Managing patients who are Opioid dependent - part 2

Sammi: Welcome to this evenings Managing Patients who are Opioid Dependent in General Practice webinar. This is the second part. The first part of this series was run earlier in the year for those of you that tuned in. For those that did not, the report is available and you can watch it on line. So let us move on. I would like to make a quick Acknowledgement of Country before we get started. 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.

So our presenters for this evening. We are joined by our presenters Dr Hester Wilson and our facilitator Dr Tim Senior. Hester has a Master’s Degree in Mental Health and 25 years’ experience working in a primary healthcare 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 healthcare workers since 2001.

Tim 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 and Senior Lecturer in General Practice and Indigenous Health at UWS. So thank you for joining us this evening, Hester and Tim.

So I will hand over to Tim now to jump into the learning outcomes and then before we hand over to Hester to jump into the content, we are actually going to be doing two quick polling questions. We will try and do them as quickly as possible as we did start a little late, which again my apologies. So Tim, over to you.

Tim: Thank you very much, Sammi. So the learning outcomes and as I say, these are the education-speak for what we are hoping to achieve over the next hour or so. So by the end of this activity, we should be able to use available checklists to record issues and consultation notes for patients preparing or on OAT. We should be able to explain the importance of working with pharmacists and other clinicians involved in the care of our patients. We should be able to identify the criteria for deciding to describe takeaway doses of methadone and buprenorphine as well as identifying risks and putting into place risk mitigating factors. And we should be able to list referral options and available resources that can assist us in caring for our patients. So, to make a start on all that, thank you very much Hester.

Sammi: We are going to be asking you two polling questions. The first one is now on your screen. We will also be asking these same questions in the post-evaluation survey. And I will launch that second one off for you now. Hester while people are answering the second one, once we close it off do you want the responses displayed on the screen to have a chat about?

Hester: Yes, that would be great.

Sammi: Alrighty. 54% of people voted. Let us get up to 60 and then we will close that off. Alright perfect. So, what I will do now is go back to the first one and I will share those results with you. So, you can see there that 41% agree, 19% strongly agree, 29% neither agree nor disagree, 7% disagree, 4% strongly disagree. Did you have any comments on that, Hester?

Hester: Look I am really pleased to see that. We have more than 50%, 60% nearly – yes 60% of this group here today, there are 116 of you, who are saying it is important. And another one third that are undecided. I am really happy to hear that, but I am also really happy that there are people who have come along who are not, who disagree or strongly disagree about the importance and are still coming along for the training. So that is really brilliant. Moving on to the next one.

Sammi: Fantastic. So then moving on to that second one. And can you see those results, Hester?

Hester: Yes. So, look this just tells us that there is a real need for this webinar, that you know, that you know 60% of you agree that it is important for you to be able to do this, but we have got much lower levels of confidence around doing it. This just means this is perfect, it is great that everybody is here and that we have got a chance to discuss this really important area of medicine with you. Terrific, terrific, thank you.

Sammi: Alright, moving on. Let us jump into the content.

Hester: Yes. So any of you that came along to the first webinar that we did back in July may remember Richard, who is a 34-year-old man who was prescribed codeine three years ago after hand surgery. He stopped it after his operation and then started to use it for pain but also to help him relax his nerves and to help him manage his life. And he was bullied at work. Twelve months ago he was taking up to eight Panadeine Forte a day which is an oral morphine equivalent, daily equivalent of 30 mg. And he saw a doctor six months ago and he was saying, look Panadeine is just not working, and was given some oxycodone and is now taking 40 mg of oxycodone daily which is a 60 mg oral morphine equivalent, daily equivalent. Working as a bar tender, he is a smoker. He has his first cigarette 30 minutes after waking which tells us he has got a significant dependency. So the time of cigarettes in the day is a really good surrogate marker for the level of dependency on nicotine. He is having four standard drinks once a week but there is no other drug use and no other medicines. The important thing for Richard was when he tried to stop two or three months ago, he felt absolutely dreadful and exhibited some of the tell-tale signs of opioid withdrawal. And he has come in today saying, I cannot go through that again. Now, and I was going to ask the question what is going on but I am aware of the time. We started late, my apologies for that. But really what we have got here is a young guy who had a legitimate reason to have some opioid pain relief, but however continued it on. And what is not clear is what the role of that Panadeine Forte or the codeine and then the oxycodone was, and why that was continued to be prescribed, and really it is a bit of a story that we do see that is due to the background of us as professionals really wanting to assist our patients with their ill-health and their pain and their difficulties in life, but just the way that opioids can actually cause more problems than good.

In the last session we talked a lot about the use of opioids for chronic non-cancer pain. Bottom line is, there is poor evidence for their efficacy. They really do not work very well. There may be some people in which they have a minor role, but the bottom line is, using other things, the active self-management of pain, and some of the non-opioid pharmaceuticals as an adjunct to that core business which is around people learning to manage their pain and some psychological therapies are useful and opioids have a small place. But we do have a group of people that become dependent and we are seeing this groups in our general practices. And I am also seeing it, I see it in general practice and I see it in the specialist drug and alcohol service that I work in as well. Can you, next one. Next slide.

Sammi: Ye, it is coming.

Hester: So as we see from Richard, you know he is nicotine dependent. He is smoking daily. He is having his first cigarette after waking, half an hour after waking. He has got some borderline what I would call borderline risky alcohol use. So four standard drinks a day, is that borderline in terms of there is no safe level of alcohol use, but as you increase the use, you have risky alcohol use and for him, given that he is having four standard drinks once a week, well maybe that is okay, but he is getting to that risky range for acute risk. And oxycodone 40 mg a day and he is experiencing withdrawals and he has been unable to stop.

So he has got a lot of the hallmarks, if we go to the next one – of withdrawal. So when we are looking at what is happening for him, he has got the GI symptoms. He has also got some insomnia and the craving. But I really just want to really focus on this, because it is quite important. It is not uncommon for me to see people who have some of these symptoms and they have lots of investigations for other things, and the fact that they have actually got an opioid withdrawal has not been picked up. There are some specific things that are really pretty specific for opioid withdrawal, pupillary dilatation, the tearing or lacrimation, the piloerection or goose bumps. But not everybody gets those. So really thinking, you know, what are the eyes, the nose, the skin, the GI, the CNS, the vital signs that might lead to us understanding that there is actually an opioid withdrawal syndrome going on for this person. And it is one of the things that we notice, that people on pharmaceuticals will not have had this experience before, so will not realise that the insomnia, the irritability and the gastro symptoms that they are having are actually due to withdrawal. Move on to the next page.

So, Richard recognises that he is using the oxycodone. He says, look I am using this because when I try and stop it I get terrible symptoms and also when I use it, I feel more relaxed, I feel happier, I feel less anxious. I am more worried about running out. I need to carry medication with me. I feel like I need more and more and I hate that. I hate that feeling. I feel ashamed and I have not told my family. It is like a dirty little secret. I need to stop but I am really worried about how I might do this. And this is a really, really common way that people will talk about their experience. They hide it from family. They feel very ashamed. They pick up that it is not going well for them, but at the same time there is this deep need to have this medication. And there is a kind of a sense for many of them that somehow they are weak or they are bad people because of this, and the reality is that this is a side effect of opioids. And depending on what literature you look at, you know the reality is that a certain proportion of people taking opioids for a certain period of time will become dependent, and the studies are saying you know, something like 30% of people taking opioids for longer than ten days will find that they start needing more to get the same effect. They can get some withdrawal symptoms and start to develop dependency. So it is a really important side effect. It is like constipation. It is like you know, the rash that people can get with medications, that with opioids you can develop dependency. It is not a sign of weakness, it is a core side effect of the medication. And it is something that we do need to deal with in a non-judgmental way because it is a real medical condition. And different people will have different trajectories in terms of managing that, but it is really important that we recognise it and treat it. Moving on.

So this is a busy slide. But I think it is quite an important one, because it is the DSM-5 categories for substance use disorder. And so you can look at it in terms of, because and the DSM-IV is compared and ICD-10. So we are looking at DSM-5 is a use disorder and it includes, the bottom two tolerance and withdrawal are a part of that. But you can have a substance use disorder without having tolerance and withdrawal. But what we want to see here in terms of helping people manage opioid dependence, is that they do have tolerance and withdrawal and they quite often will have some of the other criterion. So using larger amounts for longer than intended, craving, difficulty to cut down, lots of time and energy and salience put into getting the medication or recovering from it. Giving up other important things in their life. Continuing to use despite the fact that is causing problems in relationships, problems with jobs, problems with their mental health or their physical health. And it stops them from actually getting on with their lives. Using it in hazardous ways or in hazardous situations, so using it, becoming sedated and then driving on it. Getting into problems with the law. So all these can be ways that people present. Really from the point of view of looking at who are the people who will benefit from OAT, and that is Opioid Agonist Treatment – otherwise known as OST, Opioid Substitution Treatment, or MATOD which is Medication Assisted Treatment of Opioid Dependency, what we are talking about with that is the dependency. So the tolerance and withdrawal are the really important cause of that, but the other things that actually are indications of the dependency are important as well.

So moving on to the next slide. So, here we go. Richard has come in. Here are the options. You could do nothing. You know, really that is the reality. He could continue doing what he is doing. What I would suggest though, that it is not something that is a great thing for us to continue prescribing without assisting him to better manage what is going on for him. De-prescribing the oxycodone. So a slow, taper of the medication can work very well for some people. If you feel like it is beyond your capacity, then referral for a specialist assessment, probably in Richard’s case addiction is a better place rather than chronic pain because he does not really have any chronic pain any more. But really looking for some specialist support. And I will be saying that again and again, that doing this, prescribing OAT is not rocket science, but it is a new way of thinking and please ask for support, do not feel like you have to do it all on your own. And in terms of opioid agonist treatment, oh sorry, you moved before I finished. Yes. We have got buprenorphine and you can do it as a taper and in some people that works very well, a short term taper. Or it can take a bit longer, three weeks, three months, whatever. And / or a buprenorphine maintenance which can be once again a six month, two years maybe longer and it is really around helping people to get their lives back on track. Methadone maintenance. Both buprenorphine and methadone are very well evidenced based treatments and work really well and have good outcomes for the treatment of opioid-dependency. Naltrexone which is also marketed as a treatment for relapse prevention for alcohol dependence is a mu-agonist. So what it does, is it blocks the receptors, the mu receptors that give the opioid affect. Now, it could possibly be a really useful option but there is not that much evidence. It is a select population. We will not be focussing on that in any great detail today but I am very happy to speak to it if people want more information.

Tim: Sorry, we did have a question come in as well asking whether Targin, so the oxycodone naloxone combination, can replace Suboxone?

Hester: No. No. No, it is, I mean you might think about if you are thinking well, if somebody is on Targin we are going to do a slow decrease. The naloxone which is in the buprenorphine is not actually part of the opioid dependence treatment. The story with the naloxone in Targin, it is about decreasing the gut effects and particularly constipation. But for buprenorphine naloxone, which is a buprenorphine combination which is Suboxone, the naloxone is put in there as a safety device because it decreases the risk of people taking the medication by injection. So it does not, naloxone itself does not add to the treatment of the opioid dependence. It is kind of a population-wide safety option to actually decrease injection. Yes.

So, I just wanted, coming back to naloxone, so naloxone or Narcan at the moment is an intramuscular injection and it is something that we do need to think about. You know, for any of our patients that we are prescribing opioids for, is this person at risk of overdose? And absolutely anybody that is injecting is at risk of overdose. And anybody that is an opioid agonist program, I would always offer naloxone and training around naloxone. But also for people that are on prescribed opioids. You know, are they at risk of overdose? They are. The answer is yes. And some people will be more at risk. And for me, I have done a number of cases in the coroner’s courts where people died of opioid overdose, so drug toxicity. There was an accidental overdose and they were in a house with other people who did not recognise that they were overdosing and if they had known, if they had had naloxone, they might have saved that person’s life. So it is something that we do need to think about anytime we are prescribing an opioid. Is this person at risk of overdose? Are they on other sedating medications? Are they drinking alcohol? Is their mental health unstable? So we need to offer them and their relatives naloxone and talk to them about the risk of overdose to prevent this occurring?

Moving on. And please, Tim interrupt me with questions, please do.

So, Richard, well he wants to give it a go. He has tried it on his own. We discussed the options on the previous page and he says, look I have tried to stop and the withdrawals were bad. I know I have got to go through them at some stage, but buprenorphine sounds like a good option for me. Now one of the things with buprenorphine is that it is a long-acting partial agonist and we will talk more about its pharmacology. But because it is very long-acting, it is easier for people to slowly cut that dose down and to complete treatment. You cannot get away from having withdrawal symptoms but what we want to do, is we want to make them as mild as possible and if you do a slow decrease you can make them very mild so that people can get on with their lives, learn how to manage their lives and reduce and stop that medication over time.

Next slide. Here we go. So, buprenorphine and naloxone or Suboxone, it is sublingual so it is taken either under the tongue or in the buccal mucosa and the naloxone in it for the vast majority of people has no effect because it is not well absorbed sublingually. If you swallow buprenorphine and naloxone it is not absorbed. If you inject buprenorphine and naloxone, the buprenorphine you get a higher amount of buprenorphine and the naloxone is also active, so it discourages people from injecting it. That does happen and people find ways around it because people are clever, but the bottom line is that it is actually around ensuring that people tend not to inject it. Because buprenorphine is a partial agonist, it is one of the safest opioids. And it is a kind of a craziness I reckon that oxycodone is so easily available and buprenorphine is not, because it is so much safer. So it is a partial agonist. It is effective up to a certain dose and beyond that dose you do not get the increasing dose, the increasing efficacy or the increasing respiratory depression. So it is actually a safer opioid. And in New South Wales, we are really fortunate that we have the potential for less supervised dosing. As people stabilise, they can get up to 28 days medication. Generally we would start people on observed dosing and we will talk more about that, but as they settle and they become stable they can have up to a month’s takeaway which is similar to what you get with your other medications. And the dose that you can legally prescribe is 32 mg. Occasionally people will go above that, but you need to actually apply for that and it goes to a committee to decide whether it is appropriate.

One of the things that you do need to be aware of, because it is a partial agonist it is a weird drug. If you are withdrawing, it will act like an opioid. If you have opioids in your system, other opioids in your system, it will act like naloxone or Narcan and make you withdraw. So we do need to be a bit careful about when we start it, particularly if people are on longer acting opioids. So if you have got someone who is on a longer acting opioid, and methadone is a big one, that shift from methadone to buprenorphine can be tricky. The slow release medications, the other opioids can be tricky. And so I would really encourage you with those longer acting ones or if you have got any concerns about precipitated withdrawal, to talk to your local drug and alcohol services or to DASAS and we will talk more about them.

 

The other thing is, that it is really useful to use the clinical opioid withdrawal scale and I understand that Sammi sent that out to you, the COWS. We do have a copy of it in the PowerPoint, but it is actually a really good way to make an assessment as to what is happening with someone’s withdrawal. And you do want them in mild to moderate withdrawal before you start them on their first dose. The good thing in New South Wales, is that we now have new guidelines that allow all doctors, all GPs, all doctors to commence up to 20 patients on buprenorphine naloxone without becoming accredited. So we are really seeing a really genuine attempt on the part of New South Wales Health to expand the treatment that is well evidence based and safe throughout New South Wales. It is not the case yet in ACT, if we have any ACT listeners, but that may well change in the near future.

Moving on to the next page. So once again, yes being careful with buprenorphine. If somebody has lots of opioids in their system and is quite sedated with opioids, you can precipitate withdrawal. And this can be a nasty withdrawal. It is not the slow, natural withdrawal that happens as people’s dose comes down. It is actually a sudden, full on shaking, vomiting. It is very, very unpleasant and quite often people do need to be admitted to hospital. And what you do with somebody that has got, if you can convince them, look you are withdrawing, we just need to load you with more buprenorphine, more buprenorphine, more buprenorphine until it settles. But is a tricky thing and you do not want to induce that in your patients. For the short-acting things like codeine, the short-acting other opioids, it is really uncommon, but you still want people to be in withdrawal. So it is a really good idea to just do that opioid withdrawal scale to make sure that the person is in withdrawal. Okay, next page.

So here is our COWS. I find this a very easy one to fill in and it has got some that are people’s experience, you know bone and joint aches, have they had any GI upset? How anxious are they? But it has also got those objective things like goose flesh or piloerection, runny nose, yawning, pupil size, pulse, sweating. And those are ones that you can actually assess in your rooms and you will see the score down there is 5-12 is mild. So I am looking for a score of at least 12 if not 13 or if they are on a longer acting one I am probably looking for a slightly higher score. But it is a really useful score, a very well validated score. Next page.

Okay. So in terms, the question that often is asked is, well look my patient has pain, they have gotten into trouble with their opioids. It is not working for them and they have developed opioid dependence and they have pain, you basically start it as you would for any opioid dependence. And what we notice, and I tell you this is really important to tell your patients, that changing onto this treatment, the vast majority of people have reduced pain after they stabilise on buprenorphine. The doses are somewhere between 8 mg and 28 mg per day up to 32 mg, but most people settle on about 16 mg to 20 mg. And what you find is that either their condition stays exactly the same or they actually improve. Their pain improves and their quality of life improves. And I would just reiterate that both methadone and buprenorphine are both as effective as analgesics as other opioids. Now you know, really what I have been having saying before is that opioids in a long term situation are probably not as effective as analgesics, so these guys do not do any better, but they actually work really well for helping people manage their opioid dependence. Next page.

Okay. So as I mentioned before, there have been changes to the New South Wales opioid agonist treatment guidelines and they are available, there is a full set, but there is also an abbreviated set. And as a result of this you can commence up to 20 patients on buprenorphine naloxone combination, note that it is the combination, it is not buprenorphine on its own, and take over the care of up to ten patients who are already stable on methadone. So it is really helping us to provide more care and I would really encourage you to consider doing this with your patients. Ask for help if you are not sure. Talk to DASAS or talk to your local drug and alcohol team and I can tell you, I know that my drug and alcohol team, if a GP rings and says, look I have got this patient I really want to help them, I am not quite sure what to do, can you assist me? We would be overjoyed to assist you, to help you commence that patient and stabilise that patient and then help you support them as is needed in the future. So, please take advantage of that. Next page.

Just in terms of starting buprenorphine, so I want to focus quite a lot now this evening around the processes that you go through in order to start somebody on buprenorphine. So the treatment plan, the documentation, the authorities that you need. Sorting out the logistics of dosing, follow ups, take aways. And for me the two really important parts of take aways is the safe storage. And the thing I always say to my patients, is keep it secret, keep it safe which I am pretty sure is from Tolkien’s Lord of the Rings if anybody is into that, but keep it secret, keep it safe. Keep it in a locked box in a high cupboard. Do not take it in front of people. Particularly do not take it in front of children. Do not share you know that you have got this medication, because people do like to steal this medication. You know, keep it away from other people and just keep it private. It is really important when you are starting treatment that you do actually obtain consent from your patients so that they understand what they are getting into. They understand the risks of what they are doing now and the risks of the medication and particularly the risks of taking it with alcohol or other sedating medications and driving. While you are being stabilised on treatment, do not drive. Do not operate heavy machinery. Take that time off work if your work is manual work so that you can be safe. Let us get you stabilised. Once you are stable, you can drive. This is a tricky thing for people who are commercial drivers, so there is a whole process that needs to happen there. If you have someone that is a commercial driver who has an opioid dependency once again, I would ask you to seek help from your local drug and alcohol services around managing that. Next page.

So, the form filling. Treatment agreement form and consent. Now, I know that Sammi you have sent a number of documents to the GPs, is that right?

Sammi: Not yet. There is one hand out in the session and all the ones that we are discussing, everyone’s resources, they will be sent out in the post-webinar email with a copy of the presentation, yes.

Hester: Fantastic, fantastic. So, I have put together my own treatment agreement form and really for me, that is around just, it reminds me to run through everything that is important so I can talk to my patient about all the ins and outs of the program and that we get agreement between the two of us that that is how we are going to do it. In terms of consent, I think it is important once again to have that conversation around the fact that the buprenorphine naloxone that you are going to be starting is an opioid and it does cause dependency. They already have dependency. If they did not have dependency you would not be using it. But it is important that they understand that this is an alternative option that is going to help them get their lives on track. It is an opioid and it does have risks as an opioid. PRU which is the Pharmaceutical Regulatory Unit. There is a form that you need to fill in. And if somebody is already on treatment you also need to make sure that the exit form from the previous prescriber has been completed. So one of the really important things with this program is that you can only have one prescriber, and that is the safety boundary for everybody on the program. So there is only one prescriber that can do it and you need to fill in that form. And before you can prescribe, you need to make sure that you have got authority and that generally means ringing PRU and saying, having I got authority? And they will give you a number. As a non-accredited GP, if you are working with a specialist service you are taking over the care, PRU really likes it if you can send a letter from that specialist service saying, look this person is appropriate. They are stable. They are an appropriate patient for a non-accredited prescriber. The other thing that I always do when I see people and I am starting prescribing is to get a form and once again I have sent that to Sammi which is a temporary transfer form which has on it the 100 points of ID which is you know, drivers licence with a picture, passport, those kind of photo ID, but also has some other identifying information. So that when you send them to the pharmacy, the pharmacy can check their identity and if they want to go on holiday, which people do, then you have got all that information ready to go so that they can travel and you can send that ID information to the pharmacy they are transferring to. Take a photo if you possibly can. If you have got a digital camera fantastic. If you have not, they need to bring passport size in with them. You need to do the script. You need to find a dosing point. Now, I always call because there are only certain pharmacies that can actually dose buprenorphine or methadone under the New South Wales program. So, DASAS and there are the numbers for DASAS at the end, can give you the names of pharmacies in your local area or your patient’s local area. But you do need to call them and make sure that they have capacity. Most pharmacies only have the capacity to dose up to 50 people. They also want to check that the person that you are sending them to is appropriate. And I always check how much it costs. Now, around about most pharmacies in Sydney and it can be a little cheaper in the rural regional areas, but also more expensive. It is cheaper in ACT because it is slightly subsidised by the ACT government, go the ACT government. But you are looking at around about $35 a week. That is for daily dosing. As the dosing goes down, as they get more take aways, I would encourage you to liaise with your pharmacies and encourage them to drop the cost. Because $35 to $40 a week is a huge amount of money. You are looking at $120 to $140, sorry $140 to $160 a month which is a lot of money. Now when people move to weekly or second weekly or monthly take aways, I have been quite good at encouraging the pharmacies that I work with to drop the cost down to a cost of around about $35 a month. You do need to write a letter to your dosing point so that they have got all your details and it is very clear what their role is and what your role is. And as I said before, check with the pharmaceutical regulatory unit that you do have an authority. It is against the law to prescribe these medicines without an authority. Next page.

So here is the application to prescribe. It looks a bit weird on my screen. It is a bit squished because I tried to put in both pages there. It is an online form. At the moment though, once you have filled it in, you do need to print it out and fax it through. They do not at the moment have the capacity to do an online form submission. But it is an important form to fill in and to fill in the different categories. And certainly, if they are new to treatment then there would be some parts that you do not need to fill in, but really going through and making sure that you are filling it in correctly. You know, in particular their details, when you want to start and your proposed starting dose. And we will go through the dosing. What I would usually put, depending on what I am doing with the patient is a proposed starting dose of 8 mg and an expected maximum of 32 mg, even if I do not think I will get that high, it just allows me to go up that high without having to ask for another authority. You also do need to put the dosing point and if the dosing point changes, you need to let PRU know. For temporary transfers, if somebody is going up to Taree for a week or whatever, you do not need to. But if they are transferring pharmacy you do need to let PRU know. Your details and all their details need to go on there. Fax it through and PRU are very good at getting back to you if there are some issues with the form or they are a bit concerned. They are really keen to support and to help and to make sure that everything goes well. Next page.

Okay. So these are prescriptions that I have made up on Letter Writer. You can do them on your electronic scripts. I just find that a bit messy and a bit hard to fit everything in, and given that you want to write, that you have got to hand-write as well, I find this works really well. It is not a PBS script. These medicines are not dispensed on the PBS so it does not need to be on a PBS script. The other really nice thing for me, is that then I have got in Letter Writer, I have just got all my prescriptions in a nice row, the doses and dates are all very clear. In terms of what you need to go on, it needs your address. It needs the pharmacy address, the details of the patient, it needs figures and numbers, dates that it started and dates that it is finishing and the number of take aways and then you write that out, the doses and figures in your own hand-writing. I find that what I generally do, is I just write out the whole thing so that I have got space between the rows there just to write it out and as I am writing it out, I am talking to my patient and I am making sure that I have got those dates right. In terms of take aways, just a little reminder, when people start, generally we would not give take aways, but if you are in a rural regional area where the only dosing point is closed Sunday and you feel that it is safe for your patient to have that take away on a Sunday, then by all means do that. And certainly if it, it really depends on the level of risk and the level of complexity of a patient. If there is other drug use going on that you are concerned about, you would be more concerned about take aways, but if they are for example a codeine user who has never injected, who is not on any other sedating medications, I would be very happy to start moving them to take aways pretty quickly. Next page.

So, this is coming back to Richard. So this is day one. And I am seeing him at 10 a.m. He has decided he wants to start the Suboxone, the buprenorphine naloxone combination. He had his last oxycodone at 8 p.m. last night. This morning he is noticing some mild restlessness with some mild muscle aches and a bit of a runny nose, a little bit anxious. But his COWS is only four. So what I say to him is, look, ah look I know you are a little bit uncomfortable but I kind of need you to be a little bit more uncomfortable. So, you know go and have a cup of tea, come back at 2 p.m. and we will check how you are going. So he comes back the same day at 2, and one of the things I will always check is just to make sure he did not take any other opioids just to make yourself feel a bit better, no codeine, nothing else? Okay, okay. And he is more symptomatic now. He has got some diarrhoea, he is feeling flushed, he is sweating. He is agitated and uncomfortable and his COWS is 10. So what I did there, was I commenced him on a test dose of 2 mg with the option of going up to 8. Now, he, in this situation in the GP or the rural regional setting where you have not got a dosing clinic that you are working in, with him that would be in consultation with the pharmacist and sending him up to have a 2 mg test dose, just hang at the pharmacy for a half hour and then see how you go. And the dosing point called me at 4.30 and said, look he has gone well. He has had a total of 8 mg today. So, really in terms of doing this you do need to have some good conversations with your pharmacist and your pharmacists need to be confident that they can manage this as well. And that is why it is important that the pharmacies are pharmacies who have an authority to actually do this prescribing, because they know the ins and outs of dosing. And you know, in terms of managing the program, I cannot tell you how important the pharmacy and the pharmacist is, and what an important role they have in supporting your patient as well. Next page.

So by day three when I see Richard again, he said look I had a slightly uncomfortable first night after the 8 mg and the second day I went back and I had 8 mg in the morning and I was still uncomfortable so in the afternoon I went back and had an additional 4 mg and I felt much better on the second night. But you know what, I did not get that buzz like I got with codeine and with the oxycodone. But you know I am doing okay, I am feeling okay. I am still not 100%. And on day three, we discussed putting him up to 16 mg and stabilising on this and I also put on the script that he could decrease down by 2 mg to 4 mg if he felt sedated and please for the pharmacy to contact me at any time in the process of this stabilisation. So what you are seeing there, is on day one he had 8 mg and then 12 mg day two, and we have gone up to 16 mg day three. So these are big increases. And this is really different to the way we would stabilise someone on methadone where start low and go slow. What we know with buprenorphine and buprenorphine naloxone is that people do better and stay in treatment if we get their dose up and get their dose up quickly, okay? Moving on to the next one.

So, he is stabilising day three. I would see him at a week and then the following week and then two weeks, four weeks depending on how he is going. Every time I see him, I would call his dosing point. So I would call the pharmacy, just checking in, how is it going? Any issues? Now the things that pharmacies will notice is if their behaviour is not great, people are not behaving well in the pharmacy and if they are not paying their bills. In addition what I want to know is, are they presenting intoxicated, are they missing any doses? Are you concerned about dosing them because you are worried about them overdosing? So that is the conversation I have with the pharmacy and I always do it in front of the patient. Just ringing up. I have got Richard here. Just checking how he is going. How it is all going? Any intoxication? Any missed doses? Any problems with behaviour or with paying bills? And then talking to Richard about any other drug use. It is really important to assess that. We know he is a smoker. We know he drinks a little. There is nothing else going on there. But always checking in. You know, so any cannabis, any cocaine, any other opioids, any other drugs, any other psychoactive drugs? Just to make sure everything is going okay. The general issues, how his work is going, how his study is going, his friendships, his housing, his relationships. All those things that are important in people’s lives. And how is the dose going? How are you going on the 16 mg? And it may well be that Richard says, well look that is fine. That is really good. It is working for me. It just feels like I am a little sedated. Okay, let us bring the dose down. And what I always say to people with buprenorphine naloxone combination, is that while we get that dose up quickly, and you usually do it in about three or four days, it takes a couple of weeks for it to really settle and to find the exact dose that works well for them. Every time you see them, you do a new script. And generally what I would do when I book appointments, I would make that appointment just before the script expires because as I said before you put the starting date of the script and the finishing date. And I always fax the script directly through to the dosing point.

Now it depends on your environment and where you are working and there are other prescribers particularly in rural regional areas where there is only one pharmacy, who will actually give the script to the patient to take to the pharmacy. And that is one of the reasons that you need to document very clearly on the script which pharmacy they are to dose from. You know, so, but from my point of view, I fax it through. Then I know that it has got there. My secretary always faxes it through for me and just checks that it has arrived. That just means that it is all clear. As I say, book the next appointment just before the script expires.

And the role of urine drug screens. Now, urine drug screens can be really useful. I would not, I would not wait to get the results of urine drug screen before I commence someone on treatment if it is really clear to me that there is an opioid dependence going on. If the history does not make sense or I am not entirely sure, I might do a urine drug screen and wait for those results before I start treatment. The role of urine drug treatment is an interesting one and it can be used as a kind of punitive approach. From my point of view, that is not fabulous and that is not that useful. What I do with urine drug screens is it around, okay, I will always say to people we are going to a urine drug screen today. If I do it today what would it show? And in some ways, you actually do not need to do the screen, but what people will say is, oh Hester ah, yes, it is going to have some cannabis in it if we do it today. Or it is going to have some methamphetamines if we do it today. And so okay, well how about we can do it and we will find that, or we can put it off to another time. The times when you would do urine drug screens is if people are wanting more take aways. If they are wanting to transfer their care. If they are, you know, if they are looking to change what they are doing. If there is a change in treatment. And it is one of the things that you can actually use as a really positive part of their treatment, where you are saying, look that urine drug screen is clear. There is nothing in it. Congratulations you are doing really well. Or, okay so there is some methamphetamine in it, can you tell me what is going on there? And looking at what is happening with that use. That really what we are looking at is not to give people a hard time about their drug use, but to look at whether it is problematic or not. How much are you using? What circumstances are you using that in? Is it causing you any problems? And certainly people who have got methamphetamines on the urine drug screen does not mean that they are at risk of overdose. But if there was benzodiazepines and heroin and other opioids there, there is a risk of overdose.

One of the things about buprenorphine is that what that means is you actually need to put the dose up. If there are other opioids in place, it is very likely that the treatment and the dose that you have got them on is not actually supporting them and they are getting withdrawals. The other really interesting thing about buprenorphine is that it is, it has a really high affinity for the mu receptors and if you flood the mu receptors with buprenorphine, other opioids do not do very much. So getting the dose up above 16 mg can be a really good thing for people because what it does, is it stops them wanting to use other opioids because the other opioids have no effect. That is something that you do need to talk to people about when you first start them, because you may have a patient that occasionally wants to use some opioids and they need to know that if they put that dose up, then they will not have the effect. And for most of my patients, they go, that is brilliant. I want that higher dose because I actually want to stop using and that will really help me. It can feel a bit counter-intuitive, that if you know, if someone is using other opioids that somehow that putting up the dose of buprenorphine can feel like oh geez I am putting more opioids in the system. But once again it is around it is around that blockade, but also the fact that it is actually a dose that means that they are not withdrawing, that they are comfortable. And what I always talk about is a sweet spot. They are not withdrawing. They are not intoxicated. It is this sweet spot where they can kind of get on with life in an everyday way.

So this is in the new New South Wales guidelines, this graph which is about assessing risk. And it is really looking through what are the things that mean that people are at risk? So the stability of the medicine that they are on, adherence to the medicine, adherence to other treatment, use of alcohol or other drugs. And other health and social conditions that impact. And you know, other health and social conditions could be, are they someone that has significant cognitive defect or do they have significant respiratory impairment. What is their mental health like? And it is those things that would make you be concerned about their risk. So their risk really here is the risk that they could come to harm, and particularly overdose. Or that they do not take those medications, they lose them, the inject them, sell them or give them away. So, you know looking at the difference between low dose and high dose. Really you can look at you know, people who are attending. They are dosing. Their dose is stable. They are adherent to the medication and there is no problem with missed doses or losing doses. Good attendance at appointments. Certainly for us in the general practice setting, you may be working in a general practice setting where it is not an issue if people miss appointments. I know in my setting because it is appointment based, it is really tricky if people miss their appointments because then they turn up at another time when I have not got space to see them. And that would be one of the main reasons that someone would transfer from me in my general practice setting, because they cannot keep appointments. And it is just really hard to manage if people cannot keep appointments. I understand that there are reasons why people cannot, but me being a part timer in an appointment based system, it is really hard to manage that and so I would ask them to transfer and probably transfer them to the local drug and alcohol service.

We have talked about significant use of alcohol or other sedating drugs, particularly sedating drugs, you know that actually increase their risk of overdose and impair their function. So really looking at those, the difference between low risk and high risk, and making that assessment. And for a GP starting this in the GP setting, ideally what you want is you want to be treating people that are low risk. The high risk people who have unstable, complex and multiple drug use, poor physical health, poor mental health, they are the ones that are much better managed and stabilised in the specialist setting. There is no reason why as they stabilise in treatment, they may well improve and then they can be transferred to a general practice setting for their prescriptions. But really be aware, and it is a thing that is really important, that it is not about you as a GP, your expertise. It is about the capacity of the environment that you are working in. So if you are a part time worker in a general practice setting, you are the one that is going to do all the management and so you do need to be sure that you can manage that person, that you have got the capacity to manage all the complexities.

So if we are talking about risk that helps us to think about take aways. And first up I would always have a conversation about take aways, that take aways are a privilege, and they are, the decision is made on the basis of safety. And so generally in the first three months of treatment where people are being commenced and stabilised, you think about their take away, can they have take aways based on their risk. So if they are high risk, you know as we said before, complex drug and alcohol, mental health issues, physical health issues, homelessness, those kinds of things. Much better for them to have daily supervised dosing at the dosing point, whether that be a pharmacy or a clinic in New South Wales. If their risk is lower, if they are low risk you may move very quickly to some take aways. And that is certainly within the guidelines. You know, so really it is around how risky are they, can they manage those take aways? Homelessness is important, because if you have got nowhere to keep your take aways, if they are going to be stolen or if you are going to lose them, that it is tricky and it is much better to have people come and be dosed daily. And the thing about that daily dosing, is that dosing is supervised, so you take your medication in front of the pharmacist or nurse and show that you have actually taken it.

In terms of buprenorphine naloxone and that is the one that unaccredited doctors are able to initiate, but usually what we would say, is usually in the first three months, no take aways. The other thing that you can do depending on the dose, is you can double dose and have alternate day dosing. And once again, once people are stabilised, depending on their risk then you can move to more take aways.

Buprenorphine, or Subutex on its own is not generally used because of this risk of the dose being injected or sold on to other people. It is used in pregnancy. Buprenorphine like methadone is very safe in pregnancy and in fact probably buprenorphine probably is better in pregnancy. You have less risk of neonatal abstinence syndrome when the baby is born. But the group of people that buprenorphine is used in is pregnant women or if there is a real, legitimate allergy to Suboxone. I would not be suggesting that in the primary care setting that you would make a diagnosis of an allergy to Suboxone, that is something that needs to be referred on to the specialist setting. And once again, the same issues. You know, while people are stabilising, generally no take aways and then moving up to take aways. But as I said before, if you are in a rural or regional setting where there is not a dosing point that is open seven days a week, then you make a decision to give some take aways based on safety and based on access. And it is important that people are able to access the care. Next page.

Have we got any questions there, Tim?

Tim: We have got a few questions, but the ones that have come through have actually been answered on the slides.

Hester: Beautiful. Okay. Alright.

Sammi: We have just got seven minutes left, Hester.

Hester: Okay, well I will try to go a bit quicker. But coming back to Richard who is looking much better now that he is on treatment. Six weeks after starting on 16 mg, doing well. Starting to think about a slight decrease in take aways on the weekends. He wants to travel to Northern New South Wales and you have got two options there. You can give him some take aways, but it is fairly early in treatment, or you could organise a temporary transfer. So there are many pharmacies around rural and regional New South Wales where you can transfer the care. So it is once again, ringing up DASAS, finding out what pharmacies are available, seeing if they have got capacity and then organising that transfer. I always ask people to give me at least two weeks’ notice of a transfer if they possibly can. Sometimes things can come up and people need to travel suddenly. But generally we want a bit of time to organise that. Moving on to the next one.

So, yes, not uncommon for patients to wish to travel, need to know in advance, call DASAS for pharmacy details or the interstate drug and alcohol offices and we will provide that information for you. Overseas transfers are tricky but not impossible, but they are something that you will need to think about. The other thing is, there is a very good website, a German website that has up to date information on the laws around importing opioids into various countries and we will give you that information at the end. Moving on.

So here we have Richard again three months after starting. He is currently on 16 mg he is doing his styling work, he is doing well. He is on weekly take aways and he wants to go to Queensland for six weeks for a course. If you were concerned about his stability, you might say, look I am not sure this is a great time. But from where Richard is at the moment, I am really happy and I would organise a temporary transfer. Or if I was really happy, I could give him six weeks take aways. If I felt that he was really stable and things were going well, you could consider six weeks of take aways, but generally I would do a transfer to a local pharmacy and continue the weekly take aways. Moving on.

Three months after starting, what have we got? Doing the same. He is six months off from starting. He is down to 14 mg. He really did not notice the dose change. He is feeling much better. He has a mental health care plan. He is seeing his psychologist and is managing some of his issues with his anxiety and he is on second weekly take aways six months after starting. Moving on.

And one year after starting he has cut down to 10 mg, no problems with the decrease. He is now on 28 day take aways. He is doing well. He is seeing his counsellor. He is happy to decrease to 8 mg and the plan is to slowly decrease to complete treatment. Moving on.

He had a lovely time in Queensland, by the way. So, what to do if you are worried about a patient? And as I have said a number of times, you know, seek specialist help. If they DNA appointments, last minute cancellations, risky drug use. Their behaviour troubles you or your staff. They are missing doses. They are intoxicated. Their physical and mental health is poor or there are other issues that you are worried about. Call DASAS or call your local drug and alcohol service. This is the person that does need that extra specialist support to get them on track. Moving on.

So coming back to Richard. Two years after starting, he is down to 4 mg just in the last four weeks and happy to decrease to 2 mg. So we are discussing further reductions after 2 mg. Some people can stop very easily on 2 mg. Other people find if they move to the second daily dose or third daily dosing that works well for them. You can cut the films. Look, the company says that they cannot assure that there is going to be the same amount of medicine throughout the film, but that can work very well for people. You can also move down to the lower dose, the 0.4’s which are buprenorphine if you wish. The great thing for Richard is that he is much better. He is managing the anxiety. He has got a great job. He is in a relationship and they are planning to buy an apartment. And 2.5 years after starting, he has ceased treatment. He has not relapsed to any opioid use and he is happy and doing well. Moving on.

Yes. So the other thing is, if you want to go on leave, because we all want to have holidays, you need to let your patients know, ensure that the scripts are dated to cover the whole period that you are away. Arrange locum cover and do a handover. So what I always do in my general practice is I have got one of my colleagues, a couple of them are happy to be my locum and if there is any patients that I am worried about, I will do a very considerable handover or I just give the basic handover and I have scripts to cover the entire time I am away. If I am away for an extended period of time, I will as I say arrange the locum cover. I will send a letter to PRU and I will also arrange for one of my specialist accredited colleagues to be happy to take phone calls from my locum because the GPs in my practice are not accredited, just in case there are any issues. We have never had any problems. Yes, and inform PRU that you are going away if you possibly can. Do not leave your patients in the lurch. It is really important that you do need to have the scripts to cover the whole time.

So what do you want to do if your patient wants to come off treatment? This is the goal. People want to come off treatment and generally people want to come off treatment probably a little quicker than they can. And there are a group of people who are likely to need treatment, we have a group of people who are now moving into nursing homes who will stay on their opioid agonist treatment for the rest of their lives because of the severity of their illness. You need to do it slowly. Drop it slowly. You need to do it at a rate that they can manage withdraw symptoms and still get on with their lives. So methadone would be a dose drop of 2.5 mg to 5 mg every two to four weeks if not slower. Buprenorphine naloxone 2 mg every two to four weeks if not slower. Assess them often, and if they are struggling with withdrawal symptoms, or start using drugs or are just struggling and thinking a lot about using drugs, slow it down. Just stop on that dose or even slightly increase the dose just to help them get over that hump. Generally I find with the buprenorphine naloxone that it is just that slow, slow, slow, slow cut down and people do very well and are able to stop it with time. Moving on to the next one.

Do not forget your Medicare item numbers. You know, so a GP mental health care plan and a management plan, your team care arrangements and case conferencing as appropriate. These are significant chronic relapsing conditions and they are flagged as mental health conditions as well. They are in the DSM-5 so you can use your mental health and you GP management plans to manage them. And do use them, because that is what they are there for, to be used so we can actually be paid appropriately. Thank you. Next one.

Asking for help. So DASAS which is the Drug and Alcohol Specialist Advisory Service or DASA. Sydney metropolitan number there and the rural regional. And that is a 24/7 number. You ring up and you talk to a very experienced intake person who may be able to answer some of your questions. If not, then a drug and alcohol specialist will call you back and generally that is within half an hour or an hour. If somebody is completely unwell and needs to be seen in the Emergency Department, just send them to the Emergency Department because the Drug and Alcohol Specialist Advisory Service cannot provide that emergency care, but they can offer advice. So they are fantastic. PRU has a duty officer on call, 9 to 5 weekdays and they are really happy to help. Your local drug and alcohol service is the public one through your local health district or the private ones if you have those in your area. The private or NGO services. Your colleagues. The other thing is, if you are worried about some of the legal issues, talk to your MDU around what your legal options are. And think about joining the RACGP GP with a Special Interest in Addiction. I am the current chair. We would love to have you join, that would be brilliant. The other thing that is really useful that is being developed in all our local PHNs is the health pathways and certainly in our PHN we have good health pathways for opioids and the other drug and alcohol issues. And the New South Wales Clinical Guidelines. As I said there is an abbreviated form and then there is the longer one, so have a look at them. They are available on line and we will send you the links. Next page.

In the ACT, just in case we have any ACT listeners, all referrals and initial contact with Health Directorates’ Alcohol and Other Drug Services, there is a 24 hour help line, the Chief Pharmacist in the ACT and at the moment in the ACT all GPs are able to prescribe for up to five stable patients but you cannot commence. You do need authority and you have the same take away provisions as we have in New South Wales. Moving on.

Okay. The Opioid Treatment Line is a number for patients and ADIS as we have said before. The other option is YourRoom which is a New South Wales Health site which is really brilliant. It has great information about the OAT program. Moving on.

Okay. So once again, yes just a plug for the GPs with a Special Interest in Addiction. The other thing is that we have the Opioid Treatment Accreditation Course. There is a fundamentals course which is available 24/7 through the website and there is some beautiful, very badly filmed videos of me on that. And the fundamentals course is the first one and then you can go on and do the accreditation course if you wish to become and accredited prescriber who then can prescribe for up to 200 people in the community setting. Moving on.

Yes, so ask your patients about over the counter codeine use. I know that has changed in February, but there are some stockpiles and their prescribed opioid use. Assess and reassess their chronic non-malignant pain using the four or the five A’s, depending on which ones you use, the PEG or the BPI. So they are your outcome measures. The Brief Pain Inventory is the one that I really like which has got specific questions about the severity of pain and interference that pain causes in their lives. Give the patient support and information around the use and risks. Do what is safe and consider the risks versus the benefits before prescribing. Remember that OAT is a very well strongly evidenced based treatment that is safe and effective. You need to make sure you are following the rules and if you are worried, get help.

So I think that is where we finish. There may well be another page. All the resources. There are masses of resources so take a look at them.

Tim: I would like very much to thank Sammi for wrestling with the computer behind the scenes to get us here to the end. Thank you very much, Hester, that was an amazing trip through the opioid treatment and what we need to do. Thank you very much everyone for your attention tonight. Apologies for the technical issues that meant we have finished slightly late. The PowerPoint, the presentation will be sent to you and so all those phone numbers and links and resources are in the slides towards the end of that, so do have a look through.

Sammi: Thank you again Tim and Hester and everyone on line for bearing with me while we deal with these technical issues tonight, but we hope you enjoyed the session. Again, thank you Tim and Hester for this evening and good night everybody.