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2010 APSAD Conference

2010 APSAD Conference. Bill Loveday , Abhilash Dev , Rebecca Thompson, & Dr Sue Ballantyne Drugs of Dependence Unit Email:ddu@health.qld.gov.au. Fentanyl abuse in Queensland Identification of emerging pharmaceutical drug misuse. Overview. Fentanyl- cause for concern

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2010 APSAD Conference

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  1. 2010 APSAD Conference Bill Loveday, Abhilash Dev, Rebecca Thompson, & Dr Sue Ballantyne Drugs of Dependence Unit Email:ddu@health.qld.gov.au Fentanyl abuse in Queensland Identification of emerging pharmaceutical drug misuse

  2. Overview Fentanyl- cause for concern Precribing trends in Queensland Fentanyl misuse- issues & solutions Conclusion

  3. What is fentanyl? • A synthetic primary opioid agonist and potent narcotic analgesic with rapid onset and short duration. • Clinical setting = fentanyl administered via injection, gaseous form, nasally or in a lozenge. • Transdermal patches used to provide consistent, slow release administration of opioid analgesic for period of 48 to 72 hours.

  4. Why use fentanyl? • Typically indicated for management of persistent, moderate to severe chronic pain among opioid tolerant patients • who require continuous, around-the-clock opioid administration for an extended period of time, and cannot be managed by other means such as nonsteroidal analgesics, opioid combination products, immediate-release opioids

  5. Potency, availability & misuse issues • Approximately 80 - 100 times more potent than morphine. • 100mcg/hr fentanyl approximately equivalent to 10mg of morphine and 75mg of pethidine. • The matrix patches contain higher quantities of fentanyl to achieve the same delivery rate (60–70% more than the reservoir patches) • August 2006 = Australian Pharmaceutical Benefits Scheme (PBS) listing for fentanyl patches amended to include chronic non-cancer pain. • Result = reduced cost and increased prescribing for non cancer type pain management. • High potential for misuse and diversion due to a higher volume of fentanyl used in the matrix patches. • Misuse and diversion of used patches which have a high dose of left over fentanyl (Dumpster diving)

  6. Misuse of fentanyl • Abusers are distilling fentanyl from patches for IDU. • Distillate used to ‘boost’ other illicit substances. • Distillate crystallised to resemble ‘rock’. • Smoking associated fentanyl derivatives. • Chewing & ingestion of patches. • Placement of multiple patches on the body. • Non-medical use by individuals with no opioid tolerance is extremely dangerous.

  7. What makes fentanyl appealing to illicit drug users? Purity of product = more ‘bang’ for buck Rapid take-up = immediate euphoria / ‘high’. A belief that pharmaceuticals are ‘safer’ than street drugs. Negative opiate screen.

  8. What makes fentanyl appealing to prescribers? • Marketing - pharmaceutical companies advertise slow release transdermal patches as safe, user friendly and effective. • Transdermal patch technology allows continued analgesia for opioid tolerant patients • Fentanyl is the fastest acting opiate available; particularly applicable when used for break through pain. • Fentanyl patches can be effective in treating neuropathic pain. • Patches are useful when oral opioids cannot be used because of vomiting, difficulty swallowing or inability to administer via IV. • Fentanyl can be used in severe renal impairment situations when other opioids are inappropriate. It is metabolised in the liver and does not have active metabolites.

  9. Concerns around fentanyl use • Fentanyl carries a high risk of dependence and misuse • Can result in fatal and non fatal overdoses due to narrow therapeutic/toxic window • Deaths related to fentanyl has significantly increased in USA and Canada over the years ( Wong et.al (2010) , Martin et.al (2006)) • Emergency Department presentations for fentanyl have increased over the years in USA (DAWN, 2008) • There have been 8661 accidental opioid overdose deaths in Australia between 1988 and 2004 (Degenhardt et.al (2006))

  10. OA Prescriptions in USA – 1998-2007 • 327% increase in fentanyl prescriptions since 1998

  11. Fentanyl related ED presentations, USA, 1995-2008 • 3403% increase in ED presentations related to fentanyl since 2000

  12. Fentanyl person and script count, QLD, 1999-2009 • A three-fold increase in fentanyl prescriptions since 2005/2006.

  13. Fentanyl prescribing by age group, QLD, 1999-2009 • A rapid escalation in prescribing fentanyl patches for an older age group with a variety of non-cancer or chronic pain issues.

  14. Fentanyl prescribing by gender, QLD, 1999-2009 • It was evident that from 2006, more females than males were being prescribed fentanyl patches.

  15. Fentanyl prescriptions per person (AVG), QLD, 1999-2009 • In Queensland, the number of prescriptions per person per year continues to steadily increase.

  16. OTP patients obtaining fentanyl, QLD, 2000-09 • In Queensland, fentanyl is actively being sought and obtained by individuals with prior or current OTP registrations. Note the reverse trend where a younger age group is seeking fentanyl…not necessarily for therapeutic purposes.

  17. The Queensland Story began when… • DDU became aware of an increasing number of individuals on the Sunshine Coast presenting at hospital ED’s with apparent fentanyl overdose. • QAS subsequently reported an increase in call outs to narcotic overdoses where the patient’s presented with extreme respiratory depression and reduced response to naloxone.

  18. and then… • March 2010 police (QPS) advised DDU of two IDU deaths in the Bayside area where misuse of pharmaceutical drugs were suspected. • Initially, police thought the deceased had injected contents of ‘morphine patches’ – suspected to be fentanyl • Princess Alexandra Hospital ED reported increase in narcotic overdoses with severe respiratory depression – at least 2 more fatalities. • Some aged care facilities in the Greater Brisbane and Gold Coast area, reported persons ‘dumpster diving’ for used fentanyl patches.

  19. Fentanyl Scripts per Person (AVG) by Region, QLD, 1999-2009 • 7.4 scripts/person for Sunshine Coast in 2009

  20. Fentanyl Scripts per OTP Person (AVG), QLD, 2005-09 • The OTP patients in the Sunshine Coast region were on an average getting more scripts per person compared to State wide trend AND… • OTP patients on an average getting more scripts per person compared to non OTP patients

  21. Proportion of OTP Clients dispensed fentanyl by Region, QLD, 2005-09 • 30% OF THE OTP patients seeking fentanyl in QLD were from the Sunshine Coast Region

  22. Observations • Persons living in the Sunshine Coast region getting on an average more scripts/per person for fentanyl in comparison to neighbouring regions • Increase in fentanyl scripts for OTP patients in the Sunshine Coast region since 2007 (higher than State wide average) • Nearly 30% of OTP patients who were dispensed fentanyl were in the Sunshine Coast region ( Sunshine Coast region usually makes up 11% of the OTP population)

  23. What we did • Fentanyl alert cards for NSPs • Review of fentanyl scripts to identify any concerns • Official correspondence sent to doctors prescribing fentanyl in the Sunshine Coast area advising on the situation • Research and analysis of population trends relating to fentanyl prescriptions

  24. Prescription Drug Misuse: Issues • Illicit drug use transcending to opportunistic prescription drug misuse • Doctor/prescription shopping • Diversion to illicit markets • Iatrogenic (doctor caused) dependence • Overdose and death • Injecting Related Injury and Disease (IRID) • Chronic pain and addiction management • Legal and professional responsibilty of GPs

  25. Solutions • Improved Pain Management practice (alternative pathways, multi-disciplinary approaches) to decrease prescription drug use • Real Time Reporting between prescriber, pharmacist and regulatory body and dedicated prescription information service (e.g. DDU 24/7 enquiry service) • Improving co-ordination between GPs, pharmacists, specialists, and pain & addiction management services • Preventing drug overdose and other drug use related injuries (better education & access to support networks), e.g. fentanyl alert, overdose and vein care resources • Partnership and information sharing between treatment provider, regulatory and enforcement bodies to prevent misuse and diversion • Increased accountability and ownership from pharmaceutical companies through responsible marketing and better research and funding initiatives focussing on dependency and misuse linked to pharmaceutical drugs.

  26. Conclusion • Prescription drug misuse is increasing and National Public Health surveillance systems similar to Drug Abuse Warning Network (DAWN) and Researched Abuse Diversion and Addiction- Related Surveillance (RADARS) system will be useful. • National surveys like the National Drug Strategy and Household Survey (NDSHS), National Survey for Mental Health and Wellbeing (NSMHWB) and other drug surveys need to focus more on prescription drug misuse. • Nation wide real time reporting system that is consistent across all state and territories to be set up to prevent diversion and to improve patient management • Multi-pronged approach to tackle prescription drug misuse through partnership between public and private clinicians and allied health professionals involved in treatment and rehabilitation with regulatory and enforcement bodies to ensure ongoing sustainable long term solutions to prescription drug misuse issues.

  27. Drugs of Dependence Unit Locked Bag 21 Fortitude Valley BC QLD 4006 Tel: 07 3328 9890 Fax: 07 3328 9821 Email: ddu@health.qld.gov.au

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