Prescribing drugs of dependence in general practice

Part A - Clinical Governance Framework - Chapter 1

Introduction

Last revised: 25 May 2021

Introduction

Prescription medication misuse is a worldwide problem. In Australia, there are growing concerns about the increasing misuse and associated harms of a range of pharmaceuticals.1 Many types of medications are misused,2 particularly drugs of dependence. Of particular concern is the problematic use of benzodiazepines and prescription opioids.1,3

Reducing misuse of pharmaceutical drugs and associated harms is a national priority.4 The Royal Australian College of General Practitioners (RACGP) has developed a series of guides on drugs of dependence to help GPs play an important role in tackling the problem.

Part A – Clinical governance framework, describes the overarching principles and strategies for use with the individual drugs of dependence guides.

In 2020, changes to approved opioid indications were made across the class to help address misuse and harms in Australia. Significantly, the use of modified release opioids is not indicated in chronic non-cancer/malignant pain, except in ‘exceptional circumstances’.

Additional warnings and precautions for use were also added to Product Information and Consumer Medicine Information.

Pharmaceutical Benefits Scheme (PBS) restrictions and authority requirements have also been updated to reflect the new indications.

More detailed information on the changes is provided at Section 2 Laws and regulations.

Throughout the guide, minor updates have been made to align with 2020 changes to opioid prescribing regulations. Guideline recommendations have not been updated with new evidence.

This guide aims to improve the quality and safety of prescribing of drugs of dependence in general practice by:

  • helping practices develop a clinical governance framework for prescribing drugs of dependence that complements the Australian regulatory framework
  • supporting practices and GPs in the development of an environment of quality improvement and best practice with regard to drugs of dependence
  • promoting safer prescribing and non-prescribing within general practices
  • enabling the recognition of higher risk situations and offering solutions to manage these appropriately
  • bringing together tools and evaluation processes for patients with more complex problems
  • providing solutions to enable general practice to prevent and manage prescription drug misuse.

The intended impact is a reduction in adverse events associated with prescribing drugs of dependence.

This guide is designed to assist GPs in the management of drugs of dependence. It is not a set of mandatory rules. General practice has varying degrees of exposure to issues surrounding drugs of addiction. Each practice needs to determine which features of this guide are relevant for their circumstances.

General practices need to consider the recommendations and implement these according to their local circumstances.

The appendices contain examples of some practice policies. These examples are not individually approved or endorsed by the RACGP Council, or by the Standards. They are based on policies and practices from national and international sources. If practices wish to adopt any of these policies, they should be adapted or modified for relevance and applicability to the local context. 

Who will use this guide and why?

This guide may be used by practice owners, managers and support staff who:

  • are concerned about prescription drug abuse in their practice area and want to prevent a mishap
  • service a population with a high prevalence of mental illness, pain and/or addiction problems and want to ensure they provide the best possible care
  • have had an adverse event associated with prescription drug abuse and want to know how to prevent a recurrence
  • have doctors who have expressed concerns about what is happening regarding drugs of dependence
  • want to contribute toward reducing prescription drug abuse in their community.

This guide may be used by GPs who:

  • rarely sees patients who abuse prescription medication, but want to know more about the proper management and treatment of these patients
  • occasionally sees patients who abuse prescription medication, but uncertain of their legal responsibilities
  • felt unsafe during a consult with a patient with drug-seeking behaviour, and would like to take something to their practice manager to address this
  • saw an adverse event with a colleague, and would like to know how their practice and colleagues can manage this problem better
  • is starting in a new practice and would like a way of talking about the issues of prescribing drugs of dependence at the next practice meeting
  • works with other GPs who frequently prescribe drugs of dependence for conditions where other (safer/more effective) evidence-based therapies exist (eg insomnia), and is concerned about this practice and the risks associated with it, and would like some guidelines to discuss with them and implement in their practice
  • would like the support of professional colleagues and the RACGP in advising patients on the risks and benefits of use of prescribed opioids and be able to make an assessment that weighs the risks versus the benefits of continued prescribing and the skills to taper and terminate opioids when appropriate.

This guide may be used by medical students who:

  • were taught the harms associated with the use of benzodiazepines and opioids, yet have seen this in some practices.
  • This guide may be used by general practice registrars who:
  • are starting in a practice in their first GP rotation and want advice on how to prescribe safely
  • want assistance in implementing a policy of one prescriber for any drug of dependence
  • want to feel confident and supported in advising senior colleagues that they will not provide ongoing prescriptions for drugs of dependence to patients they do not know.

This guide may be used by a psychiatrist, alcohol and drug addiction specialist, chronic pain specialist, other medical practitioner, practice nurse, nurse practitioner, credentialed mental health nurse, psychologist, social worker, or allied health professional who:

  • is concerned about the prescribing habits of the doctors they work with and would like some guidelines to discuss with them.

Drugs of dependence have an important and valuable role in patient care. In recent years, the number of psychoactive drugs and formulations available in Australia has increased substantially.3 Many of these drugs have provided significant benefits to patients. However, the evidence demonstrates that pharmaceutical misuse is rapidly emerging as a drug problem.5

GPs need to be aware of the extent of the problem of pharmaceutical drug misuse, the factors involved and the role of general practice in potential solutions.

The extent of the problem

How Australia compares

he US6 and Canada7 acknowledge there is a serious problem with the misuse of prescription opioids.3 Prescriptions in the US account for 99% of the worldwide consumption of oxycodone, while it only comprises 4.7% of the world’s population.5 This may make Australia’s issues seem minor in comparison, however, Australian data shows a high prevalence of misuse of prescriptions opioids.2 According to the 2014 World Drug Report, the annual prevalence of misuse of prescription opioids is:2

  • Australia 3.1%
  • Canada 1%
  • Nigeria 3.6 %
  • Pakistan 1.5%
  • US 5.2 %.

While benzodiazepine prescribing has remained reasonably steady (approximately 7 million prescriptions per year8), there has been a dramatic change in the profile of the benzodiazepines prescribed and alprazolam use has increased by one-third.4

There is an understanding that the pattern of substance misuse changes over time as the types and availability of illicit and pharmaceutical drugs change.3 However, there are still a number of gaps in our understanding of problematic use of prescribed drugs of dependence in Australia.9 Research in this area continues.

Key findings of the National Drug Strategy Household Survey 201310 indicate:

  • the number of people participating in any illicit use of drugs, including pharmaceutical misuse, in Australia is increasing
  • the proportion of people using most illegal drugs has remained relatively stable and the use of some illegal drugs has even slightly decreased over the last three years
  • in 2013, nearly 8 million (42%) people in Australia aged 14 years or older had ever illicitly used drugs, including misuse of pharmaceuticals; almost 3 million (15.0%) had done so in the last 12 months, compared to approximately 2.7 million (14.7%) in 2010
  • non-medical use of pharmaceuticals in the previous 12 months had increased overall since 2007 and was at the highest level of use since 1998 (from 3.7% in 2007 to 4.7% in 2013) (Figure 1)
  • the increase in pharmaceutical misuse in 2013 was mainly due to significant increases in recent use by men aged 30–39 (from 4.5% to 6.9%) and women aged 40–49 (from 3.1% to 4.5%)
  • among people who reported recent misuse of any kind of painkiller/analgesic (3.3%), about three-quarters had misused over-the-counter pain killers and half had misused prescription pain killers.
Figure 1. Misuse of pharmaceuticals by people aged 14 and over, 1995–2013

Figure 1

Misuse of pharmaceuticals by people aged 14 and over, 1995–2013
Source: Australian Institute of Health and Welfare.


The harms

Drug-related harm is experienced by both sexes and across all ages and levels of use (experimental, recreational, dependent) and with therapeutic use. Harms includes loss of life through overdose and accidents, negative mental and physical health effects, family and social problems, psychological and emotional difficulties, and legal and financial problems.11

The factors involved

Problematic use is widespread

Pharmaceutical drug misuse problems exist on a spectrum ranging from inadvertent misuse associated with inappropriate prescribing practices through to deliberate misuse.5 There are numerous reasons people deliberately misuse prescription medications. Self-medication (pain, anxiety, insomnia), drug substitution, enhancement of other drugs and enjoyment are common examples. Vulnerable individuals may use substances including psychoactive prescription drugs to make themselves feel better.12 This new, hidden population13 may differ from the usual drug user stereotypes as they may be more highly functioning and may have higher socioeconomic status, better education and more social support.3

More drugs are being prescribed (and diverted)

Prescription rates of opioids have substantially increased: between 1997 and 2012, oxycodone and fentanyl supply increased 22-fold and 46-fold respectively.3 Oxycodone is now the seventh leading drug prescribed in Australian general practice.3 The number of opioid prescriptions subsidised by the Pharmaceutical Benefits Scheme (PBS) increased from 2.4 million in 1992 to seven million in 2007.3

Not all prescriptions will lead to improved patient outcomes.

Sources of drugs

In a 2012 study of participants in an Australian methadone and buprenorphine treatment program (ie people representing the more ‘severe’ end of the spectrum of problematic pharmaceutical drug users), most regular prescription opioid users reported buying their opioids from others. In contrast, a medical practitioner was the main source of benzodiazepines (Table 1).14

Being part of the solution

General practice prescribing practices are a key to minimising the harms from drugs of dependence.

If prescribers do not rise to the challenge of appropriate and accountable prescribing, there is a risk Australia will experience the high rates of the prescription drug abuse of other countries or face oppressive regulatory responses.

This guide encourages general practices and GPs to be part of the solution by reducing prescription drug abuse through clinical governance at a practice level and accountable prescribing at the GP level. Both levels are supported by formal and informal controls around drugs of dependence.

Good clinical governance in prescribing drugs of dependence is supported by a comprehensive practice policy and a unified approach to drugs of dependence, and these, in turn, support individual GPs to prescribe these drugs safely and appropriately.

The health sector is characterised by complexity, multiple stakeholders (national and state/territory governments, public and private providers, professions and consumer groups) and numerous regulatory agencies and regulatory standards.15 Policy makers, regulators and professional bodies all have roles to play in developing an environment for quality improvement that supports general practice in its quest for quality.

Multiple levels of regulation surround the prescription of drugs of dependence. The overarching control mechanisms are legislation and regulation. Legislation focuses on the drug, who can prescribe it, which patient is eligible and the legal penalties for non-compliance. Regulators license prescribers and can apply penalties. They provide an important level of protection for patient safety. However, legislation offers limited scope for ensuring patient-centred care or clinical effectiveness, and has little ability to drive quality improvement.

Self-regulation by GPs around quality and safety has improved.15 Although important for quality improvement within individual general practices, self-regulation is not sufficient to realise improvements across the whole of primary care.15 Media scrutiny and scandals in healthcare settings mean the public no longer accept doctors’ self-regulation of safety and quality.15

Between overarching frameworks and practitioner self-regulation is regulation at the practice level. Meta-regulation is a reasonably recent level, which evolved in response to regulatory failures (not necessarily within the health sector, although they have occurred here). Clinical governance falls within the level of meta-regulation.

Meta-regulation is enforced self-regulation.15 It enhances the self-regulatory capacity of general practices by requiring risk management and quality improvement strategies, which achieve more than legally required.16 That is, external standards are used to drive internal quality improvement.

Meta-regulation brings together general practice’s understanding of the issues and its capacity to manage them with demands and expectations of government agencies and professional bodies such as the RACGP.

Figure 2

Figure 2

Levels of practice regulation

Adapted from Healy J, Braithwaite J. Designing safer health care through responsive regulation. MJA 2006;184:S56–S59.

A ‘softer’ version of practice regulation involves learning models such as triple-loop learning17 in which practitioners evaluate their outcomes (first loop) and feed this learning into the practice (second loop).15 The third loop occurs when a regulator, such as an accreditation agency or a health department, learns from monitoring the practice’s double-loop learning and revises its regulatory goals for the whole field.15

Clinical governance

Clinical governance should ensure patient care is accessible, approachable and responsible, and a practice environment is developed that provides quality improvement in prescribing of drugs dependence.

What is clinical governance?

Clinical governance is a ‘system through which organisations are responsible for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’.18 It involves a number of interlinked structures and activities designed to ensure that managers, clinicians, pharmacists and those who govern health services are aware of their roles and responsibilities, and have the appropriate arrangements and processes in place to effect robust governance.19 For the system to work effectively, each level of service must properly take on their responsibilities

Clinical governance is a framework for quality improvement that coordinates interactions between patients, healthcare providers and the healthcare system. Each practice has tailored policies and procedures that coordinate with other healthcare services (eg pharmacies, alcohol and drug services) and align with local and national health policy (eg National Drug Strategy 2010–2015).

Clinical governance is a process made up of a large number of elements. In the context of drugs of dependence, elements of clinical governance include:20,21

  • lines of responsibility and accountability (clinical leaders)
  • risk management – practice policies and general standards to support patient safety and clinical effectiveness
  • education on clinical effectiveness – evidence-based practice
  • clinical audit – important for identifying patients at risk of dependence
  • research and development.

For many of these elements there is a range of criteria or recognised standards of good practice that can be used in audit and benchmarking.

While GPs have direct accountability for prescribing drugs of dependence, the whole practice team has a responsibility to engage in activities to improve patient safety and reduce problematic use of prescription medication in the community.

Clinical governance within a general practice

Clinical governance is achieved through effective leadership and commitment to excellence within general practice and across the healthcare sector.

Full implementation of clinical governance in any general practice may take time as policies and procedures are developed and partnerships with other providers are formed.

There are considerable gaps in available services, such as pain medicine and dependence treatment programs, and in many areas, general practice may need to take on broader care roles with complex patients. In this case, GPs may need additional training and should seek advice from distant specialist services (eg addiction medicine specialists).

  1. Leong M, Murnion B, Haber PS. Examination of opioid prescribing in Australia from 1992 to 2007. Intern Med J 2009;39(10):676–81.
  2. United Nations Office on Drugs and Crime. World Drug Report 2014. New York: United Nations; 2014.
  3. Dobbin MD. Pharmaceutical drug misuse in Australia. Australian Prescriber 2014;37(3):79–81.
  4. National Drug Strategy. National pharmaceutical drug misuse framework for action 2012–2015 – A matter of balance. Canberra: NDS, 2011. [Accessed 22 May 2015].
  5. Nicholas R, Lee N, Roche A. Pharmaceutical Drug Misuse in Australia: Complex Problems, Balanced Responses. Adelaide: National Centre for Education and Training on Addiction (NCETA), Flinders University; 2011. [Accessed 22 May 2015].
  6. Office of National Drug Control Policy (ONDCP). Epidemic: Responding to America’s Prescription Drug Abuse Crisis. Washington DC: Executive Office of the President of the United States; 2011. [Accessed 22 May 2015].
  7. College of Physicians and Surgeons of Ontario. Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis. Toronto: CPSO; 2010. [Accessed 22 May 2015].
  8. Medicare Australia Statistics. Pharmaceutical Benefits Schedule Item Reports. [Accessed 22 May 2015].
  9. [Accessed January 2014].
  10. Nicholas R, Lee N, Roche A. Pharmaceutical Drug Misuse in Australia: Complex Problems, Balanced Responses. Adelaide: National Centre for Education and Training on Addiction (NCETA); 2011. [Accessed January 2014].
  11. National Drug Strategy Household Survey [press release]. Canberra: AIHW; 2014. [Accessed January 2014].
  12. Fitzroy Legal Service. Harms caused by drugs. Melbourne: Fitzroy Legal Services; 2014. [Accessed January 2014].
  13. Harris KM, Edlund MJ. Self-medication of mental health problems: new evidence from a national survey. Health Serv Res 2005;40(1):117–34. [Accessed January 2014].
  14. Nielsen S, Bruno R, Lintzeris N, Fischer J, Carruthers S, Stoove M. Pharmaceutical opioid analgesic and heroin dependence: how do treatment-seeking clients differ in Australia? Drug Alcohol Rev 2011;30(3):291–9. [Accessed January 2014].
  15. Nielsen S, Bruno R, Degenhardt L, et al. The sources of pharmaceuticals for problematic users of benzodiazepines and prescription opioids.Med J Aust 2013;199(10):696–99. [Accessed January 2014].
  16. Healy J, Braithwaite J. Designing safer health care through responsive regulation. Med J Aust 2006;184(10 Suppl):S56–9. [Accessed January 2014].
  17. Haines F. Regulatory failures and regulatory solutions: a characteristic analysis of meta-regulation. Proceedings, Annual Meeting. Baltimore,MD: Law and Society Association; 2006. [Accessed January 2014].
  18. Parker C. The open corporation: effective self-regulation and democracy. Cambridge: Cambridge University Press; 2002. [Accessed January 2014].
  19. Scally G, Donaldson LJ. The NHS’s 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317(7150):61–5. [Accessed January 2014].
  20. Healthdirect Australia. Clinical Governance Framework. Sydney: Healthdirect Australia; 2013. [Accessed January 2014].
  21. The Royal Australian College of General Practitioners. Standards for general practices, 4th edition. Melbourne: RACGP; 2013. [Accessed January 2014].
  22. Harris S, Taylor S, Agency NT. Clinical governance in drug treatment: A good practice guide for providers and commissioners. London: NTA; 2009. [Accessed January 2014].
  23. MDA National. Things to Think About Before You… Prescribe Schedule 8 Drugs [press release]. MDA National. [Accessed January 2014].
  24. Cran A. Misuse of opioid drugs. Defence Update: A quarterly publication for MDA National Members [Internet]. Sydney: MDA National; 2013. [Accessed January 2014].
  25. Prescription Benefits Scheme. 2. Prescribing Medicines – Information for PBS Prescribers Canberra: Department of Health. January 2014].
  26. Medicare. Practitioner Review Program Canberra: Australian Government; 2013 [updated 1 August 2013, January 15, 2014]. [Accessed January 2014].
  27. The Royal Australian College of General Practitioners. What is General Practice? Melbourne: RACGP; 2012. [Accessed September 2013].
  28. Keckley PH, Hoffmann M, Underwood HR. Medical Home 2.0: The Present, the future. Washington, DC: Deloitte Centre for Health Solutions; 2010. [Accessed September 2013].
  29. American Academy of Family Physicians (AAFP) AAoPA, American College of Physicians (ACP), American Osteopathic Association (AOA). Joint Principles of the Patient-Centered Medical Home. Washington, DC: Patient Centred Primary Care; 2007. [Accessed September 2013].
  30. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient satisfaction: a critical review. Ann Fam Med 2004;2(5):445–51. [Accessed September 2013].
  31. Grumbach K, Grundy P. Outcomes of implementing patient centred medical home interventions: A review of the evidence from prospective studies in the United States Washington DC: Patient-Centred Primary Care Collaborative; 2010. [Accessed September 2013].
  32. Geisinger Health System. Presentation at White House Roundtable on Advanced Models of Primary Care: August 10, 2009. Washington DC; 2009. [Accessed September 2013].
  33. Steiner BD, Denham AC, Ashkin E, Newton WP, Wroth T, Dobson LA, Jr. Community care of North Carolina: improving care through community health networks. Ann Fam Med 2008;6(4):361–67. [Accessed September 2013].
  34. Scholle SH. Developing and testing measures of patient centred care. New York: The Commonwealth Fund; 2006. [Accessed September 2013].
  35. Beal A. Closing the divide: how medical homes promote equity in Health care. New York: The Commonwealth Fund; 2007. [Accessed September 2013].
  36. Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database Syst Rev 2011;(10):CD004147. [Accessed September 2013].
  37. Heit HA, Lipman AG. Pain: Substance Abuse Issue in the Treatment of Pain. In: Moore RJ, editor. Biobehavioral Approaches to Pain. New York: Springer Science+Business Media, LLC; 2009. p. 363–81. [Accessed September 2013].
  38. National Drug Stategy amd National Mental Health Strategy. National Comorbidity Project. Canberra: of Health and Aged Care; 2001. [Accessed September 2013].
  39. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 6: Clinical Handover (October 2012). Sydney: ACSQHC; 2012. [Accessed September 2013].
  40. Medicare Australia. Prescription Shopping Program 2014. [Accessed January 2014].
  41. Gorgels WJ, Oude Voshaar RC, Mol AJ, et al. Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study. Drug Alcohol Depend 2005;78(1):49–56. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis. Br J Gen Pract 2011;61(590):e573–78. [Accessed January 2014].
  42. Department of Health (England) and the devolved administrations. Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Govenment and Northern Ireland Executive; 2007. [Accessed January 2014].
  43. Travaglia J, Debono D. Clinical audit: a comprehensive review of the literature. Sydney: Centre for Clinical Governance Research in Health, Faculty of Medicine, University of New South Wales; 2009. [Accessed January 2014].
  44. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6:CD000259. [Accessed January 2014].
  45. Morden NE, Schwartz LM, Fisher ES, Woloshin S. Accountable prescribing. N Engl J Med 2013;369(4):299–302. [Accessed January 2014].
  46. Walter J. Prescribing for self and family: one national system, eight different rules. Sydney: MDA National; 2012. [Accessed January 2014].
  47. General Medical Council. Good practice in prescribing and managing medicines and devices. London: GMC; 2013. [Accessed January 2014].
  48. Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for better prescribing. BMJ 2006;333(7566):459–60. [Accessed January 2014].
  49. Wolfert MZ, Gilson AM, Dahl JL, Cleary JF. Opioid analgesics for pain control: Wisconsin physicians’ knowledge, beliefs, attitudes and prescribing practices. Pain Med 2010;11(3):425–34. [Accessed January 2014].
  50. Kamarudin G, Penm J, Chaar B, Moles R. Educational interventions to improve prescribing competency: a systematic review. BMJ Open 2013;3(8):e003291. [Accessed January 2014].
  51. de Vries TPGM, Henning RH, Hogerzeil HV, Fresle DA. Guide to Good Prescribing: A practical manual. Geneva: World Health Organization Action Programme on Essential Drugs; 1994. [Accessed January 2014].
  52. Ross S, Loke YK. Do educational interventions improve prescribing by medical students and junior doctors? A systematic review. Br J Clin Pharmacol 2009;67(6):662–70. [Accessed January 2014].
  53. Longo LP, Parran T, Jr., Johnson B, Kinsey W. Addiction: part II. Identification and management of the drug-seeking patient. Am Fam Physician 2000;61(8):2401–8. [Accessed January 2014].
  54. Majumdar SR, Soumerai SB. Why most interventions to improve physician prescribing do not seem to work. CMAJ 2003;169(1):30–1. [Accessed January 2014].
  55. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med 2005;6(2):107–12. [Accessed January 2014].
  56. Drugs and Alcohol Services South Australia. Opioid prescription in chronic pain conditions. Adelaide: DAAS SA, the Flinders Medical Centre Pain Management Unit and the Royal Adelaide Hospital Pain Management Unit; 2008. [Accessed January 2014].
  57. Liu Y, Logan JE, Paulozzi LJ, Zhang K, Jones CM. Potential misuse and inappropriate prescription practices involving opioid analgesics. Am J Manag Care 2013;19(8):648–65. [Accessed January 2014].
  58. Fries Taylor E, Genevro J, Peikes D, Geonnotti K, Wang W, Meyers D. Buiding Quality Improvement Capacity in Primary Care: Supports and Resources. Decisiomaker Brief: Primary Care Quality Improvement No. 2. Rockville: AHRQ; 2013. [Accessed January 2014].
  59. Elliott RA, Woodward MC, Oborne CA. Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback. Intern Med J 2001;31(9):529–35. [Accessed January 2014].
  60. Clubb B. The drug seeking patient. Brisbane: Professor Tess Cramond Multidisciplinary Pain Clinic, Royal Brisbane and Women’s Hospital; 2009. [Accessed January 2014].
  61. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition. Arlington: American Psychiatric Publishing; 2013. [Accessed January 2014].
  62. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev 2006;26(1):17–31. [Accessed January 2014].
  63. Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev 2003;(1):CD003161. [Accessed January 2014].
  64. Mitchell MD, Gehrman P, Perlis M, Umscheid CA. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract 2012;13:40. [Accessed January 2014].
  65. Kierlin L. Sleeping without a pill: non pharmacological treatments for insomnia. Journal of Pscychiatric Practice 2008;14(6):403–7. [Accessed January 2014].
  66. Hasora P, Kessmann J. Nonpharmacological management of chronic insomnia. Am Fam Physician 2009;79(2):125–30. [Accessed January 2014].
  67. Gunter RW, Whittal ML. Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access. Clin Psychol Rev 2010;30(2):194–202. [Accessed January 2014].
  68. Morin CM, Vallieres A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA 2009;301(19):2005–15. [Accessed January 2014].
  69. Patient Safety and Quality Improvement Service. Guide to Informed Decision-making in Healthcare. Brisbane: Queensland Health; 2012. [Accessed January 2014].
  70. World Health Organization. Lexicon of alcohol and drug terms published by the World Health Organization Geneva: WHO; 2014. [Accessed January 2014].
  71. O’Regan R. Drug Seeking Behaviour: Identifying and dealing with the issues. Perth: North Metro Community Drug Service; 2012. [Accessed January 2014].
  72. The Royal Australasian College of Physicians. Precription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use. Sydney: RACP; 2009. [Accessed January 2014].
  73. Therapeutic Goods Administration. Scheduling basics Canberra: Department of Health; 2011. [Accessed January 2014].
  74. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2):85–92. [Accessed January 2014].
  75. Agency Medical Directors’ Group. Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An educational aid to improve care and safety with opioid therapy. Washington: AMDG; 2010. [Accessed January 2014].
  76. Rossi Se. Australian Medicines Handbook 2011. Adelaide: Australian Medicines Handbook Pty Ltd; 2011. [Accessed January 2014].
  77. eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2013 [Accessed December 2013]. [Accessed January 2014].
  78. WA Cancer and Palliative Care Network. Opioid Coversion Chart. Perth: Department of Health and Ageing; 2010. [Accessed July 2014].
  79. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Hamilton: McMaster University; 2010. [Accessed July 2014].
  80. Robinson G. Prescription drug misuse: How to identify and manage drug seekers. BPJ 2008;(16):18–23. [Accessed July 2014].
  81. Friese G, Wojciehoski RF, Friese A. Drug seekers: do you recognize the signs? Emerg Med Serv 2005;34(10):64–7, 88–9. [Accessed July 2014].
  82. Rull G. Assessment of Drug Dependence. Leeds: Egton Medical Information Systems; 2011. [Accessed July 2014].
  83. Ford C, Halliday K, Lawson E, Brown E. Guidance for the use of substitute prescribing in the treatment of opioid prescribing in the treatment of opioid dependence in primary care. London: RCGP; 2011. [Accessed July 2014].
  84. Moeller KE, Lee KC, Kissack JC. Urine drug screening: practical guide for clinicians. Mayo Clin Proc 2008;83(1):66–76. [Accessed July 2014].
  85. National Opioid Use Guideline Group. Canadian Guideline for Safe and Effective Use of Opioid for Chronic Non-Cancer Pain: NOUGG; 2010. [Accessed July 2014].
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log

Advertising