Co-ordinated approach to illicit prescription drug abuse

Dr Greg LydallConsultant Psychiatrist, HSSD Guernsey

SSA York, 2015

What we will cover

• Small island context• Problems• 3 datasets• Findings• Action plan• Results

What we will cover

• Intro• Method• Results• Discussion• Conclusions

What we will cover

• Intro• Method• Results• Discussion• Conclusions

Introduction

• Island community• Illicit drugs are difficult to import and

expensive• Drug users look to alternative substances

mainly pharmaceuticals• Implications for local prescribers, treatment,

prognosis and prevention

Clinical picture in Guernsey• Very different to UK experience• Anecdotally, little heroin, poor quality.• Pharmaceuticals esp fentanyl and benzos

misused and implicated in ODs & deaths• Fentanyl patches ut into strips and cooked up• Extracted and injected• Street value £200-300 for 100mcg patch• Pre-filled syringes available• Suboxone street value £10/mg (vs £1/mg UK)

Clinical picture in Guernsey

Source: opiophile.org; bluelight.org; drugs-forum.com

Clinical picture in Guernsey

Image sources: opiophile.org; bluelight.org; drugs-forum.com; erowid

Drug treatment in Guernsey• CDAT: NTA tier 2-3; no T4 on island• Charity NTA T1 + NEX• AA active; no NA• OST options are mainly DF-118 (high dose) and Subuxone >

Subutex• Methadone not approved• “NHS” (Mental health, addictions, infectious diseases,

radiology, pathology)• Medical Specialists Group (chambers): all other secondary

care• Primary Care is private • All 3 different systems – including data systems!

Methodology

• 3 Audit results examined:– Unnatural deaths (2002-2011) [States Pathologist]– Substances misused from CDAT referrals (2011-13)– Prescribing data [Prescribing Advisor]

Results (1):Unnatural deaths

• n=106 (suicides, RTAs, etc)• n Alcohol = 20• n Drugs (all) = 25• M:F = 60:40• Small numbers per year - confidentiality

Source: ONS.gov.uk

Different drug death profiles

• Higher proportion of fentanyl, benzo deaths• Fentanyl = Heroin (14%) < Heroin E&W (30%)• DHC/Codeine 17% vs E&W 2%• Methadone 4% vs E&W 12%• Paracetamol 4% vs E&W 11% • Guernsey: no cocaine, amphetamine deaths• BUT: small Guernsey numbers (n=106) vs E&W

(27k)

Results (2)

• 280 drug patients were referred/3 yrs• Buprenorphine (36%), benzodiazepines (30%),

dihydrocodeine (18%), fentanyl (9%), heroin (7%) and codeine (7%)

• 90%+ misusing prescription only medicines (POMs) and over the counter (OTC) drugs, particularly opiates and benzodiazepines

• Reported patterns of use tended to follow local availability and poly-drug misuse was common

(2) Top 10 = pharmaceuticals

NTA data (2011-12)

(3) Drug groups misused at referral to secondary care addictions

Guernsey E&W* Group 2011 2012 2013 Total % %OPIOIDS (all) 65 64 76 205 73 >90%FENTANYL 9 9 6 24 9 ?BENZODIAZEPINES 25 28 30 83 30 25EDOC /NPS 4 5 9 18 6BUPRENORPHINE 26 29 46 101 36HEROIN 11 5 4 20 7CODEINE 6 7 6 19 7DIHYDROCODEINE 22 13 14 49 18

* Addiction to medicines, NTA, 2011/

Class 2011 2012 2013 Total Avg % UK*Drugs Referrals 80 97 103 280POM 75 67 79 221 79 16%*illegal 17 18 13 48 17 90%+OTC 3 5 4 12 4 ?OTC+POM 78 72 83 233 83 16%

* In 2009-10, just 2% (3,735) of those in drug treatment services reported their primary problem was with POM/OTC (referred to as ‘POM/OTC-only’). A further 14% (28,775) whose primary dependency was illegal drugs reported additional problems with POM/OTC (referred to as ‘POM/OTC+’). This means that overall 16% (32,510) of people in drug treatment services reported problems with their use of POM/OTC medicine out of a treatment population of 206,889.

Results (3): Drugs misused by legal class

Implications

• Drug users are creative and will find alternative substances and ways of using them

• Fentanyl-related deaths = heroin-related deaths at post mortem/case review

• A high risk sub-group of substance misusers (9%) injecting fentanyl (derived from fentanyl patches) was identified

• How to address fentanyl and POM availability?

Action Plan

• Discussed with service users, Public Health, Drug & Alcohol Team, and Drug & Alcohol Strategy Co-ordinator in 2011

• Suggested a forum be set up to raise concerns, share info, monitor trends, discuss strategies to address POM availability

Addictive POM Group

• Public Health, CDAT, Border Agency, Primary Care, Pain Clinic, Prison HC

Action Plan (2)

• APOM group met first in 2011 quarterly• Prescribing advisor showed fentanyl px data• Opioid px audit: Primary Care & Pain Clinic• Border agency: aware to look for APOM

imports – changed policy (personal use) and several arrests

• Prenoxad programme for high risk injectors

Results (1)

Conclusions (1)

Conclusions (1)

Conclusions (1)

Conclusions (1)

Conclusions (1)

Conclusions (1)

Conclusions (1)

Conclusions (1)

Results (2): changes in prescribing

• Over 2011 to 2013:• Fentanyl prescribing ↓ by 18% and cost ↓ by 45% • Sedative hypnotics ↓ by 13%• Morphine increased…• Oxycodone and Tramadol increased…• Increased awareness among prescribers• Support for various initiatives incl Community

Supervised Consumption, GP shared care• Annual audit of drugs misused at referral to

continue

Discussion (1)

• High rates of pharmaceutical drug misuse• May reflect the low availability of illicit drugs:

displacement• Increases demand for addictive POMs and OTCs. • Prescribers in isolated communities need to be

more cautious when prescribing addictive POMs• Pharmacists and Prescribing Advisors may need to

monitor for POM and OTC drug misuse particularly of opioid-containing medications and benzos

• Ongoing data monitoring may be helpful

Discussion (2)

• Generalizeable?• Island, small area, homogeneous population• Possible to capture almost all of the people

referred for help with substance misuse• Whether that would translate to big cities is

hard to know. But for other smaller communities, may give insights into the problem and possible solutions

Discussion (3)

• Future?• Ongoing data monitoring• Cross reference with Drug Testing results• …and Prescribing data (2013-)• …and Unnatural Death data (2012-)• …wider than fentanyl: benzos, DHC• Watch Buprenorphine referrals and as Community Supervised

Consumption was strengthened in 2014• Watch if new pain meds appear in referrals

• #1 drug cause of death though = alcohol!

Conclusions

• Creative drug users• Demand high – why?• Supply restriction: borders vs prescribers• Prescribing responsibility: wider than patient• Addictive POM group: co-ordinated approach

may reduce prescribed drugs and hence drug availability – public health initiative

• Questions? Ideas & research links welcome!

Thanks – any questions?

• Service users & carers• CDAT: Michelle Aldridge, Anna Williams, Claire

Peters, Katrina Johnston, Dr Sakhib Rahman• States Pathologist: Dr Catherine Chinyama• Prescribing advisor: Ms Geraldine O’Riordan• Director of Public Health: Dr Steven Bridgeman• Pain service: Dr Yaroslav Stefak, Ms Katie Bassett• All members of Addictive POM group

Results (1)

• Causes of unnatural death (drugs, incl alcohol) in Guernsey vs UK (2002-11)

Drug Guernsey England & Wales

Alcohol 20%

All opiatesHeroinFentanylOther

10%4%4%2%

55%28%?7%

Benzos 6% 9%

Cocaine - 6%

Amphetamine - 3%

Unnatural deaths Gsy (‘02-’11): drugsYear

Total deaths Alcohol Benzo. “Opiates” Fentanyl Heroin

2002 8 0 0 0 0 02003 9 1 1 2 0 02004 17 4 1 1 1 12005 9 2 0 2 0 22006 11 1 0 0 0 02007 12 4 1 3 1 02008 6 1 0 0 0 02009 5 0 0 0 0 02010 11 1 0 1 0 12011 17 6 3 2 2 0

total 105 20 6 11 4 4% 100 19 6 10 4 4

Top 10 drugs of misuse (self report) 2011 2012 2013

Position Drug % Drug % Drug %

1 Diazepam 29 Diazepam 28 Suboxone - illicit 24

2 Suboxone 18 DHC 15 Diazepam 19

3 Subutex 17 Suboxone 15 DHC 14

4 Heroin 14 Cannabis 12 Subutex - illicit 9

5 Fentanyl 12 Fentanyl 12 Tramadol - illicit 9

6 Codeine 7 Subutex 12 Cannabis 6

7 Cannabis 6 Codeine 7 Heroin 5

8 DHC 6 EDOCS 5 Methadone 5

9 EDOCS 6 "Opiates" 5 Codeine 4

10Codeine+

(OTC) 4 Heroin 4 Fentanyl 4