Reprinted from Drug and Alcohol Dependence, 82(2), Dasgupta et al, “Association between non-medical and prescriptive usage of opioids”, 135-142, 2006, with permission from Elsevier.

12. Australian opioid use 1992-2007 Leong, M., Murnion. B., Haber, P., 2009, Internal Medicine Journal; in press

13. Number of PBS opioid preparations Murnion, B., 2009, unpublished data

14. Over The Counter Regulation does not easily allow monitoring Complex epidemiological methods Jurisdictional variability in misuse May vary with availability of illicits Consider pseudoephedrine story Is there a need for codeine containing OTC analgesics?

15. Performance Enhancing 2007- 223,898 tests undertaken by World Anti-Doping Agency 4,402 AAF (1.97%) Anabolic agents 2,322 Stimulants 793 Cannabanoids 576 B2Agonists 399 Diuretics and other masking agents 359 Glucocorticoids 288 Hormones and related substances 41 B Blockers 27 Narcotics 21 Anti-oestrogens 18 Enhancement of oxygen transfer 3 May include TUE’s World Anti-Doping Agency, 2007 Adverse Analytical Findings

16. Recognising prescription and OTC misuse Longitudinal observation Corroborative history from other health care providers Frequent presentations with lost or stolen scripts Consider identified risk factors Morbidity (e.g. Gastric erosions, CV events ) Routine screening (e.g. elite athletes)

17. Strategies to prevent PDA Patient Drug Prescriber Governmental policy and legislation Modification of the medication

18. 1. Patient factors Prior or current substance abuse disorder places in high risk category Environment (e.g. Prescribing dexamphetamine to child whose parent/carers have a substance use disorder) Psychosocial setting may justify close monitoring

19. Risk of opioid misuse in chronic pain patients (CPPs) Adverse drug related behaviour (ADRB) in 11.5% Overt abuse/addiction in 3.27% If no prior/current history of abuse, abuse/addiction in 0.19% Urine toxicology showed 20% had non-prescribed or nil drug in urine and 14% had illicit drugs in urine Amongst 2000+ CPPs exposed to prescribed opiates: Structured Literature Review: Fishbain et al, 2008, Pain Med, 9

20. 2. Drugs Drugs with abuse potential - opioids - hypnotics - psychostimulants - anticholinergics - performance enhancing

21. 3. Prescriber High index of suspicion when unknown patients present requesting repeat scripts for high risk drugs Screening tools May feel isolated/threatened Drs known to easily prescribe these medications attract this clientele Should report aberrant prescribing Always ask about OTC and CAT use Identify colleagues and report appropriately

22. Managing PDA Diagnosis Consider need for ongoing pharmacotherapy Consider cessation (gradual dose reduction) Harm minimisation strategy Patient contracts/UDS Doctor Shopping Agreements Frequent pharmacy dispensing Supervised dosing Consider need for other treatments for underlying disorder (eg anxiety/pain) Consult senior colleague or specialist

23. 4. Governmental and legislative interventions “Rogue” prescribers may be deregistered or have prescribing limits Urgent NSW Medical Board inquiries to take action to protect the public rose from 22 in 2005/06 to 35 in 2006/2007 Due in large part to increased referrals about prescribing practices from PSB Twelve doctors suspended, 19 had conditions imposed on registration, and two doctors removed from the Register.

24. New NSW medical board requirements (1/10/2008) Mandatory reporting to medical board if practises medicine whilst intoxicated by drugs (whether lawfully or unlawfully administered) or alcohol Medical Board recommends -be vigilant in identifying doctors or other colleagues whose health, conduct, behaviour or performance may be a threat to the public; -do your best to find out the facts, then if necessary, notify an appropriate person such as the hospital chief executive or the Medical Board. Your comments about colleagues must be honest. If you are not sure what to do, ask an experienced colleague or contact the Medical Board or your defence organisation for advice. The safety of patients must come first at all times; and -report adverse events which reflect on the professional performance or conduct of colleagues to a hospital Chief Executive or Medical Board. NSW Medical Board, 2009

25. Impaired Colleagues If unable to deal with the matter yourself, consult appropriate senior colleague. If you feel able to talk to the colleague yourself, do not take on a treating role, but arrange to meet with them privately, let them know that you are concerned and why, ask them to consult with an appropriate practitioner, and provide them with contact information NSW Medical Board, 2009

26. Impaired Colleagues Follow up to make sure that they have taken your advice. Be aware that your colleague may tell you what they think you want to hear, having taken no positive steps. Consider the impact of their problem upon their work. If you believe that patient safety may be at risk, you should advise the doctor accordingly and seek the adviceof the Medical Board NSW Medical Board, 2009

27. Section 28 of the Poisons and Therapeutic Goods Act 1966 The authority of the Department of Health is required: to prescribe for or supply to a drug dependent person any drug of addiction (Schedule 8), or to prescribe for or supply to any person any preparation of dexamphetamine or methylphenidate, or to prescribe for or supply to any person other than a drug dependent person, for therapeutic use by that person continuously for more than two months, any of the following drugs of addiction – buprenorphine (excluding transdermal patches), flunitrazepam, hydromorphone, methadone or any injectable drug of addiction.

28. Governmental and legislative requirements Vary between countries and states Concern internationally that rigid legislative requirements limit access to essential medications Separate from authority through PBS (federal) Prescription of methadone liquid or buprenorphine as Subutex/suboxone through OTP requires a separate authority

29. 5. Modification of medications Limit scheduling of combination OTC products Limit to pack sizes and dose of opioid in OTC product Limit DTC advertising Reschedule substance (e.g. Ketamine) Remove from market e.g. pseudoephedrine Introduction of “abuse deterrant” formulations/combinations eg suboxone®

30. Case Study 1 JS 22yr old man Presents with agitaion, lacrimation, rhinorrhea, yawning, abdominal pain and diarrhoea PMHx Crohns Disease Rxed with Azothioprine and prednisolone Acknowledges 70+ Neurofen Plus daily

31. What are you going to do?

32. What are you going to do? Diagnosis

33. What are you going to do? Diagnosis opioid dependence question diagnosis of CD

34. What are you going to do? Diagnosis opioid dependence question diagnosis of CD Investigations

35. What are you going to do? Diagnosis opioid dependence question diagnosis of CD Investigations Treatment options withdrawal management maintenance therapy

36. Case Study 2 Ms TD 52 yr old woman Presents frequently to ED with migraine Seen neurologist-prophylactics/tryptans ineffective ADRs to morphine and oxycodone Requests parenteral pethidine and has letter form neurologist supporting this

37. What are you going to do?

38. What are you going to do? Diagnosis

39. What are you going to do? Diagnosis consider rebound headaches

40. What are you going to do? Diagnosis consider rebound headaches Corroborative history

41. What are you going to do? Diagnosis consider rebound headaches Corroborative history Very limited availability of pethidine in public hospitals in NSW Refer to appropriate local speciality Non-opioid management Patient education Stabilise opioid use and wean

42. Author Dr Bridin Murnion Staff Specialist Drug Health Services, RPAH All images used with permission, where applicable