Cracking Addiction

Just as “No man is an island entire of itself” (John Donne), so too is no prescriber an island.

You’ve decided to start prescribing MATOD. You’ve decided to start prescribing either Suboxone or methadone. Great. Very soon you will develop a following of patients who will become dependent on your prescription, your signature and perhaps most importantly, you. If you get sick or go on holiday, and don’t manage your absence properly, the lives of your patients could be put into turmoil. Furthermore if you work in a group practice your practice colleagues will need to pick up the pieces in your absence.

What if they are not MATOD trained? What if they are “anti-druggies?” Not everyone is as enlightened as you are, not everyone wants to help the most vulnerable people in our society.

Because you cannot operate in isolation, because you cannot prescribe in isolation it behoves you to establish good working relationships with your colleagues so that in the event of any absence, planned for unplanned, then at least some form of agreement can be made in principle regarding the management of your patients.

At the very least any doctor who has access to your patient record can act as your Locum and can theoretically continue a pharmacotherapy prescription – even without training. Of course Ideally, any Locum you engage or any other doctor in your practice who is prepared to manage your patients when you are away, should be trained in pharmacotherapy.

So just as you have a duty to engage with your colleagues in order to arrange Locum cover, so too should your colleagues acknowledge your expertise skills and attitudes to your patients. I have heard too often stories of GPs who have undergone special training to prescribe pharmacotherapy, who have gone back to their surgeries and told everyone the good news that they want to engage in this line of work, only to be told by the “Senior Partner” or the practice manager, that the surgery doesn’t do drug addicts.

Please, I urge all surgeries and colleagues to facilitate and encourage any doctor who wants to prescribe pharmacotherapy. By nurturing this skill, your surgery will be better able to meet the combined challenges of prescription opioid dependence and real time prescription monitoring.

Whether you like it or not the tide is coming in, these issues will affect us all, and it is better to have a pharmacotherapy prescriber on your team: imagine having to cope with these challenges without such talent batting on your team.

Prescription Opioid Crisis

I have just started using SafeScript. This is the Victorian Department of Health’s response to the current prescription opioid crisis.

I think it is fabulous. Even though it is not yet mandatory in my area, I am nonetheless able to access the service online. It has thrown up some interesting challenges.

For instance I have a female patient with a relatively new diagnosis of seronegative arthritis. She is embarking upon her journey into biological therapies. She also loves her endone. I have been a bit uneasy in dishing it out, but I have rationalised that she has a proven arthritis syndrome, she is already under the care of pain specialists who have recommended clonidine which she takes. So what the harm?

That is until now. I have just seen her SafeScript record. We have all been doing it, my other colleagues and I. We have all been feeling sorry for her and we have all been giving her endone scripts. It has mounted up.

Thanks to SafeScript I can now see that she is getting the equivalent of 50 mg daily of endone. The information was there all along had I chosen to look carefully at it, however now with SafeScript it has been presented to me in an easily digestible format with red alarms all over it. I now have to do something about it.

I have a difficult conversation ahead of me, but at least I now know the facts.

What is a Partial Agonist?

A partial agonist is a drug that, when bound to a receptor, only partially activates that receptor.

This is in contra-distinction to full agonists which, when bound to a receptor, fully activate the receptor. If you look at a dose response curve, in the case of full agonists, as the dose increases so too does the clinical effect. In the case of partial agonists, they behave differently.

At low to moderate doses they behave as functional agonists in that as the dose increases then so too does the clinical effect, albeit at a lower rate when compared with the full agonist curve.

However at high doses they behave as antagonists in that any further dose increase results in no additional clinical effect. Therefore in the case of partial agonists a ceiling effect occurs wherein beyond a certain dose no further effect is seen.

Now, what is this all about? Why am I bothering to write about this?

Well the answer is prescription opioid abuse.

More people died last year from prescription drug misuse than did on the roads in Victoria.

We as doctors are killing our patients with our prescriptions. Prescription opioids play a big part in this mortality. Most clinically used opioids are full mu opioid receptor agonists. Therefore as the dose goes up so too does the risk of respiratory depression and death.

Imagine if there was a drug which was a great pain killer, just like the commonly used opioids, but which was much less likely to cause respiratory depression and death. Wouldn’t you want to use that drug? Wouldn’t you want to at least know more about it?

Well, there is an opioid that is a partial agonist at the mu opioid receptor. Because it is a partial agonist it has a ceiling effect which occurs below the threshold for respiratory depression in most healthy adults. Therefore it is much less likely to cause respiratory depression and death.

Just think about how much safer this drug would be as compared to all the other full mu opioid receptor agonists that are commonly prescribed, including morphine and oxycodone.

I cannot understand why we as doctors are not prescribing more of this safer drug when faced with the horrifying statistics of mortality associated with prescription opioid misuse.

Want to know what this drug is?

It’s called buprenorphine. It comes as a “Norspan” patch, a “Temgesic” sublingual pill, and a “Suboxone” sublingual film.

A patient who normally saw Dr…came to me. She needed more of her fentanyl patch.

She needed high dose opioids for her right elbow pain. These drugs were the only thing that kept the pain away, and she worked as a hairdresser, so she needed these patches and her other meds to stay in work.

According to the clinical record, she was on the following interesting medications.

Fentanyl 50 mcg/hr patch
Tramadol 50 mg prn
Temazepam 10 mg nocte

I looked up Safescript.

Her record was full of red alarm bells suggesting that she was at a higher risk of death, not only because of her high dose of opioids but also because of her concomitant use of benzodiazepines.

I told her that I was unable to sanction her use of these medications.

The summary points were as follows:

Her OME was > 100 mg of morphine (fentanyl 25 = OME 100) This alone put her at an increased risk of death

Her use of additional short-acting tramadol was inappropriate and possibly indicated a dependency syndrome.

Her use of temazepam at night put her at an even higher risk of death.

The RACGP explicitly states that there is no role for Fentanyl for chronic non-cancer pain in GP-land.

She had non-cancer pain, probably osteoarthritis of the right elbow, which needed a proper assessment and a decent management plan.

I had no choice but to deny her current prescription request. I told her to stop the tramadol and immediately and I advised her to wean off the high dose fentanyl.

The next step was a 25 patch and a 12 patch in combination. This would be a step forward towards the goal of weaning her off fentanyl completely.

She was somewhat shocked and angry at this but seemed to accept what I said finally.

We agreed on a review in a fortnight.

In a fortnight she cancelled her appointment to see me. Instead, she saw Dr…, her regular doctor.

I looked at his medical record for the consultation. He had restarted her on fentanyl 50 mcg patches. I spoke to him later in the evening to ask his opinion of what was going on with the patient.

He told me that she was in severe pain and could not work because of her left elbow and that I had contributed to her increased suffering. She could not afford to buy two patches at the same time, so he had advised her to use a full 50 mcg patch again.

I asked him if he had read her safe script record. He said he had. We agreed to disagree.

The recently aired Addicted Australia documentary series on SBS provoked a lot of discussion amongst my colleagues on how we as general practitioners and society as a whole treats people with substance use disorders.

A colleague mentioned that substance use disorder is the only medical condition where it is still ‘acceptable’ to turn away or refuse to assist someone seeking help or trying to improve their circumstances. One can hide behind words or terms such as ‘too difficult’, ‘complex’ or ‘I don’t practice that kind of medicine’.

Recently a patient of mine asked for an extra supply of her medication. One would think that this was a prudent request during this coronavirus pandemic and trying to minimise unnecessary contact with other people or attending a crowded pharmacy. However, the medication that she asked for more take away doses for was Methadone. She was on four take away doses, the maximum allowed under current Victorian legislation which meant that she had to attend the pharmacy three times per week where a pharmacist would monitor her as she ingested Methadone in the pharmacy. This woman was a person who is no longer using heroin and who had not injected drugs for a number of years and felt embarrassed and judged every time she went to the pharmacy.

More Take-Aways

Fortunately, with the current coronavirus pandemic the Victorian Department of Health and Human Services has authorised prescribers to prescribe increased take away doses and longer duration scripts in suitably screened and stable patients. This is certainly a welcome intervention but leads me to wonder about the overall treatment and management of our patients on opioid substitution therapy (OST).

Methadone and Suboxone are prescribed medications given to patients with heroin or opioid use disorder. They are intended as a substitute for heroin and other prescribed opioids under the philosophy of harm reduction, understanding that there are some patients who for whatever reason will not remain abstinent of using drugs and trying to decrease the risks of harm both to the patient and to society as a whole. Some of the harms reduced include reducing the risks of blood borne viruses from sharing needles or drugs, decreasing the risks of overdose by prescribing an appropriate dosage of medication or prescribing take home naloxone, decreasing societal harms such as stealing and other criminal activity to fund an illicit drug habit.

This is an extensively researched and evidence-based form of harm reduction and personally I have seen many people turn their lives around on OST yet unfortunately there is still a dearth of OST prescribers. The reasons are seemingly obvious in that it is not well remunerated work with ‘difficult patients’ whom you wouldn’t want clogging up your waiting room. You also don’t want ‘that’ reputation as ‘the drug doctor’.

But to me this attitude is misplaced. OST provides a treatment to people who are addicted. In no other area of medicine do we ignore or try to avoid prescribing evidence-based treatment for a disorder and substance abuse disorder is a medical condition.

Furthermore, there are structural and bureaucratic issues and hurdles associated with OST. For instance, one can easily prescribe opioid medication in one’s consultation room initially. There is no need to obtain a permit immediately, no further training is required for the doctor and no real onerous conditions placed on the patient.

For Methadone the prescriber must undergo Medication Assisted Treatment of Opioid Dependence (MATOD) training and be assessed. Then when prescribing the medication the patient must find a pharmacy willing to prescribe OST to them, take an authorised photograph to the pharmacy, may be asked to prove that they can store the medication safely when they are allowed take away doses and for the first few weeks and then months have to present to the pharmacy daily where they are dosed in front of other pharmacy patients. To top it off OST is not PBS funded and the patient usually has to pay an additional dispensing fee. The system appears geared to penalise people who have acknowledged that they have a problem and are taking some of the necessary steps to rectify their situation.

These issues with OST appear emblematic of a larger issue of appropriate prescribing of drugs of dependence. The problems of harms and deaths related to prescription medication are well known particularly with the mass of information related to opioid medication deaths in America. More locally in Victoria in 2017, there were 414 pharmaceutical medicine-related deaths compared to 271 deaths associated with illicit drugs and a road toll of 258 in the same time period. Most pharmaceutical medicine-related deaths involved some form of polypharmacy-multiple different medications such as opioids and benzodiazepines contributing to the adverse outcome. In 2016-2017 in Victoria, there were 10,517 pharmaceutical medicine-related ambulance callouts compared with 11,097 illicit drug-related ambulance call-outs. This is a problem that has been growing for some time and is beginning to be tackled.

Real Time Prescribing

SafeScript is a real-time prescription monitoring system able to be used by prescribers in the state of Victoria. This software keeps a real-time log of the prescription and dispensation of certain medications (opioids, benzodiazepines, stimulants, hypnotics and other high-risk medications). SafeScript aims to reduce overdose risk via polypharmacy, multiple prescribers and identifying higher risk drug combinations. The software integrates well with existing general practice databases and uses a traffic light system to signal to a practitioner whether they should review the Safescript database. Importantly it does not tell a prescriber whether they should or should not prescribe-that decision is still up to the prescriber.

The evidence for real-time prescribing is quite robust with Tasmania having such a system in place since 2009 and multiple jurisdictions in America showing a reduction in doctor shopping and reduction in medication diversion post implementing a similar system. Many other states in Australia will soon be implementing their own prescription monitoring programs.

The most important thing post-implementation of real-time prescription monitoring is not to stigmatise those identified as aberrantly seeking medications or use this new information as an excuse to rapidly exit the patient from the consultation room but utilise the tool to start a discussion with the patient and how best to manage their needs. This can be challenging particularly if the patient has been a regular patient and one is feeling betrayed that they were using their prescribed medications in a manner not intended or seeing multiple other prescribers. These conversations can be difficult and can certainly require some degree of introspection from the prescriber about their prescribing but it is important that these conversations are held with the patient and their best interests in mind.

If someone is identified as having a substance abuse disorder then the most humane thing with any disorder is to offer appropriate treatment and management and this can range from weaning medications, referral to detoxification and rehabilitation facilities and for certain patients prescribing OST. I am hopeful that more doctors will be motivated to undertake MATOD training in order to provide more comprehensive treatment to their patients. This can seem daunting at first but there are services and people able to assist in this transition. In Victoria the Victorian Drug and Alcohol Clinical Advisory Service (DACAS) is a phone consultancy service staffed by addiction specialist and is available for any clinician requiring assistance with a patient with substance abuse disorder. There is also the Safescript GP Clinical Advisory service which is staffed by GPs to provide peer mentoring and advice to other GP prescribers who have patients with high-risk prescription medication concerns.

Real-time prescribing is in its infancy in Australia and is soon to become more widespread. It is a tool that could potentially help save lives but will also prove to be confronting to prescribers and result in them reflecting on their prescribing behaviours and habits. My hope is that it will be a tool that will help us identify and treat some of our most vulnerable patients in a more holistic manner.

Further to a literature review carried out by Austin Health the following list of medications were identified as being associated with a high risk of misuse and or an elevated risk of deathAll schedule 8 medications

Certain schedule 4 drugs including:
All Benzodiazepines
All z-drugs
Quetiapine
Codeine

Other drugs that have not yet made it onto the “watch-list” include tramadol and the gabapentinoids. At the time of the original literature review these drugs were not found to be high risk. However, things may change as further evidence comes to light

On Cracking Addiction show this week

Alcohol use disorder can sometimes be difficult to define. The DSM defines alcohol use disorder is defined by the following criteria:

• Spending a lot of time getting, using, or recovering from use of the substance.

• Cravings and urges to use the substance.

• Not managing to do what you should at work, home, or school because of substance use.

• Continuing to use, even when it causes problems in relationships.

• Giving up important social, occupational, or recreational activities because of substance use.

• Using substances again and again, even when it puts you in danger.

• Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.

• Needing more of the substance to get the effect you want (tolerance).

• Development of withdrawal symptoms, which can be relieved by taking more of the substance.

It is important to know how to define alcohol use disorder to determine the severity of the disease with mild disease defined as the presence of 2-3 symptoms, moderate disease the presence of 4-5 symptoms and severe disease the presence of 6 symptoms.

Alcohol use disorder is a chronic relapsing disease that can have a high mortality (both through the effects of being intoxicated but also the secondary health effects with associated cancers, heart disease etc.) but also significant morbidity.

There are simple screening tests that can be done to identify patients at risk of alcohol use disorder including the CAGE questions and the AUDIT-C screening questionnaires that can identify people at risk of alcohol use disorder and with early interventions and appropriate support it is possible to significantly improve and impact the course of a patient’s alcohol use disorder and their life.

This does not necessarily need to be time consuming and indeed brief interventions lasting no more than 10-15 minutes discussing someone’s alcohol use disorder has good evidence to show that it can be effective.

A good framework for a brief intervention is the FRAMES model based on Feedback of personal risks or impairment, Responsibility (the patient’s personal responsibility to implement change), Advice, Menu (of strategies to change the problematic habit or behaviour), Empathy and self-efficacy.

In this episode of Cracking Addiction we define what alcohol use disorder is, the difference between dependence and addiction and the progression of alcohol use disorder.

On Cracking Addiction show this week

Home based or outpatient alcohol withdrawal management is an area of medicine shrouded in mystery and confusion. It occurs quite often but usually in a haphazard and disorganised manner. The results of poor management of alcohol withdrawal can be dire and lead to complications such as delirum tremens, Wernicke’s encephalopathy and other harms.

Home based or outpatient alcohol withdrawal management is a safe intervention when carried out in the right environment, with the right patient, the right protocols and the right safeguards in place.

Right environment
A safe drug free environment is paramount with a place for safe storage of medications. It is also important that the patient is not geographically isolated and has access to a mobile phone and is able to make and receive calls on this mobile phone.

Right patient
The patient should be over the age of 18 and be judged to only have mild to moderate alcohol dependency. The patient should be able to provide informed consent and be able to adequately follow medical instructions. Alcohol should be the only substance use disorder present and the patient should not be using any other substances as this might complicate withdrawal management and a patient using multiple substances might be better served with a residential withdrawal management admission. The patient should not have serious or significant medical or psychiatric comorbidities and no history of complex withdrawals.

Right protocols
Usually a fixed dose regimen for diazepam is used for home based alcohol withdrawal management. Turning Point’s Alcohol and Drug Withdrawal Guidelines provide a good template upon which to fashion home based withdrawal management. It is important that prior to commencing home based withdrawal management that both doctor and patient are clearly aware of the protocols and medication dosing regimen and the regularity of follow up-this might best be outlined in a written plan. If a complication arises or there are concerns it is important for the doctor to know where to seek help and liaising with your local Addiction Medicine service or specialist may be useful. Safety must be the foremost consideration and daily review and daily pick up of medications in a staggered manner is recommended.

Right safeguards
As mentioned in an earlier section it is important that the patient is not geographically isolated and has access to a working phone. It is important that the patient is linked in with a general practitioner and that they can access this general practitioner daily and contact them freely. It is paramount that the patient not live alone and has a support person with them in the house whilst withdrawal management is occurring.