Prescribing drugs of dependence in general practice, Part A


1. Introduction
1.3 Why do we need this guide?
☰ Table of contents


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.


1.3.1 The extent of the problem


1.3.1.1 How Australia compares

The 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

 Misuse of pharmaceuticals by people aged 14 and over

Source: Australian Institute of Health and Welfare.


1.3.1.2 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


1.3.2 The factors involved


1.3.2.1 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


1.3.2.2 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.


1.3.2.3 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

Table 1. Self-reported sources of pharmaceuticals used by study participants in the 28 days before treatment entry*
 

A source

Usual source

Source for most recent unsanctioned use

Benzodiazepines

n

144

123

139

Doctor – real symptom

104 (72%)

79 (64%)

Doctor – fake symptom
Any prescribed source

32 (22%)
113 (78%)

9 (7%)
88 (72%)


62 (45%)

Gift

63 (44%)

10 (8%)

50 (36%)

Swap

22 (15%)

1 (1%)

2 (1%)

Stolen

9 (6%)

3 (2%)

5 (4%)

Forged prescription

5 (3%)

0

2 (1%)

Bought from friend

28 (19%)

12 (10%)

11 (8%)

Buy from dealer
Any non-prescribed source
Both prescribed and non-prescribed

25 (17%)
80 (56%)
80 (56%)

9 (7%)
35 (28%)

7 (5%)
77 (55%)

* Data are number (%) unless otherwise specified

Source: Nielsen S, Bruno R, et al. The sources of pharmaceuticals for problematic users of benzodiazepines and prescription opioids. Med J Aust 2013; 199(10):696–9 © Copyright 2013 The Medical Journal of Australia.

 

1.3.3 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.

  1. United Nations Office on Drugs and Crime. World Drug Report 2014. New York: United Nations; 2014.
  2. Dobbin MD. Pharmaceutical drug misuse in Australia. Australian Prescriber 2014;37(3):79–81.
  3. National Drug Strategy. National pharmaceutical drug misuse framework for action 2012–2015 – A matter of balance. Canberra: NDS, 2011.  [Accessed 22 May 2015]
  4. 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.
  5. 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.
  6. College of Physicians and Surgeons of Ontario. Avoiding Abuse, Achieving a Balance: Tackling the Opioid Public Health Crisis. Toronto: CPSO; 2010.
  7. Medicare Australia Statistics. Pharmaceutical Benefits Schedule Item Reports.  [Accessed January 2014].
  8. 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.
  9. National Drug Strategy Household Survey [press release]. Canberra: AIHW; 2014.
  10. Fitzroy Legal Service. Harms caused by drugs. Melbourne: Fitzroy Legal Services; 2014. [Accessed January 2014].
  11. Harris KM, Edlund MJ. Self-medication of mental health problems: new evidence from a national survey. Health Serv Res 2005;40(1):117–34.
  12. 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.
  13. 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.