Managing Schedule 8 Drug users
With the problem of prescription drug abuse on the rise, and GPs among the key prescribers in the Australian healthcare system (in excess of 7 million scripts per annum for PBS opioids (Monheit, 2010)), there needs to be a concerted effort to equip GPs with desirable skills to address this problem. A recent coronial finding in Victoria led to a recommendation from the state coroner calling for a real time drug monitoring database to track the scripting of such medicines. This has been universally endorsed as a further measure to counteract the misuse of such medicines; however reality is that it will not fully remedy the problem. Of equal, if not greater benefit will be to address the problem from its source, that is at the point of prescription. To achieve this means that all prescribers need to be diligent in the management of patients requiring schedule 8 drugs. ‘Easier said than done’, one might say when you consider the variety of pain management options available, the fact that experiences of chronic pain are subjective in nature and individual differences in sensitivity to pain relief medicines is widespread. This is not accounting also for the use of these medicines for the purpose of sedating oneself to cope with life challenges (in a mental health and social sense). Additionally and unfortunately, it has been commonplace for GPs to be exposed to acts of violence and aggression from patients whom seek these medications and sadly there has been many scripts written in fear by GPs trying to preserve their own health and welfare. Managing such presentations requires sound clinical governance strategy, a steadfast resolve not to bow to intimidation and that a thorough BIOPSYCHOSOCIAL assessment should occur to exclude not only the physical aspects of need but additionally the mental health and social problems as a catalyst for misuse.( Hayes 2015)
Most GPs are familiar with ‘prescription shoppers’ (sometimes called‘doctor shoppers’). These people go from doctor-to-doctor seeking prescriptions for drugs for nonmedical purposes where each doctor is unaware of supply by the others. The drugs are sought for a range of reasons. These include euphoria, and self-medication of pain, anxiety and depression, but in some cases they are sought for amelioration of heroin withdrawal symptoms or purely for financial gain. (An 80mg Oxycontin tablet or 100 mg MS Contin sells on the streetsof Melbourne, Victoria for $50, a similar street price as for a cap ofheroin, and 2 mg alprazelam can be bought for $5 per tablet (Monheit, 2010)
Recognising and dealing with patients who seek drugs for nonmedical purposes can be a difficult problem in general practice. ‘Prescription shoppers’ and patients with chronic nonmalignant pain problems are the main people who constitute this small but problematic group. The main drugs they seek are benzodiazepines and opioids.
Misuse of prescription drugs can take the form of injecting oral drugs, selling them on the street, or simply overusing the prescribed amount so that patients run short before the due date and then request extra prescriptions from the doctor. Currently oxycontin and alprazolam are the most abused drugs in Australia. Adequate prescription monitoring mechanisms at the systems level are lacking so we need to rely on our clinical skills and the patient’s behaviour pattern over time to detect problematic prescription drug misuse. Management strategies may include saying ‘no’ to patients, having a treatment plan, and adopting a universal precaution approach toward all patients prescribed drugs of addiction.