Over the Counter, Prescription only Medicines and Benzodiazepines

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.

“A Pill for every Ill”

Rise of pharmaceutical giants

R&D and marketing

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

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

Gabapentin

Pregabalin

Amitriptyline

SSRI’s

Opioid Analgesics

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.

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

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

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.

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

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

1.Can be originally given for acute or chronic problem

2.Positive effect

3.Subsequent reinforcement

• 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

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

1.Psychological – shamehidden problem, unable to get help

2.Effect dependency on self, family and otherse.g. depression, loss of work

3.Lapse into another addictione.g. alcohol, opioids

4.Physical consequences of active ingrediente.g. codeine, constipation,

5.Physical consequences of another ingrediente.g. paracetamol OD

Patients:

Older adults

Adolescents

Women

Along with other illicit drugs

Prison population

Healthcare professionals:

Doctors

Nurses

Pharmacists

Dentists

Anaesthetists

Veterinary surgeons

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

ATM poorly recognised by clinicians and patients

Misunderstood and hidden problem

Lack training and guidance

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”

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

Ask

Careful use of repeats

Make use of pharmacists (local & PCT)

Surveillance (run regular in house reports)

Monitor patients’ use of drugs that may indicate indicate increasing problems and / or toleranceincreasing 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

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

(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.

Prescribe if they are neededthey 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

1. Assessment

2. Preparation

3. Psychological support

4. Prescribing

5. Wraparound / peer support / groups – local or internet based

Full assessmentAsk all about drugs, including OTC and alcoholDrug history, alcohol, other drugs inc. BZ

Aspects of dependency:Drug seeking behaviourLack of interest in other activitiesPhysical withdrawals

Mental health assessment - underlying issues?

Pain?

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

Address anxiety /depression

IAPT

Counselling / CBT / Motivational interviewing

Behavioural change

Buprenorphine

Codeine

Dihydrocodeine

Methadone

Morphine (MST, MXL)

Support groups

Codeine free me

Narcotics Anonymous

SMART

Social Services

Befriending

Activity Groups

Stabilisation

(drug & psychosocial)

Detoxification

Aftercare

Good therapeutic relationship

Management of associated problems:Mental health issuesPain

Wraparound support Psychological interventions

Time and patience

Same drug

Advantagesfamiliar

Potential problems:easy to use on

topno blockade

SubstituteAdvantages

blockade with buprenorphine

longer actingsupervision possibledifferentiable on

toxicology

Problemsconversion uncertainunfamiliar drug StigmaWithdrawal effects

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?

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. 

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

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? 

Carol

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.

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.  

Margaret

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? 

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.  

You realised Tim’s use had gone up and he was requesting 100 tablets at less than 2 weekly intervals so you asked to see him. You knew he had always drunk above safe levels, but from what he told you it had gone up to about 10 units a day since his injury, as he was drinking more because it seemed to help the pain.  He said that he was not only using at least 8 prescribed co-codamol a day but he was also buying Solpadeine on top. He was markedly constipated but if he tried stopping the medication developed diarrhoea and abdominal pain and was irritable. Every time he tried to reduce his tablets his alcohol intake went up. His mood was low and he had become withdrawn and isolated, staying in bed till the afternoon in an effort to control the amounts he was using.  

Tim

Tim

He had lost his job a year ago and said he needed a sick note as the benefits office didn’t think he was fit to look for work..  NB Solpadeine Plus is a combination of Codeine Phosphate (8mg) Paracetamol (500mg) and Caffeine (30mg) and is available in packs of 16 and 32

 What else would your initial assessment involve? What are Tim's risks? What would be your treatment plan? What are your prescribing options? Who else would you involve? 

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What are the effects of benzodiazepines?

What clinical indications are they used in?

For how long?

Hypnotic / anxiolytic

Used in clinical practice for treatment of anxiety, panic, insomnia, seizures, alcohol withdrawal, muscle spasticity

Prescription is only recommended for short term use (2 - 4 weeks)

Have become an extensive and significant problem in drug users, and prescribing guidelines do not recognise the complexity of this

The drugs most frequently used in combination with opioids

May be the sole drug of abuse

Usually taken orally but the tablets can be crushed and injected

Addictive and lead to significant problems with withdrawal

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56Table 2: Primary therapeutic actions of benzodiazepines (BZ)

Action

Clinical Use Short Term (< 2-4 weeks) Common Uses

(commonly initiated in primary care)

Clinical Use Longer Term (> 4 weeks)

Very Rare Uses (typically initiated by specialists)

Anxiolytic

Acute stress related reactions, adjustment disorders, acute stress reaction prophylaxis

Anxiety disorders

Treatment resistant persistent severe anxiety disorders (see mental illness section)

Anxiety due to medical illness

Hypnotic

Acute insomnia, with brief situational stress & definite identifiable endpoint, e.g. grief, acute pain

Predicted acute insomnia, e.g. funeral, exams, journey

Re-establishing a better sleep routine

Treatment resistant persistent severe sleep disorders, due to chronic physical or psychiatric disorders, e.g. chronic pain

Anticonvulsant Acute seizures due to any cause

Epilepsy resistant to treatment with anticonvulsant drugs

Seizure prophylaxis

Myorelaxant Muscle spasms, e.g. due to back pain

Spastic disorders

Amnesia Premedication for operations,

sedation for minor surgical procedures

None

Alcohol withdrawal

Acute alcohol withdrawal syndrome

Harm reduction in those with severe alcohol damage

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Benzodiazepine Dose equivalent to diazepam 5 mg

Chlordiazepoxide 15mg

Clonazepam 0.25mg

Lorazepam 0.5mg

Nitrazepam 5mg

Temazepam 10mg

Dose conversion table for equivalent doses of benzodiazepines to diazepam 5 mg

Dose conversion table for equivalent doses of benzodiazepines to diazepam

Approximately 90% of drug users report using benzodiazepines at some point

The reasons why people use benzodiazepines may include:To make them feel normal, or enable them to cope

To treat anxiety or low mood

To treat insomnia

To potentiate the euphoriant effect of opioids

To combat opiate withdrawal symptoms

To ‘come down’ from stimulants

To improve confidence

To decrease psychotic symptoms such as auditory hallucinations

To enjoy the effects of a binge

High doses or binges can lead to impulsive behaviour, amnesia, increased risky behaviour and other problems

Long term benzodiazepine use can lead to emotional suppression

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The liability to abuse of different benzodiazepines varies. The major factor increasing abuse liability is speed of onset of the drug which is unrelated to its elimination half-life.

Diazepam and flunitrazepam have rapid onset of action despite very different half-lives. Oxazepam has a short half life but slow onset so has lower abuse potential. Clonazepam [long half life] increasingly abused via both prison and internet.

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The reason is that rapid onset drugs are associated with “good” subjective effects, and therefore result in psychological reinforcement every time the drug is taken, which over time strengthens the psychological component of any addictive process. The second most important factor related to abuse is the dose of benzodiazepine, as a higher dose leads to better buzz.

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Withdrawal of a benzodiazepine prescription needs to be done with care and should be patient-specific. Two main areas should be considered:

Dose reduction: This should be tailored to the individual. It may take weeks, months or even years but there should be no hurry, as the person needs to learn how to manage without drugs; hence it is better to handle dose reduction mainly in the community, as inpatient measures can be too rapid. Going too fast will cause the patient enormous difficulties and often leads to failure. It is best to allow the patient control. If there are problems, reduce speed but try not to go backwards.

Psychological support: Provide as much or as little as the person requires, ranging from simple measures to long-term interventions. Ongoing support should always be offered, self-help should be encouraged, and, if appropriate, alternative coping skills training, such as anxiety management and CBT, should be arranged.

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• Longer-term prescribing increases the likelihood of dependency.

• RCGP data looked an available sample of a large national cohort also prescribed opiate substitution therapy

• Median length of prescription = 29 days

• 35.3% longer than 8 weeks

• 50% in subset with concurrent OST.

Complex, as there is little or no evidence that maintenance prescribing of benzodiazepines reduces harm

In substance misuse, not licensed for maintenance prescribing, only for detoxification from benzodiazepine dependence

Prescribing benzodiazepines in many people does not affect the use of street drugs

Long term high dose benzodiazepines (above 30mg diazepam) may cause harm

Should only prescribe if you feel the benefits of treatment will outweigh the risks (diversion, overdose etc.)

Treat underlying cause (anxiety, insomnia) first

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Need to establish physical dependence (rather than intermittent use)

Test urine to confirm benzodiazepine use

At least 2 positive urine screens

No negative benzodiazepine screen in the last 4 months

Use benzodiazepine withdrawal scales

Define and agree clear goals with the patient

Prescribe for structured detoxification only – no role for maintenance prescribing

Convert all to diazepam (see DH Guidance)

Keyworking and psychosocial support should be in place in conjunction with prescription

Review frequently

Set boundaries and stick to them (e.g. no replacement or additional scripts, agreed time limits etc.)

Be more reluctant to initiate a prescription of benzodiazepines than opioids

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Case study - Stephen Stephen aged 32 came to see you at the GP surgery. He is prescribed methadone by one of the partners at the surgery and had a drug treatment review last week. At this review it was reported that he was prescribed 65mg of methadone and disclosed no illicit drug use. He has a history of heroin and crack cocaine use (for 5 years), but has not used either since stabilising on methadone 9 months ago. He reported at this drug treatment review that he felt the methadone was “holding him” – he reported no withdrawal symptoms and felt that he needed no changes to his methadone programme at that time.  He has a history of moderate depression, and is also prescribed mirtazapine 30mg, which he has been taking for 6 months.  He has presented today to disclose that he has been buying illicit diazepam. He did not mention this at the review last week, and reports that he used to take diazepam “occasionally” when taking heroin, but has been taking increasing amounts of diazepam over the preceding 3 or 4 months.  

 What would your initial assessment involve? What other information do you need? What are Stephen’s risks? What are the issues that you need to consider that influence a decision to prescribe benzodiazepines? What would be your treatment plan? If you decide to prescribe, what would you prescribe and what would be your ongoing plan with respect to this? Who else would you involve? 

Stephen

Case study - Irene Irene is a 54 year old female patient who has recently joined your practice and presents to you saying, “I need my zopiclone”. She had seen the GP Registrar the previous evening and they refused to prescribe any zopiclone and told her it was “practice policy not to prescribe sleepers”. She is very distressed this morning, and presents tearful and anxious. On questioning she reveals that she is prescribed 28 x 3.75mg tablets per month (or so) and takes “1 or 2 each night” to help her sleep. She says she has been told in the past that the zopiclone is “bad for you”, but she feels that she “can’t cope” without them.  She says they were initially prescribed by her previous GP when her husband left her 5 years earlier, and has been picking them up “without any problem” ever since. She moved into your practice area recently to be nearer

to her daughter.

Would you continue her prescription? What are the risks to Irene? What other issues are there? What would be your treatment plan? What are your prescribing options? Who else would you involve?  

Irene

Case study - Mary

78 year old woman, comes to see you with her 43 year old daughter who lives 15 miles away. Family concerned as several falls and ambulance had to be called once when daughter away. Also says she has been a bit forgetful lately but she blames her age. Had a “nervous breakdown” in 1972 and was started on lorazepam 1.5mg tds and temazepam 10mg at night

Case study - Mary

She is well dressed and good eye contact, she repeatedly apologies for bothering you.

On exam she has a mild tremor and is slightly unsteady when walking.

MMSE scores 26

Case study - Mary

What would your initial assessment involve?

What other information do you need? What are her risks? What would be your treatment plan? Who else would you involve?