1 JUNE 2016
Dealing with prescription drug-seeking behaviour
The latest issue of Australian Prescriber raises awareness of the challenges of dealing with people seeking prescription drugs.
Dr Jenny James, Medical Coordinator for the Substance Misuse Program at the Sydney West Aboriginal Health Service, calls for all GPs to develop practice policies that clearly state their approach to prescribing drugs of dependence, “All general practices should have a practice policy on prescribing drugs of dependence, as appropriate, and safe prescribing is not possible unless there is a team approach”.
“I see how the harms of prescription-drug misuse extend far and wide into the community,” Dr James says. “Between 2001 and 2012 more than 800 Australians died from use of the prescription painkiller oxycodone, and more than half of these people died accidentally. Options such as opioid substitution therapy, controlled prescribing and controlled dispensing should be considered.”
Indicators of drug-seeking behaviour include aggressive complaining about the need for a drug, asking for specific drugs by name, and anger when questioned about symptoms such as pain.
The author says, “Harms from prescription drugs, including deaths from overdose, continue to rise in Australia. Dependency on prescription drugs can occur at any age, within any cultural group and across any educational class.”
Dr James says, “GP practices need to respond to the strong evidence that serious harms can result from misuse of prescription drugs of dependence.”
People who misuse prescription drugs are most commonly seeking prescriptions for opioids and benzodiazepines. Other misused prescription drugs include the new antipsychotics such as quetiapine and olanzapine, and stimulants such as dexamphetamine and methylphenidate. Anabolic steroids are also increasingly misused.
There have been large increases in opioid prescribing in Australia, with the total number of prescriptions on the Pharmaceutical Benefits Scheme (PBS) increasing threefold between 1992 and 2007 (2.4 million to 7 million). Oxycodone was the seventh leading drug prescribed in general practice in 2014.
Dr James recommends that general practices have a practice policy on prescribing drugs of dependence. All Australian GPs should register with the Prescription Shopping Information Service, where they can ask if a patient has been identified as a prescription shopper in the previous three months. The patient’s consent is not necessary for this inquiry.
“When a patient is asking for a drug of dependence, it is a challenging situation, with GPs put in a difficult position. GPs can say ‘I don’t prescribe drugs of dependence’, then shift the focus towards seeing what other strategies can be used to help the patient with their presenting problem. If a patient requires an ongoing prescription for a drug of dependence, a full biopsychosocial assessment needs to be done. Clear boundaries need to be set with prescribing as well, such as no telephone requests for extension or allowances for ‘lost’ scripts.”
The latest issue of Australian Prescriber also provides an update for dentists by Christopher Daly, Chair of the Dental Therapeutics Committee, Australian Dental Association, on drug-seeking behaviour. Dentists should be aware that patients may seek prescriptions for benzodiazepines or opioids in order to misuse or sell those drugs. And they need to be suspicious of requests for opioid prescriptions from patients who claim to have severe dental pain, present with self-inflicted intra-oral injuries, or who have deliberately irritated previous dental work.
To access the articles, go to nps.org.au/australianprescriber.
1 JUNE 2016
Latest edition of Australian Prescriber out now
Final print issue for icon of Australian medical publishing
Changes to Australia’s leading journal for prescribers<http://dx.doi.org/10.18773/austprescr.2016.042>
After more than 40 years in print, the June 2016 issue of Australian Prescriber is the journal’s final print edition. The journal will now be moving solely online to nps.org.au/australianprescriber<https://www.nps.org.au/australian-prescriber>.
NPS MedicineWise CEO Dr Lynn Weekes writes about the company’s future vision for Australian Prescriber and explains the decision to cease print publication and distribution.
Switching and stopping antidepressants<http://dx.doi.org/10.18773/austprescr.2016.039>
There are over 20 antidepressants currently available in Australia. These can be divided into 13 clinically relevant groups. Nicholas Keks, Judy Hope and Simone Keogh explain the prescribing principles behind switching and stopping these drugs and provide a table of guidelines to help prescribers manage these changes. A poster of these guidelines is included with this last print issue of Australian Prescriber. The authors provide details on antidepressant withdrawal symptoms, relapse and exacerbation of depression, and how gradual dose reduction over days to weeks reduces the risk and severity of complications. The edition also includes a comment for dentists about the oral and dental effects of antidepressants.
Meldonium and the WADA Prohibited List<http://dx.doi.org/10.18773/austprescr.2016.032>
With the Olympics just around the corner, Dr David Hughes, medical director of the 2016 Australian Olympic Team, comments on the recent positive doping test for meldonium by Maria Sharapova at this year’s Australian Open Tennis Championships.
Where to find information about drugs<http://dx.doi.org/10.18773/austprescr.2016.023>
With so much information on medicines and health conditions, prescribers are faced with a problem of information overload. To overcome this issue, Richard Day and Leone Snowden provide a list of useful sources of drug information and examine the shortcomings of relying on internet searches. They recommend the most reliable resources to best answer specific questions about medicines and their use. A quick reference guide for sources of drug information is included in the article.
The challenge of costly drugs – editorial<http://dx.doi.org/10.18773/austprescr.2016.037>
Medical advances are producing innovative but expensive new drugs. Charles Denaro and Jennifer Martin consider the challenge of costly drugs and deciding who will receive them.
From June 2005 to June 2014 the annual cost of the Pharmaceutical Benefits Scheme (PBS) rose from $6 billion to $9.15 billion, an increase of 52%. At the same time the Highly Specialised Drugs and Section 100 programs of the PBS, which subsidise the most expensive drugs, increased by 200%. This growth has been largely driven by expensive biological therapies, antiviral therapies for HIV and hepatitis C, and a variety of small molecules used to treat subsets of various cancers. The authors recommend that an electronic national formulary for all Australian hospitals could be beneficial.
Secondary osteoporosis is less common than primary osteoporosis and results from specific clinical disorders that are potentially reversible. Angela Sheu and Terry Diamond say that there are no guidelines regarding appropriate laboratory tests for otherwise healthy people. They recommend how to investigate secondary osteoporosis and advise that bone biopsy is now rarely needed.
Other articles in the June issue of Australian Prescriber include:
* Dealing with drug-seeking behaviour<http://dx.doi.org/10.18773/austprescr.2016.022>
* New drugs: Ceftolozane sulfate with tazobactam sodium<http://dx.doi.org/10.18773/austprescr.2016.044>
2 JUNE 2016
TYPE 2 DIABETES: WHAT’S NEXT AFTER METFORMIN?
NEW NPS MEDICINEWISE PROGRAM
A new educational program aims to help health professionals keep up to date with the latest evidence on second and third line medicines for lowering blood glucose.
The latest NPS MedicineWise program—‘Type 2 diabetes: what’s next after metformin?’—will encourage GPs, pharmacists, practice nurses and diabetes educators to an individualised approach to diabetes management, balancing patient with medicine factors when choosing between the wide range of available glucose-lowering medicines.
NPS MedicineWise medical adviser Dr Jeannie Yoo says that medicine selection for treatment of type 2 diabetes is rapidly changing with increasing numbers of new medicines being introduced.
“With over one million Australians living with type 2 diabetes, and the number of people undiagnosed with type 2 diabetes also on the rise, it’s critical for health professionals to stay up to date with current approaches to managing this condition,” says Dr Yoo.
The first resource for the new educational campaign, a new edition of Medicinewise News on ‘Type 2 diabetes: when metformin is not enough’, is being distributed in print to more than 90,000 health professionals this week. It provides an update on current medicine options for particularly when considering add-on oral glucose-lowering medicines to metformin. It also discusses how to individualise therapy according to medicine and patient characteristics.
“While we are specifically hoping to improve use of second and third line therapies, strategies for improving adherence to the typical first line therapy metformin is another important focus for our new educational program,” says Dr Yoo.
“Despite high prescribing rates from GPs in line with guidelines, we know there are high levels of non adherence to metformin and would like to encourage health professionals to consider not just medicine but individual patient factors to try to improve adherence.
“Ultimately we hope that through health professionals being better informed about medicine choices, we can help people with type 2 diabetes achieve improved glycaemic control, reduce associated long term complications and minimise medicine related adverse effects.”
The NPS MedicineWise type 2 diabetes educational program will also include free educational visits and CPD activities including an interactive online case study for all types of health professionals, as well as an updated online knowledge hub for both health professionals and consumers.
Find out more
Read the latest edition of Medicinewise News – ‘Type 2 diabetes: when metformin is not enough’ at www.nps.org.au/news-diabetes-2016
Consolidate your knowledge on type 2 diabetes, brush-up on current guidelines and practices and earn CPD points through our continuing professional development activities at www.nps.org.au/type2diabetes.
Book an educational visit
To book a free one-on-one educational visit (for GPs) or small group case-based meeting (for up to 10 health professionals) with a NPS MedicineWise clinical services specialist, go to www.nps.org.au/diabetes-visit.