Prescription opioid misuse: Understanding the problem and meeting the challenge

1. Prescription opioid misuse: Understanding the problem and meeting the challenge • Dr Owen Bowden-Jones • Consultant Psychiatrist • CNWL Club Drug Clinic 1

2. Anna 26 year old accounts manager, living with flat mates in West London Previous history of recreational poly-drug use (cocaine, MDMA, ketamine, alcohol) Stopped when started working in London

3. One period of depression while at University • Saw councilor and felt much better after 5 sessions • No family history of addiction or any other mental health problems • Enjoys work but finds it stressful • Describes a “hectic’ social life

4. During a period of work stress, Anna experienced insomnia for several weeks GP prescribed small amount of a sleeping medication. Only given 7 tablets. When prescription had finished, Anna still experienced insomnia, Tried exercise, hypnotherapy and homeopathic remedies. All unhelpful.

5. In the past, Anna had used Nurofen Plus for headaches and remembered that they also assisted with sleep She began to take them at night and found them very helpful. They also made her feel calmer and more able to achieve deadlines at work Anna bought the tablets from her local chemist

6. Over the next month, her use gradually increased from one to two to three tablets a day. • Anna was a little concerned by this escalation but when she tried to reduce found she did not sleep “at all” and felt “terrible”. • With three deadlines due at work in the next two weeks, she decided to continue using the codeine

7. Her use increased further and she became embarrassed to buy the drugs from her local chemist, who had commented on the amount she was using. Instead she went online and was surprised to find that there were many websites that sold both Nurofen and codeine only medication in large quantities and at reduced cost.

8. Anna ordered 200 codeine tablets which arrived the next day.

9. That was 2016 • Anna has been using codeine continuously since then. • Her dose has increased significantly and she now takes up to 10 codeine tablets a day, starting in the morning • She recognizes that she is “addicted” to the medication but has told no one as she is “embarrassed”

10. What are opioid medications

11. Opioid medications • Chemically diverse group of medications which share the common feature of action on the brain’s opioid receptors to mediate their analgesic effect • Different medication ‘strengths’ determined by the strength at which the medication binds to the opioid receptor. • Codeine versus fentanyl

12. How big a problem is misuse of prescription medication from online sources in the UK? We do not really know

16. All non medical prescription drug use Large variations globally United States 26.6% lifetime prevalence in 18-25 year olds Europe Probably less common. More likely to be benzodiazepines and stimulants than opioids.

17. What about the UK?

18. Which groups are most likely to purchase medication online? • Key groups – male, young people, students, clubbers, MSM • Association with mental health problems, PTSD, other (illicit) drug use

19. What about treatment?

20. The CNWL Club Drug Clinic

21. Why did we set up a specialist clinic for club drug users in 2010? • Small number of ‘club drug’ users presenting to local services. Quite different from ‘typical’ users • Demand from other parts of health frontline • HIV/Sexual Health • Accident and emergency • Mental health acute wards • Reports of shift in using profiles of younger people away from heroin towards club drugs and NPS • Increase in use in MSM – ‘chemsex’ • These ‘new users’ don’t feel traditional heroin and crack orientated services have the skills to treat them

22. Every clubber has a phone ! 16:59

25. How online purchasing is changing? Our patients tell us… Initially about buying so-called legal highs from online sites (clear net and dark web) Then market developed to include illicit drugs Moved from website to social media platforms Whatsapp Instagram Then addition of prescription medication

26. Online purchasing: why do people buy online? • No medical consultation or prescription needed • Rapid- next day delivery • Convenient – through the letter box • Confidential – encryption • Cheap – bulk offers No medical consultation for potential harm or interaction with other medications Counterfeit - no drug, too much drug, another drug Adulterants Perception of safety

27. Addiction to online medication service (AtOM) • Responding to  use of prescriptions medication • Online purchasing • So far • Benzodiazepines • Cognitive enhancers –pregabalin, Ritalin • Opioid medication • Usually part of broader range of polysubstance misuse

28. ATOMIC Addiction to Online Medication Improving Care

29. A final word about Anna Entered treatment severely dependent on opioid medication having lost her job due to her drug use Needed a one week medically assisted detoxification Followed by anti-craving medication and psychological treatment (relapse prevention) Now 3 months without using drugs, but optimistic about working again

30. https://clubdrugclinic.cnwl.nhs.uk www. neptune-clinical-guidance.co.uk Owen.Bowdenjones@nhs.net @owenbowdenjones