Cracking Addiction

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.

On Cracking Addiction this week

Residential withdrawal management is one of the hallmarks of addiction medicine as a specialty. Residential withdrawal management is for those patients for home a home-based alcohol withdrawal is unsafe or contraindicated doe to significant medical or psychiatric comorbidities.

These patients require closer monitoring and medical and nursing support and this can only be accomplished in a supervised setting. The rationale for the treatment of alcohol withdrawal is to prevent minor withdrawal symptoms to escalating into more severe or complicated withdrawal symptoms which can be distressing for the patient, those around them and in severe case can lead to significant adverse health outcomes or death.

The most severe complications of alcohol withdrawal include alcohol withdrawal seizures, delirium tremens and Wernicke’s encephalitis. The goals in residential withdrawal management is to decrease the chances of severe complications by preventing dehydration and electrolyte imbalance, preventing thiamine deficiency which can lead to Wernicke’s encephalitis and adequate dosing of diazepam (or oxazepam in select cases with significant liver impairment) to decrease the chance of withdrawal seizures or delirium tremens occurring.

Management of alcohol withdrawal in residential setting is usually guided by scales and is protocol driven. The two most commonly used scales to determine alcohol withdrawal are the Alcohol Withdrawal Scale (AWS) and Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) with the goal being to keep the AWS under 5 and CIWA-Ar under 10.

Although as mentioned alcohol withdrawal management is somewhat protocolised it is also important to acknowledge an individual’s particular risk and vulnerabilities. Diazepam loading may be required for some patients whose withdrawal scores are rising despite medication given or those who are at risk of a complicated withdrawal.

Similarly, for those with severe liver disease whose livers may not be able to process diazepam an alternative benzodiazepine oxazepam is used as this does not need to undergo phase 1 metabolism in the liver and thus there is no increased risk of a potential build up to toxic levels within the body. There are a number of such variations to the standard protocol which are utilised to ensure that a patient’s medical and psychiatric conditions as well as individual needs and requirements are catered for.

Residential withdrawal management is about managing potentially high-risk patient who may be at risk of significant complications during their alcohol withdrawal in a safe, humane and holistic manner using evidence-based tools and interventions. In this episode of Cracking Addiction we delve into more detail and practicalities of how to do this.

This week on MedHeads

Maintaining medication safety at home can be daunting as the prescriptions increase.
Medication errors at home can be fatal or leave you in harm’s way.

As complex health conditions can come with increased medications and specific times that they are required or other medications that cannot be taken at the same time, there can be increased stress and fear.

Reminders:
If you are tech savvy, there are apps that can assist in reminding to take medications with notifications. One such app is the Medadvisor app. It links to your local pharmacy, and you can upload prescriptions. Medications can also be delivered. Carer mode is also available – You can manage medications and prescriptions for kids, elderly, and other family members under one Medadvisor account. This is a free app but must be approved by your pharmacist. However, a lot of people either are not tech savvy or don’t want to rely on a reminder, this also may not be appropriate if you have many medications.

Dosette box:

A dosette box is an option for someone who has a few prescriptions. It may also be known to some as the Monday –Sunday pill box. These can be very beneficial for many reasons including travelling. However, the down side is that they also require the unpacking of medications form bottles, an awareness of each pill and an awareness of the time that the pill needs to be taken. Dosette boxes usually don’t facilitate medication dispensing at different times of day, but rather, act as reminders for daily dispensing.
Cost and accessibility: 5-10 dollars

Webster packs:
Webster packs are a useful option for clients who are prescribed multiple medications that need to be dispensed at multiple and specific times during the day. Webster packs are great for those managing complex regimes and can also relieve carer strain/stress and increase peace of mind for all involved in a person’s life.
Webster packs come in a range of options such as the vision impaired version, multilingual version, and the Parkinson’s disease specific version. They can be hung on the fridge and even have photo ID picture placed on the pack.

The generic webster pack has symbols for the time of day and the day of week across and down the side of the pack, the user just sees the time and date needed and pops the medications out of the blister.
Cost and accessibility: 5 dollars per week for pensioners, pending on pharmacy.

Sachet roll: dose aid :
Sachets- up to 5 medications in a pack
DoseAid’s range of medication management solutions are designed to increase medication compliance and reduce the frequency of adverse incidents.

DoseAid’s medicine sachets are a safe and effective way for people to keep track of their daily medicines. To complement its sachets, DoseAid has also partnered with Medido to make a one-of-a-kind compliance device available in Australia.

The medicines are sorted by day, dose, and time into individually labelled sachets with easy tear packaging in chronological date and time order. These sachets are then rolled up.
Each individual sachet can hold up to five different tablets. So, for example, if someone takes seven different tablets in the morning, their morning tablets will be divided between two sachets.

Every sachet is clearly labelled with:
•The patient’s name
•The date and day of the week
•The dose time
•Names and physical descriptions (shape, colour) of the medicines
•The quantity of each tablet.

This information can be easily adapted depending on the specific needs of the individual.
Cost and accessibility: similar to Webster packs under PBS

Where to get help
•Your doctor
•Pharmacist
•NPS Medicines Line call 1300 633 424
•Adverse Medicines Events Line call 1300 134 237

Taking your medication safely
•Your doctor will monitor your prescription medication, but you need to make sure you follow your medication instructions, including:

•Take all medication exactly as instructed by your doctor or pharmacist.

•Do not take medication prescribed for someone else.

•Learn about your medication and know the importance of taking your medicine correctly. Ask your pharmacist for a Consumer Medicine Information (CMI) leaflet, which answers common questions about your medication (or look for it online as many drug companies publish them on the web).

•When buying over-the-counter medication, ask your pharmacist about side effects and interactions with other medication (including vitamins and herbal supplements) you are taking.

•If you are not confident that you will remember the instructions for taking the medication (such as dosage and time of day), write them down, or ask your doctor or pharmacist to write them down.

•If you are taking multiple medications or find you are forgetting if you have taken a dose, talk to your pharmacist about dosage aids (as described above)

•Ask your doctor if making changes to your lifestyle (such as diet and exercise) could reduce your need for medication.

•Ask your doctor if you may benefit from a Home Medicines Review. This is where a pharmacist reviews all the medication you take, and it can be done annually. You may be able to stop taking medication you no longer need.

•Throw out unwanted and out-of-date medication, as the active ingredient may no longer be effective. You can also return it to your pharmacy for safe disposal.

•Do not stop taking a prescribed medication without discussing it with your doctor. If it is not working for you, speak with your doctor about an alternative.

 Watch this weeks show on MedHeads

This week on MedHeads

I have just chatted with Dr Andrew Rees about human needs and benzodiazepines. In both our clinical experiences benzodiazepines cause more angst and grief than opioids and alcohol misuse.

The question is often asked, why do I need to come off benzodiazepines. Well firstly they are harmful, and secondly, they impair engagement with psychosocial interventions. The harms of benzodiazepine use include respiratory depression, accidental overdose and unfortunately in extreme cases death. They increase the risk of falls and impair cognitive functioning. These effects are more pronounced as we age, so therefore the adage of “let sleeping dogs lie”, and failure to wean the elderly off a “stable” dose of benzodiazepines that have been used for years is not ethically tenable.

Getting off benzodiazepines seems to be more of a challenge than getting off prescription opioids or alcohol. But why is this the case?

I think that they are universally experienced as a sticking plaster. They help with the immediate sting of psychic pain. But unfortunately, unlike other sticking plasters which can facilitate healing, the benzodiazepine sticking plaster does not stimulate healing. I liken the psychic pain and suffering that benzodiazepine treat to a persistent hangover.

The open wound remains, and when the pills wear off (and when the plaster is ripped off) the pain and suffering come back. No healing occurs and in fact all we are doing when we use benzodiazepines for more than four weeks is contributing to the development and then perpetuation of an additional mental health condition i.e., a chronic benzodiazepine dependency associated with withdrawal symptoms that can be as bad or worse than the original symptoms for which the benzodiazepine was initially prescribed, and which are relieved by ongoing use of benzodiazepines. The perpetual cycle continues.

Th appropriate management of such dependency relies on two simultaneous approaches, firstly the gradual weaning of the dose of the benzodiazepine, and secondly the appropriate adequate treatment of the underlying condition for which the benzodiazepines were initially prescribed. These two approaches really do need to occur simultaneously, because on the one hand benzodiazepines impair engagement with psychosocial therapeutic interventions, and secondly without such treatment the underlying illness will continue to cause psychic pain.

The idea of having to Come off benzodiazepines can instil horror in some people. Immediate thoughts of “How will I cope” dominate our thinking. To those who react this way I offer a message of hope. Coming off benzodiazepines is not inevitably associated with severe withdrawal symptoms, and most people can tolerate a very gradual wean off benzodiazepines. The trick is to do it slowly, especially when you get to lower doses. During this time, it is also important to engage with other therapies to deal with underlying mental health disorders.

Dr Andrew Rees suggests the use of a coaching approach, whereby rather than telling the patient why they need to come off benzodiazepines (and deflecting the almost inevitable rebuttal and assertion that they need to stay on their benzodiazepines) a doctor should ask the patient what their ideas concerns, and expectations are of their underlying disease process. What would health look for them? What would they want to do were they to be free of the shackles of their mental health disorder (and free of their benzodiazepines use)? Teaching the patient how their benzodiazepine use is impairing their dreams may be a way of unlocking both those dreams and the patient from their benzodiazepine dependency.

Our dreams are part pf our creativity, an essential human need. Tapping into this seam of common human experience may allow doctors to connect with patients with more empathy and understanding and hopefully less combatively.

As Andrew says: “If you don’t have dreams, how do you know if you have achieved them?”

On Cracking Addiction this week

Managing alcohol use disorder requires several interventions to ensure success. One of the most effective tools that best predicts against relapse prevention are behavioural interventions. Behavioural interventions force individuals to confront their thoughts and beliefs surrounding alcohol and develop strategies and modify behaviour in order to maintain alcohol abstinence or controlled drinking.

Alcoholics Anonymous (or AA) was founded in 1935 by Bill W and Dr Bob and in the ensuing 86 years has helped an untold number of people achieve meaningful and sustained behaviour change in their relationship with alcohol. The only requirement for membership of AA is a desire to stop drinking. AA is a close social network supportive of abstinence and is based around the 12 Steps and 12 principles outlined in the AA manuals. The 12 step model is based around themes of powerlessness, self-awareness and spirituality. New members are encouraged to attend90 meetings in 90 days. A Cochrane review in 2020 by John Kelly and his team found that manualised AA and 12 step framework programs were more effective than other behavioural based interventions in achieving abstinence.

SMART Recovery is an acronym for ‘Self Management and Recovery Training’. The program is based around four points of:

• Build motivation

• Coping with urges

• Problem solving

• Lifestyle balance

The program is based around weekly classes of 90 minutes facilitated by a trained peer or AOD clinician and focusses on the addiction behaviour rather and on any substance. Patient goals are identified and the participant is set achievable goals and tasks for the upcoming week. The focus is to concentrate on the present and future rather than the past. The basis of SMART Recovery is around cognitive behavioural therapy and motivational interviewing. This is also an extensively studies and reviewed methodology with good evidence for it’s success.

On Cracking Addiction this week

Alcohol use disorder is a common, well known but at the same time large and mystifying field. It can sometimes appear confusing how to manage patient with alcohol use disorder given it’s chronic relapsing and remitting nature. There is a plethora of information out in both the medical literature and journals as well as common media about alcohol, treatment and management and it can be easy to be overwhelmed with all the varying information sources.

Furthermore, patients can also come in with their own agendas or treatment preferences and it can be difficult to find the balance between being patient centred but practice evidence based and safe medicine.

The answer to dealing with the glut of information is to find trusted resources and paradigms for the management of alcohol use disorder.

One must know the rationale for managing withdrawal, how to manage complications related with alcohol withdrawal, how to risk stratify patient for home versus residential withdrawal, which medications to prescribe, how to management relapse, how to prescribe anti-craving medications and which services to refer patients to treatment manage the underlying behavioural issues which assisted in the formation in alcohol use disorder.

In our episode of Cracking Addiction this week we address all of the above issues and complexity and provide simple and evidence based guidelines to treat patients with alcohol use disorder.