Misuse of Opioid Drugs

Case history

Dr P received a letter from the Health Department requesting an interview in relation to six patients. Dr P had been prescribing oxycodone to these patients over a prolonged period without a permit.

Discussion

The misuse of prescription drugs, particularly opioid analgesics and sleeping tablets, is emerging as a serious public health issue. In 2008, there were 551 accidental overdoses due to opioids in Australia, of which 70% were thought to be due to pharmaceutical opioids.¹

Research has also shown a 152% increase in oxycodone prescriptions from 2002-2008.² Recently, attention has been drawn to the alarming levels of misuse of benzodiazepines. While not currently classified as Schedule 8 drugs³, benzodiazepines (and in particular, alprazolam) are being associated with serious health risks and crimes, and have been detected in heroin-related deaths over the past 21 years⁴.While opioid analgesics play a legitimate role in the management of pain⁵, the increased availability of opioid analgesics has seen an associated increase in the non-medical use and diversion of these drugs to persons other than the person for whom the drug was initially prescribed . Further, prescription opioid analgesics have significant "street value" and may be sold on the black market for illicit recreational use or may be traded for other drugs. For instance, a concessional prescription for 50 alprazolam tablets purchased under the Pharmaceutical Benefits Scheme (PBS) can yield a potential street value between $150 to $250.⁴

Throughout Australia, the prescription of opioid analgesics (categorised in health legislation as Schedule 8 drugs or "S8s") is closely regulated because of the drugs' addictive potential and prevalence in misuse and trafficking. Before prescribing an S8 drug, a medical practitioner must take all reasonable steps to ensure that a therapeutic need exists. Once a therapeutic need is established, medical practitioners are required to comply with state-specific health legislation and, where necessary, obtain an authority (or permit). These authorities are distinct from, and in addition to, any authority under PBS for scripts.

In general, the regulatory regime that applies to the prescription of S8 drugs distinguishes between the treatment of drug dependent and non-drug dependent persons. In the context of prescription drugs, a drug dependent person is defined as someone who consumes prescribed drugs in a manner that presents a risk to that person's health; or, as a result of the repeated consumption of a prescription drug, acquires an overpowering desire for the continued consumption of that drug and is likely to suffer mental or physical distress upon ceasing the drug.⁵ Characteristics of a drug dependent person include having a history of substance misuse and being identified as a "doctor shopper". Tactics typically used by drug dependent persons in support of their request for particular treatment include:

• Claiming to have recently moved from the country or interstate and needing to continue receiving treatment.
• Feigning pain and requesting a particular drug by name, by description or by exclusion of other drugs.
• Claiming to have either lost a prescription of tablets or been a victim of theft (police reports are often produced as "proof" of the theft).
• Presenting with a convincing description of their symptoms, from exhibiting old scars or other signs of injury or physical defect to the production of a report and/or x-ray from a hospital or another doctor.⁶

In all states and territories, it is a mandatory requirement for medical practitioners to seek authority from the appropriate Health Department to prescribe a drug of dependence to a drug dependent person. This authority is required whether or not the prescription is written on the PBS.

In addition, Health Departments in some states require medical practitioners to provide consultant support with an accompanying application for authorisation in respect of the proposed treatment of drug dependent persons with S8 drugs.

The following table summarises the legislative regime that applies in each state and territory when treating non-drug dependent patients with S8 drugs.

Summary Points

• Ensure compliance with the state and territory regulatory regimes for the prescription of drugs of dependence. It is mandatory to obtain an authority or permit from the relevant Health Department to prescribe a drug of dependence to a drug dependent person.
• Ensure there is evidence-based support before prescribing opioids and benzodiazepines to patients, particularly those suffering from chronic non-cancer pain.
• Strictly monitor prescribing rates.
• Be alert to tactics used by drug dependent persons to access drugs.
• Utilise the Prescription Shopping Information Service.

1  Degenhardt P. Prescription opioids: a painful problem. National Drug & Alcohol Research Centre, University of New South Wales, 30 October 2012 ndarc.med.unsw.edu.au/blog/prescription-opioids-painful-problem (accessed March 2013)
2  Ibid
3 The TGA is considering whether to change the classification of benzodiazepines to the more restrictive S8: Rintoul A, Degenhardt L, Nielsen S. Why the TGA should make it harder for people to get Xanax. Available at ndarc.med.unsw.edu.au/blog.why-tga-should-make-it-harder-people (accessed March 2013)
4  Ibid
5  Recent research suggests there is mediocre evidence-based support for the long-term use of opiates: see Holliday S, Hayes C, Dunlop A. Opioid use in chronic non-cancer pain. Part 1: Known knowns and known unknowns. Aust Family Physician 2013: 42(1/2): 98-102.
6  Roxburgh A, Bruno R, Larance B, Burns L. Prescription of opioid analgesics and related harms in Australia. Med J Aust 2011: 195(5): 280-284.
7  Rintoul A, Degenhardt L, Nielsen S. Why the TGA should make it harder for people to get Xanax. Available at ndarc.med.unsw.edu.au/blog.why-tga-should-make-it-harder-people (accessed March 2013).
8  South Australian Health. Legal Requirements for the prescription and supply of drugs of dependence. Available at sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/medicines+and+drugs/legal+control+over+medicines/legal+requirements+for+the+prescription+and+supply+of+drugs+of+dependence (accessed March 2013)
9  South Australia. Recognising and handling drug dependent patients. Available at sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/medicines+and+drugs/drugs+of+dependence/recognising+and+handling+drug+dependent+patients (accessed March 2013)
10 Tasmania: relevant specialist report endorsing opioid treatment and dose to accompany 59E application. If patient is drug dependent, the Notice of Drug Dependency must be included with the authority application. Western Australia: from 1 January 2013, the Schedule 8 Medicines Prescribing Code came into effect. Under the Code, for a patient meeting any one of the "high risk" criteria, consultant support is required before the Department of Health will consider authorising the proposed treatment

References relating to Table 1. The Legislative Requirements when treating non-drug dependent patients with S8 drugs.

8  The two month period relates to the duration of treatment and includes any preceding period of treatment by another prescriber. Exceptions apply where a prescriber has "standing approval"- see ACT Government Health. Guidelines for Prescribers Prescribing Controlled Medicines. Available at health.act.gov.au/health-services/population-health/health-protection (accessed March 2013)
9  The following drugs of addiction: any injectable drug of addiction
- Buprenorphine (except transdermal patches)
- Flunitrazepam
- Hydromorphone
- Methadone
10  Private prescriptions may not contain endorsements for repeat prescriptions.
11 Authority is not required when prescribing or supplying a drug of dependence to: a patient aged 70 years or more and the drug involved is not pethidine; a patient whose life expectancy is < 12 months if the drug is not pethidine and the prescriber has informed the Minister of the patient's name, address, date of birth and the nature of the condition for which the drug is prescribed ("Notified Palliative Care Patient"), SA Health. Prescribing drugs of dependence. Available at sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/medicines+and+drugs/legal+control+over+medicines/legal+requirements+for+the+prescription+and+supply+of+drugs+of+dependence  (accessed March 2013).
12  The 8-week period includes any preceding period of treatment by other medical practitioners. Exceptions to the permit requirements apply in respect of cancer pain, childhood ADHD, prisons, residential aged care services and hospital in-patients.
13  Written specialist support for the use of S8 medicines will be required for a notified addict; high dose S8 medicines prescribed for longer than 60 days; or short acting S8 preparations (immediate release or injectable formulations); or when existing support is several years old renewal of written specialist support may be requested: WA Pharmaceutical Services Branch, Schedule 8 authorisation requirements. Fact Sheet Version 260911AG-1.