Managing patients who are Opioid dependent - part 1

Sammi: Good evening everybody and welcome to this evenings Managing Patients who are opioid dependent in general practice webinar. My name is Samantha. I am your host for this evening, and thank you for joining us. Before we get started I would like to just make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present. Alrighty, I would like to introduce our presenters for this evening. We are joined tonight by Dr Hester Wilson and Dr Tim Senior. Hester has a Masters degree in Mental Health and 25 years’ experience working in the primary health care setting. Hester is also a staff specialist in addiction at Sydney’s Langton Centre Drug and Alcohol Clinic, and has facilitated training for doctors and other health care workers since 2001. And Dr Tim Senior is a GP at Tharawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, a Senior Lecturer in General Practice and Indigenous Health at UWS and an RACGP Medical Educator. So, welcome Hester and Tim and thank you for joining us tonight.

Hester: Thank you.

Tim: Thank you very much and good evening everyone.

Sammi: I will hand over to Tim now to take us through the learning outcomes for this evening and then Hester will make a start with the rest of the presentation. So over to you, Tim.

Tim: Thank you very much, Sammi. So, these are the learning outcomes, which is the educational way of saying this is what we want to achieve tonight. So by the end of this online activity, we should be able to evaluate patients who are using opioids by applying the five A’s. We should be able to set safe boundaries of care based on the safety assessment. We should be able to assess our patient’s appropriateness for opioid agonist treatment, or OAT in the general practice setting, based on the complexity, need and risk. And we should be able to review issues which should be discussed with the patient who is commencing OAT, including consent, risks, polypharmacy and fitness to drive. And we will review these again at the end just to check that we have covered them all off. So, Hester, over to you. Thank you very much.

Hester: Thank you so much. And it is so great to have so many people dialling into the webinar. There is quite a lot to get through in the next hour, but at the same time Tim and I both welcome your questions and will endeavour to answer them if we possibly can.

Now, this graph that we are seeing here just very quickly, just illustrates what has been happening with opioid prescribing in Australia and it is something that I am sure we are all aware of. Australia is amongst one of the highest opiate consuming nations. Now, we are a first world country. We have easy access. There are other parts of the world where there is not enough opiates available for people that need them. But the really interesting thing about these graphs is looking at what has happened. We can see what has happened with codeine up until 2014. It will be very interesting to see what happens with codeine since the change in scheduling. We can see the rise in tramadol and on the graph on the right, we can see the rise of fentanyl and of buprenorphine as well. As well below that is the OxyContin in which we can see a rise and really what we are seeing is that these drugs are being prescribed and unfortunately this increased supply is associated with increased harm. Sammi, if you could move it on.

And one of the really important harms from opioid use, is opioid deaths with increasing mortality. So you can see here if we look at this very simple graph from 2000 to 2011, and this is Australian data, that yes heroin has been the culprit for a significant number of overdoses. However, pharmaceutical opiates are increasingly being seen in overdose deaths. And in terms of the pharmaceutical opioids, this also is from pharmaceutical prescribed opioids and opioids obtained illicitly.

So, let us look at chronic pain and opioid use disorders because this is where the rise in opioid prescribing has taken place. This is in terms of chronic non-malignant pain, and this idea that we could cure your pain and we just need to take the dose of opioids higher and because opioids are fabulous medications in the management of acute pain and are very, very useful in end of life care, that they should be just as useful in chronic pain. The fact is that unfortunately this is not the case. And when we look at the rates of addiction and there is a whole story around addiction, but dependency and then the aberrant behaviours that can happen out of that, it averages between 8% and 10% of people will become dependent and addicted. The Pain and Opioids IN Treatment study, the POINT cohort, which is an Australian study recently conducted. What it looked at was in terms of the people who were in treatment for opioids and pain, 24% nearly one in four met the criteria and one in five met lifetime criteria for an ICD-10 pharmaceutical opioid use disorder. Now one of the really important things here and it is one of the things that I always stress when I am talking to people, is that all of us are at risk of coming to harm from opioids. There may be some individuals who because of their past history or their family history may be at slightly higher risk, but any of us with ongoing use of opioids, could be at risk of harm, could be at risk of side effects and many people have side effects from opioids and many people cannot tolerate them because of the side effects, things like constipation, nausea, sedation. But also, this risk of addiction, dependency and risky use and overdose as a consequence. The other really important thing that has come out of a number of studies including the POINT study, is that the risk of harm is dose dependent. And so, this old understanding that we had that you could just keep taking the dose up and there is a number of people that are on very, very high oral morphine daily equivalents, was that it was okay. What we are seeing now is that it is very clear that as the dose goes up, your risk goes up. And unfortunately, the benefit that you get from it plateaus. You do need of course, to take into account the individual morbidities, for example, people that have respiratory issues or sleep apnoea – those kinds of things will increase risk as well.

So, let us come to Richard, a 34-year-old who was prescribed codeine three years ago after hand surgery. He ceased it postoperatively, but then started to use it because he found it helped to relax his nerves. He had been bullied at work. He had been having a really tough time at work. Twelve months ago he was taking eight Panadeine Forte tablets a day, so around about 30 oral morphine equivalents and he saw another doctor, so he was getting those he had worked up from the codeine, the Nurofen Plus, up to the Panadeine Forte and he had seen a doctor six months ago who had said, “look codeine was not working, let us change you over to some Oxycodone” and this was increased over time to 40 mg daily, which is 60 mg of morphine, of oral morphine equivalent. Now he tried to go cold turkey two or three months ago and presented with these symptoms; sweating, shaking, poor concentration, nausea and vomiting. And he said, “I cannot go through that again, that was appalling.” Now what else? I am going to ask you guys if you can type some messages out there; what else do you want to know about Richard?

Tim, I am not seeing anything. Is that because nothing is being typed?

Tim: Oh right. Yes, no, we have got some answers coming through. So people are saying, are there alcohol… sorry it in the questions box that we can see… So people are saying, other alcohol and other drug use, the social history, the support networks, hobbies and lifestyle, are they on other medications, do they have other mental health issues such as depression? Physical illness such as liver disease. What treatment have they already tried in terms of rehab. Using pain scales to determine the level of their pain. Other morbidities. Their understanding of pain and chronic pain. And are they working? So, a good range of answers.

Hester: Yes. Really great range of answers and some of them we will come to further on in the webinar. Moving on. So, Richard he is a bar tender and he is studying as a student. And he drinks four alcohol, standard drinks of alcohol a day once a week. There is no history of injecting or other drug use. No cannabis, no methamphetamine use. He is a smoker. He started smoking in 2001. There is a family history of alcohol dependence. So there is that family history that does slightly increase his risk, but in terms of his other risk and also he is dependent on nicotine, but he has not been someone that is using other drugs. He is drinking four standard drinks a day one day a week, so he is within the safer drinking levels for one, a number of drinks on one occasion, but he is above the safer drinking levels for lifetime risk. But that is another webinar. Moving on.

So, and this came up in your questions. How do you know if someone is dependent? And you know, once again, I would come back again to this can happen to anyone. And it is not a moral issue. It is not a measure of that person being a good or a bad person. And while opioid risk tools can be useful in terms of looking at who are at slightly risk, the majority of people who do actually get into problems with the opioids actually do not have a history. They are not in that higher risk group. So something like, from the studies, around about 65% of people will not have a history. So you cannot consider because someone does not have a history or does not have a family history, that they are not at risk. In terms of presentations, there is a wide spectrum from the person who is injecting, homeless, poly-drug using, very, very unwell, significant mental health issues, to the person at the other end like this patient who is working, who is studying, who started off after a medical procedure and has found that he is using those opioids because they are centrally acting and they affect your affect, that it helped him at a difficult time. And now he is finding that he cannot stop it. So, we will come on to how do you know someone is dependent and coming back to that question, moving onto the next page.

This is a great graph and I have asked Samantha to include it in your PDFs that are sent to you, because what it does is it looks at the definition of substance use disorder or dependency. And this looks at DSM-4, DSM-5 and ICD-10. ICD-11 is not there. But when you look down at the criteria it is using larger amounts for longer than intended. Persistent desire or unsuccessful efforts to reduce use. Craving or strong desire. Time spent actually getting the medications, using them or recovering. Giving up your social, occupational or other activities that you used to enjoy. Continuing use despite interpersonal problems, work problems, social problems. Continuing use despite recurrent physical or psychological problems. Not fulfilling your major rolls. So you know, interfering with your parenting or your work or the other things that you enjoy doing. Legal issues despite, you know and continuing them despite the use. Hazardous use, using them in hazardous situations. And as well as those tolerance with withdrawal. So tolerance is the needing greater doses in order to get the effect and withdrawal is those symptoms that our patient was talking about there. So it is a really nice way to think when you are seeing a patient, different people will have different criteria and they will not have all of them. And certainly in terms of DSM-5, we would look at well, there is a mild to moderate and severe opioid use disorder and it depends on how many of those criteria people fulfil.

So moving onto the next one. And one of the other really important things is that this is work that you need to do collaboratively with people, understanding that this could happen to you or I. It could happen in our family. It can happen in our patients. And framing it from the person’s experience from their perspective. And certainly for this patient, he has come in saying, “I have got this issue and I have had these dreadful symptoms and I cannot go through it again. I am looking for your help.” Now other people may not be so able to express it in an easy way in that way, but it is really important to work with them around what is happening for them and use non-judgmental language. Things like “addict” or “junkie”, those kinds of words are not very useful. And working with them to look at what are the good things about the opioid use? What are the less good things about their opioid use and where do they sit with it? And as I say here, many people on high doses will self-identify concerns. There is a lot out there in in the media, but there is also this real concern around, “I have a real condition and I have pain, and you are, you know, the medial services are going to force me to not have my medication that I need.” What we know is that there is not a lot of evidence for use in chronic non-malignant pain. There are some people who do benefit, but that benefit is around 30% decrease in pain severity. And the other areas of life can be really adversely affected, even if pain is improved. As I said before, higher doses and long term use is associated with few benefits, so there is diminishing returns as you take those doses up. So what we are moving to now, is to looking at guidelines including the American guidelines and the Australian guidelines to really look at, let us limit the dose. Let us do a trial of opioids. If it does not work, do not keep taking the dose up because it is not going to work. So at 50 mg oral morphine equivalent which is around 40 mg of oxycodone, associated with increased overdose risk and at 100 mg it just exponentially goes up from there.

Moving on to the next slide. The four A’s of chronic pain. Now, what we mentioned at the beginning in the learning objectives was the five A’s, which is the five A’s from the SNAP guide, from the smoking, nutrition, alcohol and physical activity guide through the RACGP, which is Ask, Assess, Advise, Assist and Arrange. These are not them. There is a four A’s, but I have added a fifth one, but it is the four A’s of chronic pain. And one of you would have said in the post there that it is about a pain score. I get it. I want a pain score and we will look at some pain scores that actually give me an idea of function, and I will say to people, I am actually not interested in your pain that much, I am much more interested in how, in your function. So I really want to know about the activities of daily living, how are you going? What can you do? Can you do the things that are important to you? Analgesia – yes, you know it may well be that your pain has improved but that may be modest but it may be meaningful, but it is not the whole story. Adverse effects, what is happening with constipation? What is happening with sedation? What is happening with your sexual function? What is happening with nausea? Aberrant drug taking behaviours. Are there any things that fit into that criteria that we looked at before, which suggest that people are starting to get into trouble with their opioid use? And finally, affect, mood, the emotional response. It is a centrally activing drug. It effects the way you think and feel. And we really need to think about the framework that we have for monitoring how people are going and how we respond to that.

Moving on to the next page. These are a couple of pain scores. The first one is the PEG, which is a three item score, really great if you have only got a little bit of time. So it is Pain on average, which is P. Enjoyment of life, which is E. And general activity which is G. So the PEG score. The one that I like is the Brief Pain Inventory, and this shows one of two pages. The reason that I like that, is that it actually is a little more complex. It has more questions that it asks and it gives you a sense of how much does the pain interfere with their life and how much does it interfere with their enjoyment. So, if you are someone that likes doing measures these are available on the web. Just google them and you know, use them. And one of the things they are great to do is do the initial assessment as part of your work up with someone if you are thinking this is chronic pain, I might like to try them on some opioids. Then what you can do is you set up a plan to trial and with really clear guidelines around what change you are looking for and what will happen if you do not get that change, or if it does not improve, or there are side effects, and then repeat the score so that you have got some validation from where you began with and where you ended up with for your patient.

Moving on. I wanted to point out this website. This is the New South Wales Agency for Clinical Innovation Pain Management Network Site. So just here as you can see, the health professional tag that I have put down there has masses of resources. They have got a really good decision making tree called the quick steps through pain management. They have got lots of resources for practitioners and they have got all the measurements and treatment agreements and lots of information there. And they have also got another section which is for everybody which has videos which explain what chronic pain is and has patients’ lived experience of chronic pain and how it has affected their life and how medications and how other treatments they have had have helped or not helped. It is a really great website and I would really encourage you to take a look at it. If you just google pain management network ACI, you will find it. We have also got the details at the end of the webinar.

So looking at the general principles around pain and opioid use. You really to do a comprehensive assessment. This is not something that you can do quickly. And the other thing is that we know that the active management strategies which are not pharmaceutical work better and they help people to retrain their brain. The other thing is, people will talk about using a universal precautions approach. So you really need to be talking about the risks and benefits and the outcomes and what you are going to do collaboratively together, and really think about, I need to be thinking in all my patients, if I am considering opioids, if I am considering starting, how am I going to manage this? And what are going to be the risks and benefits? Time limit opioid use. Really thinking about what is the role of opioids in this person’s life? Now I know that many of us will have patients who are already on opioids and have been on them for some time. And this can be tricky to start to change for people. And one of the options, depending on how people are presenting is what we are covering today, which is looking at how you can treat people who now have an opioid use disorder. In terms of a patient who has been on opioids for some time, it is really important to very slowly drop that dose. You really need to be working together with your patient, get their agreement, but at the same time you have got to make a risk assessment and do what is safe. And if you have someone that comes into your rooms who is using those medications very unsafely, and you are not able to work with them collaboratively, you do not have to give them a prescription. You can encourage them to go elsewhere, to go to a pain clinic, to go to a specialist service, and I know there are issues around access, but I want really to send that message that if you are concerned about the safety, you do not have to prescribe. You can also put some boundaries around that, prescribing small amounts, doing staged supply which is where you get, the person goes to the pharmacy and gets small amounts you know a day, two or three days, maybe a week at a time or supervised dosing where they actually get an observed dose in the pharmacy setting. Having said that, if they are on very, very high doses and they are becoming very sedated or they are overdosing, even if you do staged supply that it is not going to make it all that much safer. But really someone, and it is a tricky area and it is kind of outside what we are looking at in this, but if people are on doses and you are concerned and you need to start bringing them down, wean them down slowly. There is some really good information on the ACI website to help you with that as well.

Moving on.

Tim: Yes, and there is a question here or comments about sudden abrupt withdrawal and the longterm…

Hester: Yes, and absolutely. Absolutely. And look the bottom line is, in terms of withdrawal from opioids it is not life threatening like alcohol. It really is not. But it is intensely unpleasant. It is awful. It is a really awful process to go through and it frightens people. And as well you will have someone who is going to be in pain if they are using opioids for chronic pain, they are going to be in pain. Because one of the other really unfortunate things about opioids with long term use, is it actually sensitises you to pain, so people feel pain more. So that is another thing that can happen for some people. But I would not suggest that you know, you stop abruptly, but you do need to do what is safely and work collaboratively and cut those doses down to a safer dose or wean and terminate the medication altogether. The other thing is, in terms of your practice, working together in a practice. Now one of the things I have seen with some of the work I have done with the Coroner’s Court is that there has not been good collaboration between practitioners within one practice and so that can get in the way of the best care for individuals. So case conference difficult cases, talk with your colleagues in your practice and put a plan together so that you are all are working together. Ideally one prescriber and one pharmacy. Talk to your pharmacist. Consider a home medicine review if you have got a pharmacist that can do that for you. Staged supply and supervised dosing as I suggested.

PBS scripts versus private scripts. This is a really important area. One of the issues with private scripts is that they do not have the same oversight. So if there is someone who is doctor shopping, and you ring up the prescription shopping information service, private scripts do not turn up on that. And so while it might seem like it is a good idea to give a private script, really consider what the impact of that is. A sign in the waiting room that says, you know, “No drugs of addiction will be provided on the first appointment” can help to prepare your practice for this. I would not say that you must say absolutely no I will never prescribe opioids. Life is not like that. There are times when opioids are really, really useful. You know, acute pain end of life care and for some people with chronic non-malignant pain. Particularly interval dosing. Particularly if they have started to get into their physio and they need something just to help them get moving again. But certainly, really letting people know that it will not be provided on the first appointment, you would need to do that comprehensive assessment. And Tim I am sure that you are the same as me, I cannot do a comprehensive assessment in 15 minutes. You do need to spend more time and you know, be prepared to do follow up appointments. And, but in that first appointment make it really clear that you want to help and you need to do what is safe and you are going to make the appropriate assessment in order to ensure that.

Tim: Yes, absolutely. The thing that I notice, often people have other problems as well as their chronic pain and so going into those as well, reassure the patient that you are not just having a discussion about opioids.

Hester: Absolutely. Absolutely. And people who, many people who get into problems with the opioid use actually have as you say other issues, and they do need help. They might have mental health issues, they might have other really significant health, physical health issues, quite often that are not being adequately addressed. So they do need help. And it is ensuring that they get the right amount of help in the right setting and understanding that us in general practice may not be able to do it all. So you know, ask for help. Really, really get your local services involved. And as I said before, I know this can be difficult. The other service is DASAS which is the Drug and Alcohol Specialist Advisory Service which is a 24/7 number through St. Vincent’s Hospital. We have got the details at the end. Where you ring up and you can get advice from an addiction specialist if you are concerned about someone who you think may have opioid use disorder.

Tm: Sorry, there are a few comments coming through about some people who have sought help from local pain clinics or pharmacists and it has not been that helpful. So I think it is about trusting and working out who you can trust in your local referral networks, too.

Hester: Yes, yes. I mean we certainly have been doing a lot of work with the multidisciplinary pain clinics and there is a real issue around access and we have not quite solved that one because they are small organisations, but certainly the ACI website and Chris Hayes who is the doctor you see on that opening page are really leading a change in the way that pain services work. And certainly it has been my experience in the past that pain services have not been helpful. I have sent someone to them who I have been concerned about opioid use and they have come back on bigger doses. You know, it is just like, really! But what I am seeing now is that they are getting much better, that pain doctors are getting much better at understanding the role of dependency and working better with addiction services. And being able to support the non-pharmacological and non-opioid management as well. But look I do totally understand the issues for some of us with local services.

So, but back to Richard. You know, thinking about Richard. He quite clearly from his presentation is someone that has a dependency. He is tolerant. He is withdrawing. He escalated quickly and he is asking for help. Now, thinking about how you might help him. You may well decide that you want to refer him for specialist assessment and it may be that might be a call to DASAS just to work through, is this dependency? Is it appropriate to be thinking about opioid agonist treatment? So opioids used in a setting of a program, and we will be talking a lot more about that over the rest of the seminar, to actually manage his opioid use disorder, or his opioid dependency?

So, opioid pharmacotherapies that we have to help people overcome an opioid use disorder are buprenorphine taper. Now this is something that works for some people. For other people it does not work so well, but it gives them a taste of evidence based treatment and means that they then continue on the treatment. So in terms of the medicines that we have got to help somebody manage their opioid dependency or their opioid use disorder, we have buprenorphine, buprenorphine and naloxone, methadone maintenance and naltrexone. Now, buprenorphine is a really interesting drug. We will talk a little bit more about it. Generally we use it in combination with naloxone and I will talk about the reasons for that. The other one is methadone which is a long, has been with us for a long time, very good medicine for treating opioid use disorder. The final one is naltrexone which we would know as a medication to stop alcohol craving. It is a mu antagonist so it blocks opioid receptors. Do not give this drug to someone that is opioid dependent. You will send them into a really – sorry, who is opioid dependent and still currently using. If they are tolerant to opioids, they have still got opioids in their system. If you give them this medication, you will send them into a really, really nasty withdrawal. It can be useful we think, we are not entirely sure because there is not a great deal of evidence, in a group of people who have a history of opioid dependence, have withdrawn and want to not use again. Because it blocks the effects of opioids. Once it is in your system if you use opioids you do not feel anything. My experience with it is that there are a small group of people highly motivated, psychologically minded, lots of good support who may benefit from that. But there really is not a great deal of evidence. And what is outstandingly clear is that methadone and buprenorphine and buprenorphine naloxone, are highly evidence based, effective treatments that help people to recover, decrease the risk of overdose, decrease blood born virus transmission because people do not inject and do not share, you know they work. They work really well. And one of my sadnesses is, that we still do not have full access to treatment for people in a country like Australia, let alone in other countries. There is therapy that works, that allows people to recover and get on with their lives is not actually at the moment accessible to everyone.

The other thing on this, is just to remind me to just briefly talk about naloxone. Naloxone or Narcan, is short acting at the moment injectable mu antagonist, so if somebody has overdosed or is at overdose risk, naloxone can reverse that overdose. And we have got programs running and it is going to be more available into the future where people who are using opioids or their families where there are concerns about overdose, can actually keep naloxone at home and give the naloxone to their family member if needed. We are looking at an intranasal format of that coming into Australia in the near future.

So coming more into opioid agonist treatment, which is the focus of tonight. What is it? So, opioid agonist treatment it is a structured program which helps people to overcome their unsanctioned, out of control, messy, risky, overdose prone opioid use disorder. Now, it may not be appropriate for all patients who experience problems and I have had some patients particularly on low dose opioids like codeine, where they have not actually needed to have opioid agonist treatment. When you look at that criteria of opioid dependence, there has been some markers, but they have been able to cut down their dose of codeine and withdrawal and have been fine. And other people may be using opioids but may not be dependent, so there may be people that use occasionally or who mix it in with lots of other things where they are not actually dependent. So it is not appropriate in that group as well. So you do need to confirm that they fulfil the criteria for opioid dependence, not just the opioid use disorder, but for dependence. And look at whether they have had attempts to manage opioids with other strategies and whether they have worked. So for our fellow, he has escalated his dose. He tried to stop. He had dreadful withdrawals. He cannot do it on his own. He wants our help. As I said before, people that are at risk of overdose, or people that have stopped their use and they have started again and are dependent again. If they relapse into use, they have got a chronic illness. They have got a chronic opioid use disorder and chronic dependency. And they are an ideal group and they also need to want to do it. So we are not going to force anybody to have this treatment who does not want it. But it really, what I would be saying to you if you think you have got a patient who might consider this treatment, we will talk about how you might commence the treatment, but even if you do not, if you can give a really positive story to your patients around this is an excellent treatment, well evidence based. It helps to consider it you know and at the very least refer them on to the Drug and Alcohol setting where they can access treatment. That is fantastic. So it alleviates the signs and symptoms of withdrawal and that is what many people are looking for. It diminishes and alleviates the craving so they do not have to keep rushing around trying to get their medications, buy them on the street, steal them from people, whatever. And it allows people to gain access to an oral or sublingual legal medication that is within a program that helps, because one of the things with dependency and substance use disorders, is that loss of control. So what happens in the program, is us as their providers and the pharmacies and the other staff involved, support them and take some of that control because they have lost control themselves. The other really important thing is it allows time to engage in other treatments. It allows people to engage in their lives. It gets the whole craving and craziness that can happen around having to get and use and recover, that subsides. So people get to actually be the parents, the good parents that they want to be. They can get back to work. They can get into the other treatments that they need, hepatitis C treatment, their mental health treatment, whatever. It really is a fantastic treatment.

Moving on. So methadone as I said before has been around with us for a long time. It is an oral liquid and it is only available as an oral liquid through this particular program. Largely supervised dosing. People generally will have up to four doses that they can take away from a pharmacy per week. Occasionally people will have a little more but the guidelines are generally only four. It is exactly the same medication as physeptone which is a 10 mg tablet that is available on the PBS. I would not suggest that in this situation that you consider doing a PBS script of physeptone for someone that you are treating for an opioid use disorder or dependency, that they actually, that you register them as part of this program and use the liquid. It is sedating. It does have side effects. And the really important thing with this drug, it is quite idiosyncratic in terms of doses, but generally we would start people on a dose of 20 mg to 30 mg if it is clear that they are dependent, and what we know is that people do better if they do get up to a decent dose. Most of my patients would be on somewhere between 80 mg and 120 mg and the longer they are in treatment, the better their outcomes are. Now for all of you guys, if you have not done your OTAC training, your accreditation training to become an opioid prescriber for this program, now with the new guidelines that are hot off the press, it allows for you to take up to 10 stable patients. So this is people who are already on methadone, who have been stabilised, who are working, who are housed, who are getting on with their lives and are on this methadone because it actually helps them to do that. And some people will stay on methadone for a couple of years. Some people stay on it five, some people stay on it 30, 40. Some people will still be on it as they get towards the end of their life. And there are very different stories for people as to what happens with that. But the bottom line is, that now all of us if we chose, can have up to 10 stable patients. We do not need to accreditation in order to do that. Which is brilliant. It is a way that we can really start to open up some access for this really fabulous treatment.

Moving on. I wanted to spend a bit of time talking about buprenorphine / naloxone. So, it is a combination drug. Its trade name is Suboxone. At the moment, they are sublingual films which is the Suboxone film. We have been involved in some studies in Australia looking at a depot injection, which is a weekly or monthly injection. And I have to say, I think that it is really great to have different modes of administering this medication and for my patients that have been involved in the depot injection trials, they have really, really liked it. It means you do not have to take a medicine every day. It means you do not have to attend the pharmacy as often and it actually it means they do not have this constant daily reminder of this health issue that they have. And it has been really effective for a number of people who have been ready to complete treatment and come off treatment but they have their last dose of the depot injection and then they just stop. And the injection dose just fades away and they have not relapsed to further use. So the depot injection is going to really change things in a really positive way for some of our patients. The important thing with buprenorphine is to understand that it is a partial agonist. Now this is, it is a strange drug, but it is really useful that it is a partial agonist. One of the most important things is that it gets to a certain dose and it is somewhere between 24 mg to 32 mg daily, over which it does not actually have any more effect, so there is a ceiling effect. So it does not cause any more side effects and it actually does not, you cannot, there is not much point in taking over 32 mg because it does not have much benefit or effect or side effects. The other really important part of the ceiling effect, is that it minimises the respiratory depression. So if you have someone who has sleep apnoea or respiratory issues and you are concerned about their respiratory function, buprenorphine naloxone combination is a really good option for them because it risks less overdose risk. If you have got someone that has problems with other drugs that they use, alcohol or benzodiazepines, once again because it has a ceiling effect and has minimal respiratory depression, it is a safer one. But it is really important once again, to be thinking about those risks of overdose. Also in New South Wales, once people are stable, they can at the moment have up to 28 days’ supply that they take with them, just like we would get a month’s worth of our anti-hypertensives or our cholesterol lowering agents. They can go to the pharmacy once a month and get their medications. One really important thing with this is, because it is a partial agonist, if the person is opioid dependent and they are withdrawing, they have not got their usual dose of opioids in their system and they are withdrawing, if you give someone buprenorphine it will help relieve their symptoms and manage their symptoms. However, if someone has opioids on board, they are very comfortable, they are a bit sedated and you give them buprenorphine, you will cause a withdrawal. So it is a really important issue to be aware of if you are going to start someone on buprenorphine. When they have those first doses, they do need to be in withdrawal. And using the clinical opioid withdrawal scale, and there is a link to that at the end, or the COWS, will give you a really good idea of what is happening with their withdrawal. And generally I would want someone, particularly with the prescribed opioids as an issue, to actually be in withdrawal. I want to see that they are in withdrawal, that they are starting to yawn. That they are starting to tear. That they are starting to have gooseflesh. A little bit agitated. Because then we know when we give them the buprenorphine it will relieve that rather than making it worse. The other really important thing is the naloxone in it. Now the naloxone generally is not active if you take it sublingually. But if you inject it, the naloxone kicks in before the buprenorphine kicks in and you will have some withdrawal symptoms. So, Suboxone, or buprenorphine / naloxone is injected but it is not injected as often. It still has a street value. It is still used on the streets so it is really important that its use is controlled. But it is not used as much, is not injected as much as others. Now with our new guidelines, once again all of us without training can commence up to 20 patients on buprenorphine / naloxone. So you can have 20 people that you are prescribing for and you can actually start them on that treatment. So all up, all of us if we wished could have 30 people that we are seeing in our practice and being the authorised prescriber for, 20 of them for buprenorphine / naloxone and 10 of them for methadone, should we wish.

Moving on. So, once again, I really want to just remind you of this precipitating acute withdrawal. It is nasty. It is really awful. You know, so please think about if I am going to commence it I want to ensure the person that I am seeing is in withdrawal. Do a COWS. If they are not withdrawing, do not start it until they are actually withdrawing. Beautiful.

Moving on. What are opioid withdrawal symptoms? Certainly our patient has told us about some of these and I have mentioned some of them. But dilatation of the pupils. Lacrimation or tearing up. Runny nose. Goose pimples. Nausea, vomiting, diarrhoea, tummy cramps, stomach upset. Tachycardia, hypertension, fever, restlessness, irritability, insomnia and craving. These are specific, some of these are specific to opioid withdrawal including you know the pupillary dilatation, lacrimation and the rhinorrhoea and the piloerection very clearly are unlikely to be present in other conditions in this setting. Whereas if somebody has got nausea, vomiting and diarrhoea it can be other causes as there can be for the vital signs and CNS. But the other thing is, and it is an important thing in terms of people who are using pharmaceutical opioids, as with our patient he did not know what was going on. And I have certainly had patients before who have actually been in withdrawal and have been seen by doctors but have been investigated for other things because the patient did not pick it up and the doctor did not pick up that this was actually about their opioid use and withdrawing. So talking to people who are on opioids around what withdrawal symptoms look like, can help them to identify that and seek help when they need it.

Moving on. Okay, so once again, this is coming back to the efficacy and effectiveness, the last Cochrane Review and there has been oodles of papers on this. Opioid agonist treatment is effective. Longer term treatment is better than short term and people with codeine or other pharmaceutical opioids actually do better than those people with heroin issues. Now I suspect this is because people with heroin issues quite often have much more marked biopsychosocial issues, being homeless, lots of mental health issues. It is not universal, but certainly people using codeine and pharmaceutical opioids, we actually found that they do better. That they manage their opioid agonist treatment well and they get back into life and they recover into life well. Just be aware that adjunct treatments, psychological, CBT, counselling, supportive counselling can be really useful for people to understand what it was that may have been one of the risks or the factors that led to them using and having problems with using. But it is not, and you do not have to, and some people do not need it.

Moving on. Okay, buprenorphine / naloxone for pain, for people who have pain and opioid dependence, you start the same as for any opioid. And people changing to this treatment from their prescribed opioids actually had reduced self-reported pain reports after they transferred to this treatment. So to a certain extent, this will treat their chronic pain but it is not the focus of it. The mean doses were somewhere between 8 and 28 and as I say I have got people from you know, 2 mg up to 32 mg a day and it depends on the individual. And really in terms of pain and quality of life, either they stay the same or with many people, they actually improved. And methadone and buprenorphine are both effective analgesics. Like other opioids they have the same issues around you know, in terms of using them to treat chronic non-malignant pain, they are as effective as other opioids.

Moving on. Okay, I want to just quickly move through this because I am aware of the time. This is the Pharmaceutical Services webpage for New South Wales Health. And there is some fabulous information on it. Moving on to the next one. If you click onto medical practitioners. Click again. Move on again. There is a whole heap of application forms. Prescribing S8 opioids for pain management is the really important one there. And it gives you all the issues around how what you need to do in order to prescribe S8’s for opioid pain management. And the authorities that you need, which is different from an authority for prescribing medicines like buprenorphine and methadone for opioid agonist treatment.

Moving on. Once again, there is the information there and down the bottom you can see the application for an authority to prescribe. The other thing is that the staff at the PRU, Pharmaceutical Regulatory Unit are fantastic. So if you have got any questions, give them a call.

Moving on to the next one. Yes. Moving on to the next one. So, I just want to remind you that under the PBS, it may be that you are writing authority scripts for opioids. That is a different process, so it may well be that you need an authority to prescribe in New South Wales for an S8 drug of dependency as well as your PBS authority, yes? So they are two authorities, and they are different once again to the opioid agonist treatment authority that you need to get if you are going to prescribe for someone who is opioid dependent.

Moving on. Also, just some really good stuff on the site around chronic pain management and authorisation to prescribe opioids.

Moving on. So there are lots of resources. Once again I have pointed you to the ACI website, but there are lots of resources and some of them are actually linked through to the ACI website as well.

Moving on. Yes, so this is really exciting for me. We have been working on the new opioid agonist treatment guidelines for some time and they are hot off the press. They were put up on the website yesterday. So there is the link there. As I said before, all GPs are authorised to prescribe for up to 30 patients at any one time without further training. You can commence up to 20 patients on the buprenorphine / naloxone combination and take over the care of up to 10 patients who are already stable on methadone. Now, it may be that there are not that many people out there who are thinking “great, take on 30 people!” I would suggest starting with one or two, your patients that you know well and asking for help if you are not sure. Local services, DASAS, really this is a really important treatment to have available and I have to say in my job practice setting, I have a lovely group of patients that I see and I really enjoy supporting them and helping them with their health issues as a GP, not just with their opioid dependency but also all their other health issues if they have got them.

Moving on. There it is, very exciting.

Moving on to the next page. So coming back to Richard. So really what we saw with him was that he has a family history of alcohol use. He is a lower risk drinker. He is a smoker. He had got into trouble with his opioids and he had clear withdrawals and he is saying, I need help to do this. So after a conversation we decided, he decided with me, to start on Suboxone, the buprenorphine / naloxone combination.

Moving on. So if you are thinking about starting someone, there is a whole heap of things that you want to actually just run through with your patient. First of all, consent. You need informed consent. Your patient needs to understand that you are prescribing them a drug of dependency, that buprenorphine / naloxone is a drug of addiction, a drug of dependency just like the opioids that they have been on. You need to talk to them about the privacy of that information. They will when they are put on the program, their details will be kept by New South Wales Health at the PRU, the Pharmaceutical Regulatory Unit. But there are really good boundaries and privacy boundaries around the storing of that information. You also need to talk to people about the fact that this drug is a strong opioid. I always say to my patients, keep it sage and keep it secret. If you have got the medication at home, if you are getting take aways, you need to store it in a locked box out of the way. Do not take the medication in front of children and be aware that this is a really significant child poisoning risk, just as the other opioids are as well. Document that you have been through this with your patients. Thinking about risks, you know so you need to assess the risk to the individual. You know, what is going on with their opioid use and how risky is that? And really look at the way that buprenorphine / naloxone in their situation is actually going to really improve the quality of life and is actually going to be safe. What are the other health issues? What are their other physical and mental health issues? What is their social situation? Are they a high risk of overdose? Have they had overdoses in the past? Particularly if there is polypharmacy and this is other substances, all sedating substances including medications, yes? So things like anti-histamines, anti-psychotics that are sedating. Anti-depressants that are sedating. The medicines like pregabalin and gabapentin are sedating. If they are using other drugs, alcohol, benzodiazepines. Those things that will actually add up and increase the overdose risk. The other thing is just to consider drug interactions. So, one of the issues with methadone in some people is it will cause changes to the QTc, so if somebody is on another medication for example, some of the anti-psychotics or amiodarone, you may need to consider the drug interactions. The other really important thing is fitness to drive. And this is the same as for any potentially sedating substance. While people are stabilising, while they are getting their dose right, and if they are not stable, if they are using other drugs or they are drinking a lot, you know, really counsel about them not driving. They really need to put some time and energy into getting themselves stable. But once they are on stable treatment and they are not using other drugs and not sedated for another reason, there are no other health issues that might make it unsafe for them to drive, if they are on stable treatment and the treatment is stabilising them so they are not sedated, they absolutely are safe to drive. Once again, if you are uncertain about any of this, ask for help. Ask for help from your local service, from your local drug and alcohol service, DASAS. I really, really encourage you to do that.

Moving on. Okay, with Stewart, he came in day one at 10 am and he had his last OxyContin at 8 pm the night before. He had mild restlessness and some muscle aches, bit of a runny nose, a bit anxious, but his COWS was only 4. I was not happy, that is not high enough. I would be concerned about sending him into precipitated withdrawal, so I saw him again at 2 pm. By this stage he was more symptomatic. He had diarrhoea, he was flushed, sweating, his COWS was 10. And so I commenced him on a 2 mg test dose and then he went to the pharmacy and he had a total of 8 mg on day one. Now, one of the things sometimes people do get a bit anxious about giving that dose of up to 8 mg on the first day. It really depends on what people are using. If they are on codeine, 2 mg may well be enough. And really you cannot always just say well, you have got an oral morphine equivalent of this, so this is what you will need. And I would not suggest that you give someone more than 8 mg on day one, but you know, really start them on 2 with a test dose to make sure that they are not going to be sent into precipitated withdrawal and then they may have more during that first day just to make them more comfortable.

Moving on to the second page, no next page. Day three, so he was reviewed after commencement of his buprenorphine / naloxone, slightly uncomfortable the first night. He had 8 mg the second day but then had a further four, so 12 mg day two. And slept better on the second night. He did not have any of that euphoria. He did not have that Nirvana feeling and had 16 mg by day three and was really thinking, look you know, I am okay on this dose, but had in terms of the dose, had the capacity to decrease or ask for a decrease of dose down to 12 mg if he felt sedated. Now just to mention, buprenorphine comes in two doses, a 2 mg and an 8 mg, so you can kind of mix and match to get the dose you need.

Moving on. Three months after starting, he was still on 16 mg. He was going well. He had finished his study as a hairdresser and was getting some work, and was considering a slight decrease. Six months after starting, he had cut down by 2 mg and did not really notice the dose decrease. His mood was doing better and he was thinking about going to see a psychologist under a mental health plan. He had issues with anxiety. His mum was highly anxious and really he was starting to consider that mental health might be an issue for him.

Moving on. One year after starting, he decreased down to 10 mg, so a drop of 6 mg since starting and had no issues with the dose decrease. He was getting fortnightly take aways, so getting 14 doses every second week from the pharmacy. His life was going well. He had seen a psychologist and the decision was to cut down from 10 to 8 mg today with a possible further decrease if he felt he needed it. Two years after starting, he had been on 4 mg for the last six weeks, decreased down to 2. And we looked at further reductions, 2 mg, and what you can do because it is a very long acting medication, is you can move to second or third daily dosing, and that is one of the ways that you can drop the dose down lower than 2 mg. Some people can stop very easily on 2 mg, some people need to have a slightly lower dose. And importantly, he had being seeing a psychologist and really felt like he was managing his anxiety well. Two and a half years after starting, he had ceased his treatment two months ago and was doing well. Now, it is possible for someone like Stewart that he may relapse, because opioid dependency, opioid use disorder does tend to be a chronic relapsing condition. And one of the things I will always say to people, is if this becomes an issue for you, if you find that you start craving, if you have got a stressful time in your life and you start thinking about, it would be really great to get some oxy’s to help me manage my life, or if you do relapse, come back. Come back as soon as you realise it is happening and we can get you back on treatment for a period of time just to restabilise. Other people do not ever look back and it really is not a part of their lives any more.

So in summary, oh, go back. Ask your patients about over the counter use. Now this is changing now that codeine is no longer over the counter. But they may well have, there are some people who I understand have stockpiled. But it is also thinking about that history. Have they had problems in the past with over the counter codeine use? What about prescribed opioid use? And assess and reassess their chronic non-malignant pains with the four A’s, the PEG or the BPI and ongoing assessments and reviews. Give a patient support and information and really help them to understand the risks and what can happen and this can happen to anybody and there are good treatments. Consider the risks and benefits before prescribing. Opioid agonist treatment is a very well-evidenced based treatment, and it is safe and it is effective and once again, get help if you are not sure.

Moving on. Asking for help. There are the DASAS numbers. The Pharmaceutical Regulatory Unit which has a duty officer on during the week. They are great. They are really great people to talk to. Your local drug and alcohol services. Now, local drug and alcohol services in the past have been a little bit kind of invisible to us in general practice, but there is quite a lot of work going on now within the local health districts and the drug and alcohol services to improve connections with general practice. Talk to your colleagues. Talk to your colleagues. Some of us have more interest in this area, but it may well be within your practice that you can you know, you can seek some support. Talk to your medical defence union if you have got any issues around what is appropriate in terms of the law. Join the GPSI in Addiction, which is the GPs with a Special Interest in Addiction Faculty. I am the Chair at the moment of that through the RACGP. I would be really happy to have you guys join that group. Health Pathways. Many of the Health Pathways around New South Wales actually do have pathways for drug and alcohol and opioid use. And importantly have a look at the new hot off the press clinical guidelines for methadone and buprenorphine treatment that have arrived. And there is also an abbreviated version that is going to be out soon.

So we are smack on the end of 8.30. There is one more slide, I think which is all the resources. Now, I just, I know we are on 8.30, but Tim are there any questions that you think are important that we just need to quickly address before we finish up.

Tim: So people have been sending through some queries about difficult patients that they have been seeing and I think it is worth people seeking help from their local area and going to Health Pathways and going to those, because we are probably not able to deal with individual clinical queries. There are some complicated patients out there. Just to clarify, people can take, do not need to do the training course any more, they can take 20 patients with the buprenorphine / naloxone without the accreditation that they used to have to do.

Hester: Yes, yes. The other thing that I would say about that though is that we are just updating the training and there is now, and I think it is the next page, I hope, if Sammi turns it over, is that there is an online 24/7 training program. Yes, the Fundamentals course. So if you are interested, if you are thinking geez I would like to have a little look but I am a bit concerned, it is available 24/7. You just work through it. It has got some absolutely dreadful videos of me which I need to redo because I look like I am growing horns. Just go and have a look at it for that. But that is available, but you do not have to. You do not have to. That is there just for support. If you do want to do more of this, there is an accreditation course and we are updating that at the moment, which then allows you to take up to 200 people for opioid agonist treatment.

Tim: Excellent.

Hester: Look, just in terms of those more tricky patients, I would really encourage you as Tim was saying to actually seek support for those, because they are hard and you would not probably be wanting to take your first baby steps with prescribing these medications with someone that was really, really complex.

Tim: Yes, excellent. Well, there is the learning outcomes up again. Hopefully we have met all of those. I would like to thank Sammi very much for operating all of our technology so well as well behind the scenes. Thank you very much Hester and I do hope, and there will be a copy of the presentation distributed to everyone as well. Have a great evening, everyone and I think hopefully we are all a little bit more confident in doing this with some of our choice patients now. Thank you very much, Hester.

Hester: Thank you so much and good night everybody.