Addiction to Medicines

1. Addiction to Medicines Over the Counter, Prescription only Medicines and Benzodiazepines

2. The Rise of Polypharmacy • Four out of five people aged over 75 years take at least one medicine. • 36 per cent of this age group take at least four medicines. • The Audit Commission calculated ADRs cost the NHS £0.5 billion each year in longer stays in hospital.

3. Cultural Shifts • “A Pill for every Ill” • Rise of pharmaceutical giants • R&D and marketing

4. Evidence of Misuse in USA • In 2007, 20% of all people in USA age 12 and up - had used prescription drugs non-medically at least once in their lives • The number of people misusing pain relievers climbed from about 0.1% of the population in the mid-80’s to 13% in 2007 (US National Survey on Drug Use & Health, NSDUH) • 430% increase in the rate of treatment admissions for the misuse of synthetic opioids from ‘99 to ‘09

5. Evidence of Misuse in USA

6. What Medicines Do People Misuse? • Addictive drugs: • e.g. opiates (oxycodone, tramadol), codeine-based, benzodiazepines • Often with physical withdrawal syndrome • Non-addictive drugs may still be abused: • for their effects e.g. tricyclics • for regular self-medication e.g. antihistamine for sleep • in a compulsive way e.g. laxatives • to enhance the effects of other drugs e.g. SSRI’s

7. More than just opiates and benzos • Gabapentin • Pregabalin • Amitriptyline • SSRI’s

8. The relentless rise in prescribed opiates

9. Opioid Analgesics

10. Geographic differences Opioid Analgesics

11. Interesting but... • Trend data tells us something about the use of these medicines • Levels of prescribing can identify areas where there might need to be further focus (particularly at a practise level.) But: • Higher levels of prescribing do not necessarily mean that these drugs are not being used appropriately.

12. Treatment Data • In 2009/10 there were 32,510 people reporting POM/OTC (16% of treatment population) • 11% of these (3,735) POM/OTC only • Most local areas provide treatment

13. Geographic distribution Variation at sub-national level with North East having the highest proportion of POM/OTC in treatment

14. Demographics • The vast majority are white. • POM/OTC + illegal drug user very similar to general drug treatment population in terms of age and gender. • POM/OTC only are almost twice as likely to be female and over 40.

15. Service models and route of access

16. Addiction to Opioids: Analgesia or Fix?

17. OTC misuse • Most common codeine containing with either paracetamol or ibuprofen • 12.8mg per tablet codeine highest dose available • 7.46mg per tablet dihydrocodeine also available • Other medications –laxatives, sedative antihistamines

18. OTC misuse • May present due to effects of co-ingredient • May be suspected by pharmacist • Difficult to identify • Need to specifically ask about OTC meds and usage

19. Prescription only Medication • Can be originally given for acute or chronic problem • Positive effect • Subsequent reinforcement

20. Long–term prescribing • Longer-term prescribing increases the likelihood of dependency. • Does the prevalence of long-term prescribing give us an indication of the prevalence of dependency? • Dependency is not inevitable • There are conditions where long term prescribing is advised

21. Co-morbidity • Can have dependency along with mental health problems • Physical co-morbidity common • Self-medication psychological or physical • Prevalence chronic pain is 30-50% in treated substance users, compared with 10-15% of the general population

22. Potential harms • Psychological – shame hidden problem, unable to get help • Effect dependency on self, family and others e.g. depression, loss of work • Lapse into another addiction e.g. alcohol, opioids • Physical consequences of active ingredient e.g. codeine, constipation, • Physical consequences of another ingredient e.g. paracetamol OD

23. Who has problems with ATM? Patients: Older adults Adolescents Women Along with other illicit drugs Prison population Healthcare professionals: Doctors Nurses Pharmacists Dentists Anaesthetists Veterinary surgeons

24. What happens when go for help? • Over Count Study • those patients who approached there GPs saying that they felt they had a problem didn’t get the help and support they required

25. Why getting help difficult to get? • ATM poorly recognised by clinicians and patients • Misunderstood and hidden problem • Lack training and guidance

26. Recommendations of APPDMG Concerning GPs That, when GPs prescribe drugs known to have the potential to cause physical dependence or addiction they must: • explain these potential risks to the patient • set up procedures to monitor the patient. … The practice of repeat prescription without review for these drugs must end”

27. Publications www.nta.nhs.uk/addiction-to-medicine.aspx

28. Prevention & Monitoring • Ask • Careful use of repeats • Make use of pharmacists (local & PCT) • Surveillance (run regular in house reports)

30. Detection of Prescription Drug Problems • Monitor patients’ use of drugs that may indicate increasing problems and / or tolerance : • rapid increases in the amount of a medication needed/frequent lost scripts • Frequent requests for refills or running out before due • Seeing different doctors in practice

31. Chabal 5-point checklist • This physician-administered checklist evaluates a series of behaviors that suggest or are consistent with prescription opiate abuse rather than relying on answers to specific questions. Patients meeting 3 or more of the following criteria are considered prescription opiate abusers

32. Chabal 5-point checklist (a) overwhelming focus on opiate issues; (b) pattern of 3 or more early refills or escalating drug use without acute changes in their medical condition; (c) multiple telephone calls or visits to request additional opiates or early refills; (d) pattern of prescription problems due to lost, spilled, or stolen medications; (e) supplemental sources of opiates from other providers or illegal sources.

33. Governance • Prescribe if they are needed for good clinical reasons • Put on as acute medications and don’t slip into repeat without discussion or intention • Discuss with colleagues and document

34. What can we offer? • Assessment • Preparation • Psychological support • Prescribing • Wraparound / peer support / groups – local or internet based

35. 1.Assessment • Full assessment • Ask all about drugs, including OTC and alcohol • Drug history, alcohol, other drugs inc. BZ • Aspects of dependency: • Drug seeking behaviour • Lack of interest in other activities • Physical withdrawals • Mental health assessment - underlying issues? • Pain?

36. 2. Preparation Information-Risk of OD, Risk of S/E’s List benefits and adverse things that get from using Keep drug diary of use for 1-2 weeks Engage with support Explain tolerance

37. 3.Psychological support • Address anxiety /depression • IAPT • Counselling / CBT / Motivational interviewing • Behavioural change

38. 4. Prescribing • Buprenorphine • Codeine • Dihydrocodeine • Methadone • Morphine (MST, MXL)

39. 5. Mutual Aid • Support groups • Codeine free me • Narcotics Anonymous • SMART • Social Services • Befriending • Activity Groups

40. Dependence, treat like you would any other addiction Stabilisation (drug & psychosocial) Detoxification Aftercare

41. Support with…. • Good therapeutic relationship • Management of associated problems: • Mental health issues • Pain • Wraparound support • Psychological interventions • Time and patience

42. Reduction and detoxification interventions Same drug Substitute Advantages blockade with buprenorphine longer acting supervision possible differentiable on toxicology Problems conversion uncertain unfamiliar drug Stigma Withdrawal effects • Advantages • familiar • Potential problems: • easy to use on top • no blockade

43. Conclusions • Under recognised problem, and increasing • Evidence growing but scope for further research • Little formal guidance and training • But many things can do to help • Don’t forget: assessment, psychological help, prescribing and group support • And detox is only part of the process not the end • Important GPs ,Pharmacists and all health care professionals are educated about this problem • Need for more help and services for people who have problematic use, how should these be delivered?

44. Case study - Carol Carol, a 46 year old teacher comes to see you with acute abdominal pain. She smokes a few cigarettes a day, and does not drink alcohol. She tells you that she is now taking Nurofen Plus daily; having initially been given them after having some extensive dental work done. When she took them, she found that they helped the pain, and also made her ‘feel better’ and improved her mood. She has no history of substance misuse. She started taking the tablets at the recommended doses, but after a few months felt that they were less effective, especially after a stressful event, so she took more. After 6 months she is now on about 30+ a day.

45. Carol Around this time her abdominal pain started. When she stops taking the Nurofen, she feels unwell. She has had to find more and more pharmacies to buy from, plus she buys off the internet. She becomes anxious when she knows her supplies are running low. She now desperately wants to stop and wants your help with this. NB: 12.8mg codeine (and 200 mg ibuprofen) in x1 Nurofen Plus tablet, and are available in packs of 12, 24 and 32

46. Carol What else would your initial assessment involve? What are Carol’s risks? What would be your treatment plan? What are your prescribing options? Who else would you involve?

47. Case study - Margaret Margaret, a 58 year old librarian who has been seeing your senior partner for several years comes to see you as he has reduced his hours and she couldn’t get an appointment with him. She has been told she has fibromyalgia and says the fentanyl 50 patches she has been on for the past 6 months only help so much and she needs to take 6-8 tramadol a day on top and also has 20mg of temazepam at night. She had been given a trial of gabapentin but stopped it as it made her feel dizzy.

48. Margaret She has lived alone since her 86 year old mother died 5 years ago with breast cancer and had a short course of fluoxetine following this although she stopped it after 3 months as she felt ok. She has previously had X-rays which showed minimal osteoarthritis of her hips only. Blood tests showed no evidence of inflammatory arthritis She had no history of drug use and drinks less than 10 units of alcohol / week.

49. Margaret What else would your initial assessment involve? What are Margaret’s risks? What would be your treatment plan? What are your prescribing options? Who else would you involve?

50. Case study - Tim Tim, a 52 year old electrician, first saw you about 3 years ago after he had acutely injured his back when he slipped off a ladder. He had had gastritis previously so you had given him an acute prescription of co-codamol (30/500) for the back pain. 6 months later he attended with low back pain without any obvious trauma, he was again given co-codamol 30/500. He found them helpful so he attended the emergency surgery - where he saw a locum - to ask for more and he requested them to be added to his repeat prescription, which they were. The reception staff noticed he was overdue a medication review and passed his request for more co-codamol to you.