SAMMI: Good evening everybody. It is 7:30 so in the interest of time we do want to make a start so welcome to this evening is “Opioid Treatment in General Practice” webinar, “Assessing for Dependency and Understanding Treatment Options”. We are joined tonight by our presenters, Dr Hester Wilson and Dr Linda Mann. Before we get started I would just like to make a quick acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work.
Ok and I will just give you a bit of background on our presenters this evening. We have Dr Hester Wilson. Hester is an addiction medicine specialist as well as chair of the RACGP Addiction Medicine Network. She has a Masters degree in mental health and 25 years experience working in the primary health care setting. Hester is also a star specialist in addiction at Sydney is Langton Centre drug and alcohol clinic and has facilitated training for doctors and other healthcare workers since 2001.
Dr Linda Mann is a fellow of the RACGP and member of the RACGP Antenatal and Postnatal Care Network. Linda has both local and international medical experience especially in genetics and women is health. She is a GP representative on various national and local government committees and is an experienced medical educator. In saying that I will now hand over to Linda who will take you through the learning outcomes for this evening.
LINDA: The learning objectives for this webinar are as follows. By the end of this online QI&CPD activity
You should be able to explain how to ask, screen and assess your patients who are using opioids including over-the-counter codeine for opioid dependence and understand options for treatment.
You should be able to assess which patients are appropriate for opioid agonist treatment, also called OAT, in the community setting based on complexity need and risk.
You should be able to discuss the process involved in starting a patient on buprenorphine, naloxone and understanding when takeaway doses might be appropriate.
You should be able to explain the legal framework for prescribing S8s and list where to find additional clinical support and information to improve patient care.
SAMMI: Fantastic. We will handover to Hester to start the presentation for this evening. Thanks Hester.
HESTER: Thanks SAMMI. Hi, everyone. It so fantastic we have a huge amount of you online. It is really really brilliant. We have a lot to get through in the hour and as Linda said we do have specific outcomes that we are looking at but even getting through those is going to be a bit of a task in the hour so I would try and get through things quickly, Linda keep me on track. I just wanted to do a little bit of background around opioid prescribing in Australia and this is a pretty busy slide but the really important things that I wanted you to look at was first of all look at the rise in codeine, look at the rise in tramadol, look at the rise in oxycodone on the left there, look at what has happened with fentanyl and with buprenorphine and that buprenorphine and this one is talking about is Norspan patches, not buprenorphine specifically for the treatment of opioid dependence. We will be talking about that as well. Hydromorphone.
So what we are seeing is increased use, increased use of these medications and there is no doubt that opioids are essential medicines. They are on the WHO is list of essential medicines and they are brilliant for the management of acute care. Their role in the management of end-of-life care is very important as well. Their role in the management of chronic, non-malignant pain is much more contested and I would argue that we really need to think hard about how we are treating that and how we assist our patients. We will talk more about the problems with the opioids in using it in chronic, non-malignant pain but what we have clearly seen is with the increased supply we have seen increased harm and here we have and I guess that this is old data but what we are seeing is between 2000 and 2012 increasing mortality, so we look at heroine you know that heroine is a dangerous opioid. It has a very quick onset. There is a high risk of overdose but what we are seeing is increasing overdoses, increasing deaths from overdose, from pharmaceutical opioids and this includes the ones that we prescribe to our patients, not just the ones that are kind of obtained from mates or bought on the street. These are our patients who we are prescribing for.
So chronic pain and opioid use, now one of the things that is tricky for us is that with chronic, non-malignant pain we want to treat people is pain. It is a really significant thing that really affects people is lives and there has been an enthusiastic uptake of opioids to manage this. The problem is that for some people they actually not only become dependent but actually have addiction or aberrant behaviours and certainly you know the rates of addiction, and that is not just dependents but these aberrant behaviours between 8-12% depends on the populations that you are looking at, it may well be higher. The POINT cohort, which is a recent Australian study, 1 in 4 met the criteria for addiction. 1 in 5 met a lifetime criteria from the ICD 10 for opioid use disorder and one of the things I really want you to take home from this is this is not the drug-using, heroin-using patient though it can be. It is our patients as well and these people that had these issues are our patients in general practice and they are not injecting. They are taking it orally and all of our patients who are on opioids are at risk of harm. This is both dose-dependent, as the dose goes up, the risk goes up and it is also affected by the other comorbidities that people have.
So just coming to one of the hot topics at the moment is the over-the-counter issues and the over-the-counter codeine and I think one of the things that is really interesting as we do not know quite what is going to happen with the change of codeine from being over-the-counter to prescription only. I do not want to go into a great deal of detail around the reasons for the change however I do think it is a good idea because of the risks and the harms that are happening to people in our community from over-the-counter codeine use. When I look at the use of over-the-counter codeine really it is a spectrum of presentations that we are seeing and will continue to see and maybe we will have a larger group of people after the change. We will have a group of people who go to their pharmacy and the pharmacist says, “look sorry we cannot give you the Nurofen Plus anymore but there are these other options” and they will go, “oh well I used it for my headaches occasionally but this will do me as well, thanks very much”. There will be the people at the other end who quite clearly have become dependent and have what this SUD is, a Substance Use Disorder. They have the dependence, withdrawal and tolerance and also the aberrant behaviours and certainly when we look back at some of the studies we are looking at 1 in 5 people actually being part of this criteria so I will come to that in a moment but just looking at the spectrum, at one end you have got the occasional user who quite happily moved to another OTC medication. You have got the people at the other end who quite clearly are dependent, then you have got this group in the middle and they are a group who will need some assessment and some thought around where they fit. It may be that you decide, sorry.
F1: You may remember I mentioned a patient of mine who fits into that criterion.
F1: This was a patient who went to his chemist routinely for paracetamol and codeine 15 mg. The chemist sent him to me for Panadol Forte once the chemist could no longer provide the lower dose stuff. When I assessed him he turned out have three pains, one was postherpetic neuralgia, one with sciatica and one was mechanical low back pain and he was much happier on Lyrica and an NSAID.
HESTER: Yes, yes. I think it is that thing of really doing that assessment and sorting out what is the appropriate treatment and you may decide that you are prescription codeine is the way to go but you will want to do a really good assessment for that and I have to put in a bit of a plug around codeine. It is a prodrug. It is being metabolised to morphine and its variables so it is a tricky drug to work with and there are some people that get no effect and some people that get a lot of morphine and are at risk of overdose so it is not one of my favourites I have to say but moving on the issue for people using OTCs is that they did not know where to go. They have been using them as over-the-counter and they may not always be coming to us and saying I am using this. Ideally hopefully what we will see is that they will go to the pharmacy, the pharmacy will say look, go to see your GP and then we are in a position to actually intervene and do, to ask the questions, do a good assessment and work it out.
Coming to Richard, now Richard is a guy who has been using Nurofen Plus for three years for an infected wisdom tooth. He stopped once the wisdom tooth was removed but actually started using it as a crutch to help relax his nerves. He was having a really tough time at work and by the time he was seen he was taking 45 tablets a day of Nurofen over the last 12 months so roundabout 500 to 600 mg of codeine roughly equivalent to 50 or 60 mg of morphine taking into account that it depends how well he metabolised or did not metabolise the morphine. He tried to go ‘cold turkey’ but had sweating, shaking, poor concentration, nausea and vomiting and says, “I cannot go through that again, that was just really tricky”. So my question for you guys is and I want you type it in there, what else do you want to know? So people saying what is his renal function, absolutely. Does he use any other alcohol and other drugs, other comorbidities, background history, alcohol, mood disorder, recreational drugs, other drugs, pain, history of alcohol, other substances, allergies, psych history, other comorbidities, full medical history, gastric symptoms, beautiful, beautiful. Ok, alright, can we move onto the next slide.
So a little bit more about Richard. He is a bartender, also studying IT at Uni, four drinks a day, one day a week, yeah so it is four standard drinks one day a week. No history of injecting other drugs, no cannabis or methamphetamine use. He is a smoker. Other social history is his father had alcohol dependence and this is a man who has had no mental health history in the past other than that at the moment he is incredibly stressed with work and with the bullying that is going on, so what do you do. Type in some answers. Listen assessment of health, address mental health, negotiate tapering, counselling, mental health care plan, regular follow-up I guess, liver function, counselling, psych support, psychiatrist, gradually tapering off drug and alcohol referral, assessment of health, reassure, renal referral, plan for reduction, offer other options, assess readiness to change, advise that drugs is not a solution, refer to pain assessment, psych review, smoking cessation, has to come off, apply for an authority to prescribe, on that point I am going to move on.
Next slide please, okay so what I wanted now is to just really quickly look at this third group that I spoke about before, the people that have the dependence, tolerance, withdrawal and the aberrant behaviours and really looking at, so we have got DSM-IV which many of us grew up with, DSM-V and ICD-10. They are going to bring out ICD-11 soon but we are not quite sure what that is going to look like. One of the really important things to look at is the dependence versus use disorder, so dependence is about the tolerance and the withdrawal and we know from our patients that we have got here that he is having withdrawal symptoms. He says, ‘I cannot go through those again,’ but the other thing is looking at this, the criterion and this is looking at using larger amounts for longer than intended, persistent desire, unsuccessful attempts to cut down cravings, great deal of time spent using and recovering. Now this young man was racing around to different pharmacies buying his Nurofen Plus from a number of different pharmacies, reducing his other activities, continuing use despite the fact that it actually was not helping him. He was having interpersonal problems as well, continued use despite recurrent physical and psychological issues, recurrent use resulting in failure to perform major roles, recurrent use despite legal problems, recurrent use in hazardous situations and intolerance and withdrawal. So when you are looking at your patients and thinking where do they fit in this spectrum, where do you think this guy fits in that spectrum? So we are looking at yeah we can change easily to something else, clearly needs to actually have treatment for his dependence and aberrant behaviour, his substance use disorder or it is somewhere in the middle, use disorder, substance use disorder, use disorder, dependence use disorder, use disorder dependence, both, use disorder. Ok all right so I am just to let you know that there are essentially people who will send you out that page. I think it is a really nice summary of the different ways that you can look at it, I think SAMMI you are planning to send that out at the end.
Moving onto the next page, so the next thing and it is a really important thing is how you actually talk about this and I think that you may well be right that this young man is in that third group and therefore we need to look at what are the most effective options to help him manage. How we speak about this to people is really important. There are reasons why our patients may not tell us about this stuff because they do not realise it is important. They do not think it is part of our role or as was the case with this patient, feels incredibly shameful. I feel just so shameful that I am running around to all these pharmacies and this is out of control and I am trying to hide it for my family and friends, and so it is really important the way that we approach it, the language that we use, the support that we give, looking at the potential benefits of the drug use, and the negative aspects, and just coming back once again what do we know about opioids. This is important information to share with our patients. Really there is not much evidence that it works that well in chronic, non-malignant pain in the vast majority of patients, higher doses and longer term use, you have diminishing returns, really it is fewer benefits the longer you use it and the higher the dose. 50 mg oral morphine equivalence is associated with increased risk and over 100 mg is even higher so getting that dose down and I would also say getting people off long-term use and moving towards intermittent or other options is actually where we should be heading.
Next page, and for me this may sound cruel but in a way I am really not interested in their pain. I know they are in pain. I am much more interested in your function. I am much more interested in what your life looks like, so we do have the four or the five As of chronic pain and really for me the activities of daily living, I want to know how they are going, how are they going when they get up in the morning, are they able to get to work, are they able to do some exercise, are they able to hug their kids, are they playing, doing some physical activity, how are they sleeping, what, how much is their pain and this treatment that they are using affecting their lives. Analgesia, it is important to have that conversation about pain because that is the patient’s experience but it is as I there it is modest but meaningful. Adverse effects, what are the side effects? Is there constipation? Is there nausea? Are there vision changes? What are actually happening? Are there problems with their gut and with their kidneys? Also I would put this in the side effects. I am always really fascinated that somehow dependence and substance use disorder get put aside from adverse effects. This is an adverse effect of this medication, so this is a side effect, treated as a side effect that can happen to anyone. It is not a moral conversation about someone who is using. It is actually about this medication and the ways it is affecting them, the aberrant drug taking, addiction related things, so things like racing around to different chemists, using more than they intended, coming in early for extra scripts and things being out of control. The other thing is managing their mood, so certainly it is quite clear with Richard that he was using this medication to manage his stress and his anxiety about work. Now many of you may have seen these and some of you may love them and some of you may hate them. I really like them. I will just quickly go through it. The peak pain screening tool is three questions, so it is quick and easy and it gives you a sense of what is happening with their pain, their enjoyment of life and their general activity. The other one on the right here is the brief pain inventory. Now I have not put down these two pages so there are actually four questions about pain and there are seven questions about pain interference. These can be really useful because they can be, they are validated tools so they are a way that you can quickly get to what their scores are and you can look at scores over time so you either love these outcome measures and these tools. They are a bit like the DASS 21 in terms of the way you use them. Have a look at them, a copy of them is going to be sent out to you but you can also just Google and find them online and if they are useful for you, go for it. I really like the BPI, the Brief Pain Inventory but I happen to know Linda that you hate them. Is that right?
LINDA: Well I do not hate it. I do find the three questions stuff really helpful. In fact I have men auto fill in my (18:40) so that when I forget what the questions are next week, there is something else is coming I will remember how to use them. That is what I found but I do not have the same collection of patients as you have so you know
HESTER: Well I think the autofills are really great because once again and it is just a quick and easy to remind you in that is one of the things for us as GPs, there are so many things we have got to remember. I have a lot of auto fills and they are really useful. Just wanted to highlight the pain management network so this is part of the agency, the clinical innovation, really great website, lots of information for patients, for young people, for people with specific spinal cord injury pain but also for us as health professionals and lots of stuff around assessment and management of chronic pain, lots of resources and a quickstep so you can kind of go through what are your red flags, where do you need to go, really encourage you to go and have a look at it. There are also some great videos of the patient story, of patients talking about their experience.
Moving onto the next page, okay once again I think for me the idea that opioids are going to cure and wholly manage what is chronic, non-malignant pain which is of a complex experience is naive and in terms of looking at people’s chronic pain, really looking at I need to understand this person, their biopsychosocial-ness of them and the other really important thing is putting in those other active strategies to help them manage their pain and retrain their brain, lots of information on the ACI website about that, the non-pharmaceutical and the non-pharmacological strategies and universal precautions so think about this for everyone. Time limited opioid use, intermittent opioid use to get people moving again and if you are thinking about weaning, some people can do it easily but for many people it needs to be done quite slowly. There is some really good information on the ACI website about de-prescribing and weaning.
Next slide, once again some of the stuff on here is a basic approach. You need to work collaboratively in your general practice, case conference your difficult cases, one prescriber one pharmacy, all of your pharmacists, consider staged supply or supervised dosing so pharmacies can, you can say, look I want this person to get two days dose of time or a week’s dose at a time or I want this person to come in and have be dosed in front of the pharmacy so we are actually observing them taking their dose. No drugs of addiction will be provided on first appointment can actually help in terms of the walk-ins who are looking to find drugs. The other end of it is also understanding that this is complex and people with problematic opioid use they need help. You do not need to do it all, do ask for help. I will have some more information at the end about where you can go. Contact the Prescription Shoppers Information Service, look if there are limitations on it but it is as good as it gets at the moment and I have to say I have a patient at the moment who has come up on the pharmaceuticals shopping line and in the last three months he has seen 113 prescribers and got 114 scripts for Endone so it was very useful for me to ring and find out that information. The role of urine drug screening. It has a role, do check with your local pathology what tests they actually do because they do not always check for all of the prescribed opioids unless you check that they do. The other thing is check cost so before you actually do that and I would not say that that is the be all and end all but it can be useful adjunct for finding out information supporting the plan and keeping the patient safe. The other thing is your patients have a care plan or contract and there is heaps of information on the ACI website but also the Hunter Integrated Pain Service has some really good stuff as well. Anything you want to say about that, Linda?
LINDA: I think the interaction between you and the pharmacist is good. I did not understand until we are preparing for this that in fact all pharmacists have the ability to undertake this. It is not a special characteristic of special pharmacies so if your own pharmacist is a bit wary it might be worth having a chat and saying we could do this together, let us just start with one or two people and see how we manage. My personal experience is that we have visited pharmacists particularly in different circumstances but, for palliative care patients for example, the pharmacists are over the moon, that have come to the chemist shop to actually have a chat with them because I regard them as colleagues. It is great.
HESTER: Yeah, yeah absolutely, we will talk a little bit more about the role of supervised dosing. Can we go onto the next slide?
Okay so coming back to our Richard, so he is taking 45 tablets of Nurofen Plus per day for the last 12 months. He has clear withdrawal symptoms and you guys, vast majority of you said yes he is in that dependent substance use disorder category, some people said maybe he is in the second and third group, may be a little bit different, it is difficult to know and certainly some of you, when we said what do you do, you said I am going to refer, brilliant. Now that is certainly an option. The issue with referring is you have got to know where to refer and you have got to ensure that there are services to actually do that. The other thing is your Opioid Agonist Treatment, methadone and buprenorphine plus naloxone are both treatments that are, if we are saying this man has an opioid use disorder, dependency and opioid use disorder, there is no doubt the methadone and buprenorphine plus naloxone, also known by its trade name Suboxone, are really fabulous strongly evidence-based treatments that work and we will be coming to that in more detail. We are going to be focusing on Suboxone rather than methadone but I will talk a little bit methadone as well. The role of naltrexone which is a mu antagonist or an opioid antagonist it is possible it does have a role. There really is not a great deal of research that has been done around this. There are some people that are doing naltrexone implants but that is clearly experimental. It maybe that it is useful in a group of people who have totally withdrawn from their opioids, you cannot use this for people on opioids otherwise it will make them withdraw but it may be the naltrexone can help some people to prevent relapse but it is a very small group. Naloxone, I have put that up there to remind myself just to remind you guys, naloxone is something to think about with patients, all of our patients that are on opioids. If they are at risk of overdose how do we assess if they are at risk of overdose, you can look at their comorbidities and the dose that they are on, have they ever had an overdose before, also talking to family members, think about describing naloxone. Now shortly we hope that we will get an intranasal form of naloxone but this is using this Narcan or naloxone to actually treat overdose. Do not underestimate how often overdose happens, we can see the deaths that are happening there, they are happening in our patients and I have certainly seen it in the coroner’s cases that I have been a witness for where general practice patients who are not injectors, overdose and die and quite often they are in a house with family or friends and people do not realize. They do not have the skills. They do not know what to do when the person dies. Moving on, yes.
F2: On a related subject one of the questions is why is not weaning codeine an option and I was wondering if you may be worried about working out how much a person is actually taking, what would happen if you just stop that and this is relevant to Richard.
HESTER: Yeah so the issue first of all with Nurofen Plus you could, you could absolutely and that maybe what Richard wants to do, is to slowly cut down the dose and that is certainly an option one of the issues, one of the problems with the Nurofen Plus is first of all taking massive doses of Nurofen, yeah, you do not want this man to be continuing on these massive doses. This is a real risk to him. The other thing is the codeine is short-acting so as you try and cut down even if you did it with the codeine on its own it is a short-acting medicine so people have to take it very often and they will have, it is hard to actually work out what the best way is to do so we would not generally cut it down using the Nurofen Plus, particularly given that he is taking such a high dose. If it was a lower dose, if it was within the range that you felt look it is not a particularly high dose of Nurofen you certainly could try and for some people that will work. You need to see them regularly, you need to have a clear plan, you need to be helping them to work through it just as much.
Okay so Opioid Agonist Treatment. Opioid may not be appropriate for all persons as we have said but it is appropriate when you know that people are dependent but they have tried to manage it, yes, so they have tried, he has tried stopping it and it has not worked and he has gone through terrible withdrawal. If they are at risk of overdose or relapse, and if they are willing to consider it, you know people may say no way I do not want to do that, in which case you are trying your other options to help them manage their withdrawals, it could even be things like we are going to try and manage your withdrawal symptoms with things like Maxalon and (28:05) tool to manage their symptoms. My experience with that is they have worked particularly well but that is an option. The thing that you can do with thinking about Suboxone is that you can, it is brilliant for alleviating the symptoms and signs of physical withdrawal and helps to get people’s lives back on track, to stabilise and allows time for them to get things back on track and I cannot underestimate how fabulous that is for many many people. So Richard like many of my patients who have gone into problems with over-the-counter medicines and racing around pharmacies, they will start on Suboxone and they will say to me within days, ‘oh my God Hester, I feel so much better. I feel so much less anxious. I am sleeping better. I am not racing to pharmacies. Why did not I start on this earlier?’ Moving on, so I wanted to talk a little bit about buprenorphine naloxone. It is an interesting medication. This is a combination of buprenorphine naloxone and Suboxone is what its trade name is. It is the only one in Australia so just to make things simple I will use the trade name. It is sublingual, you put it under the tongue or on your buccal mucosa and it is a partial agonist and this is a really interesting part of this drug. It makes it really safe. It makes it much safer if people take too much but they do not overdose because it has this ceiling effect. The other thing is that if you are withdrawing, you have opioid withdrawal, it will act like an opioid, an agonist and it will relieve the withdrawal. If however you have another opioid in your system it will act like naloxone and send people into a nasty, very full on withdrawal, so it is really important to be aware of that if you are looking at starting somebody on Suboxone you want them to be in withdrawal before they start. Codeine is short-acting so you can start them on pretty quickly and we will talk about how you do. It is up to a maximum dose of 32 mg but that is a huge dose of buprenorphine. When you are looking at the ones you might have had experience with Norspan patch, Norspan patch is in the micrograms where as this is in the milligrams. If you are looking at trying to sort out is somebody in withdrawal and how much withdrawal are they in and I would say you want to start on a low-dose and commence when the patients in moderate withdrawal there is a clinical opioid withdrawal scale and there is a copy that being sent out to you guys. They can just really help you to know is this actually withdrawal so you can give your score and tells you when it is mild-to-moderate.
F3: Hester one of the questions was exactly about that, about the risks of overuse abuse etc of this drug.
HESTER: Yeah, yeah all opioids have risks but this one is much less risky because it has a ceiling effect and it is from about 32 mg that it just does not cause the respiratory depression that other pure agonist cause, that is much less risky. If however you take it with a whole heap of alcohol and some other sedating drugs you know benzodiazepines, sedating antipsychotics you can still overdose on this but it is much safer than the pure agonists. It is true that some people will end up misusing this medication and that is an issue however it is much less of an issue than it is in terms of say for example the oxycodone misuse and having the naloxone in there means that people are much less likely to inject it because what happens if you inject it is the naloxone becomes active, so if you take it under the tongue the naloxone does very little, but if you inject it, you actually get withdrawals so people tend not to inject it. It is safer. I wanted to point out it is really important change, that is in italics at the bottom there, there are new guidelines that we hope are coming out very very soon. It is now under the guidelines in New South Wales, all of us can actually commence up to 20 people at any one time, you can have 20 people on our books that we are commencing on buprenorphine naloxone Suboxone without doing additional training and that is because this is such a safe drug. The only issue that I would warn you about is just be clear that you do not want somebody that has got opioids and he has lots of opioids in his system, if you put the Suboxone in at that point they will withdraw. It is not going to kill them but it is really really uncomfortable so wait until they are in withdrawal but it is a very safe medication and I would be encouraging you guys to think about this. May be the first time you start commencing, have a chat to your local drug and alcohol team or you know your local clinic to look at getting some support around doing this because it is new but it is a very safe drug and it is really effective. What we know in this group of patients is that it is actually even more effective than it is with the injecting heroin user who has a much more entrenched lifestyle around the drug use.
Moving onto the next page, very quickly this is opioid withdrawal symptoms. Now many of these signs are not specific but taken together particularly the tearing, the goosebumps, the runny nose, the yawning, the dilatation of the pupils, irritability, tachycardia, nausea, vomiting, all those things taken together, you can give a really clear picture. I am interested Linda with your patient that came in was he having any withdrawal symptoms?
LINDA: It was actually a bit difficult to tell because he actually has got a long-standing skin condition which always makes him a bit restless and itchy and he has pallor or itch as a function of that. He had no nausea. He did not have any withdrawal headache and he and I decided that he was not dependent and that is why he was willing to think about other drugs.
HESTER: Yeah, yeah. I am certainly thinking of one of my patients who was seen by another doctor and she was complaining of nausea and vomiting and diarrhoea, mostly diarrhoea, and had a whole heap of gastro investigations but it turned out she did not tell my colleague and my colleague did not ask about her 60 Nurofen Plus a day but in actual fact she was actually presenting with opioid withdrawal.
LINDA: I have always thought that nighttime diarrhoea is secret doctor business. Anyone who gets up to go to the toilet and have diarrhoea is either overdosing with alcohol or codeine or has an actual proper gastro disease. The real secret.
LINDA: Yes, something to think about. Just want to go, there is a question about the use of this drug in the ACT. Do you know whether or not?
HESTER: Oh gosh, yeah, I am not entirely sure because that is out of New South Wales. It is another world. I do understand that there are opioid agonist programs there, I am not sure if you can actually commence Suboxone. What I would suggest if you are an ACT GP, my apologies, I should have thought of this, because of course RACGP is in New South Wales ACT, have a talk to the ACT Drug and Alcohol Service and check out if you can actually commence people on Suboxone. I can also check with my colleagues there and maybe SAMMI you can send out an email so that people know.
SAMMI: Yeah no problem.
HESTER: Next slide. Yeah so once again be aware of precipitating acute withdrawal. Your patient will not like it, you will not like it so then you need them to be in active withdrawal, start them on a low-dose and then build the dose up. Moving on, there was a Cochrane review in 2016 in people that have prescribed opioid dependence. It is quite clear arm that they do well on opioid agonist treatment and do better than heroin users. The other thing is CBT to support them to manage their anxiety, their pain. We know that psychological therapies are really effective with chronic, non-malignant pain so do think about as well. Moving on so okay this once again is some of the evidence around how effective buprenorphine and buprenorphine naloxone is for pain and opioid dependence. You start the treatment the same as for any opioid and what you find with people is that their pain is reduced. They get up to pretty good doses, these are the doses I am using with my heroine dependent patients. They have greater improvements in their quality of life and both methadone and buprenorphine and buprenorphine naloxone are effective analgesics, as effective as opioids can be in chronic, non-malignant pain. So really good information on the NDARC website, if you want to go to that and that is certainly in the list of our resources that we will give you at the end.
Moving on, so we wanted now just to pull back and just have a little look at, first of all this is New South Wales health so my apologies to my ACT colleagues but this is looking at, this is the New South Wales health website which looks at pharmaceutical services and particularly in terms of your legal responsibilities so medical practitioners there. Clicking on, so here we have the things that you need to do so once again prescribing an S8 opioid for pain management, click on that, if we are going to prescribe in New South Wales for a drug dependent person and we have already said that Richard is drug dependent or for a non-drug dependent person for longer than two months who has any of the following we need to get an authority and you can see that particular authority down the bottom there. It is an authority to prescribe an S8 drug of addiction and this is what you need to do in New South Wales, so you can apply for an authority to prescribe a drug of addiction. This is an authority to prescribe methadone or buprenorphine. Now for you if you are non-accredited you can apply for an authority to commence buprenorphine or you can apply for an authority to continue. The person is already stable in either methadone or buprenorphine so this is the form that you need to fill in so there are two forms, the first one is an authority to prescribe an S8 and it is those particular drugs that we saw on that previous screen and on this one this is an application to apply for methadone and buprenorphine and as I said before you can now actually commence buprenorphine and we will spend a bit of time looking at how you actually do that. I just saw a question people saying how long does it take. In terms of an authority to prescribe under this with this form a day; in terms of the S8 form a week or so, but you can move quicker, give them a call the PSU guys are really friendly, the pharmacists who work there love talking to us they know their stuff. They are really really good. Going back okay so I would really encourage you to have a look here. There is a lot of information here. We have got the chronic pain management, lots of stuff that you can look at on this site. Also there is the stuff around the S8 benzodiazepines. The other thing I wanted to point out is you can go to the pharmaceutical benefits page since this is sometimes a bit confusing. There is also a PBS authority so the PBS authority is a federal thing and it is different to the New South Wales authority. If you are going to prescribe then you probably need to apply to both depending on the situation so do not get the two confused. The other thing is do not ever give a private prescription. You really really want to do it through the PBS. Guys have a look at Hunter Integrated Pain Service because they have a whole heap of information there as well so I hope I have made that clear because it is really important in terms of legally prescribing. Ah here we go. View this beautiful stuff there. It is really important that you are doing this legally so that if you have someone that is drug dependent and you are going to continue them on codeine or oxycodone or fentanyl you need to apply. If you have got someone that is on those list of medications that are on the website and they are not drug dependent in your opinion but they have been on it for longer than two months you need to apply. You also need to think about your PBS authority. My apologies to my ACT colleagues. I will check out what the story is there and SAMMI can e-mail you guys, so moving on.
F: Just, are there any questions there Linda?
LINDA: Yeah there are a number of questions about pregnancy so a number of GPs have said can I prescribe this in pregnancy to which my response is GP should not be doing this on their own. It needs to be done under the vision and friendly help of specialists even in remote Australia so another person has said well they do have a friendly specialist but the GP sees the patient in between the specialist attends. Give us a (41:35) sketch on that issue.
HESTER: Yeah, first off Linda you are absolutely right. If you have got someone who is pregnant and is opioid-dependent get the specialists involved. Really it is tricky because you do not want that woman withdrawing so you really get the advice. We do use buprenorphine in pregnancy. We do not use buprenorphine naloxone. Buprenorphine has been clearly shown to be safe in pregnancy and in fact babies have less of the neonatal abstinence syndrome than they do with methadone but we do not use naloxone because this is a risk and because of the withdrawal symptoms in the foetus which damage the foetus so get help with that. You are absolutely right, thank you.
Okay so coming to the changes and I have highlighted this already. So all GPs will be authorised all of us, do not have to do any special training to prescribe for up to 30 patients at any one time. You can commence up to 20 people on buprenorphine naloxone combination, not buprenorphine on its own. It needs to be the buprenorphine naloxone combination and you can take over the care of up to 10 patients who are already stable on methadone and you want there to be people who are really stable and doing well and once again ask for help if you are not sure. Do not do this on your own if you are not sure. So coming back to Richard so he is on his 45 tablets. He has got features of substance use disorder and after conversation he has decided that he wants to start on the buprenorphine naloxone combination so how do you do it, so day 1, he is seen at 10 am, now the really important thing about this is that you are not going to be doing this in your rooms. You need to actually look at, depending on where you work, doing it with your local pharmacy, doing it with your local private clinic or doing it with your local public clinic. The way that you do it is you get the person to stop the night before. Because codeine is quite short-acting he stopped at 9:30 pm last night and it is now 12 hours later and he has mild restlessness with mild myalgia, nasal stuffiness, a bit of mild anxiety. His clinical opioid withdrawal scale is 4 so he is not in withdrawal enough now. Starting Suboxone at this stage may well send him into precipitated withdrawal so what we do is, hey look, hang around or go for a bit of a walk, have a cup of tea, have some lunch, look after yourself if you are not too nauseous, come on back at 2 pm, now he is more symptomatic, diarrhoea, flushed, sweating, agitated, COWS of 10. We started him first of all on a test dose of 2 mg when he had no reaction at all and actually felt a little bit better, another 2 mg and with the option of going up to 8 mg on the first day. So the pharmacy then we made a call and he had a total of 8 mg so he was actually started in the pharmacy in this setting but it could just as easily have been started in a clinic if you have access to those where you work, so on the first day he had 8 mg. One of the really important things about this is you are looking to titrate the symptoms and you want to do it quite quickly. You want to induce people into the treatment quite quickly so you do not need to worry about conversion. If however he was only taking 8 to 10 codeine I would start on a much lower dose and in that case we would be looking at, because for you guys at the moment what the government is saying it has to be Suboxone, that you would need to involve unfortunately, if you did not want to, but a good idea if you do, your local drug and alcohol team to prescribe buprenorphine mono and you would be looking at 0.4, 0.8 and 1.2 doses.
Moving onto the next page, day 3, so we have reviewed him again so he was uncomfortable the first night, had 8 mg on the second day and then a further 4 mg in the evening. He is feeling much better by the second night. He was kind of surprised that he did not get any of the euphoria and we looked at moving that dose up and took up to 16 mg and said lets try and settle on that dose but he can take it down if he gets too sedated and the pharmacy can call me so I am in contact with the pharmacist, looking at how he is going and it is really about symptom control. The other important thing to say to people is it is not all going to be perfect by day 3. It takes a couple of weeks for it to totally settle so hang in there, take some time off work, look after yourself, get some support.
Moving onto the next page, three months after starting you are still on 16 mg of Suboxone. It is working well and it has actually got him involved in some hairdressing, styling work and is starting to think about decreasing it so this is in the realm of people with substance use disorder at three month starting to think about cutting down. It is pretty sure that this is a man who is working, who is doing pretty well and is looking at a slight decrease. At six months he is going well at 14 mg. He really did not notice that dose decrease. He has been thinking about seeing a psychologist and he is thinking about how that has affected him, so at six months he is on 14 mg now when you are looking at this once again he is being dosed probably in a pharmacy, may be in a clinic but much more likely to be in a pharmacy and it is really important to have ongoing conversations with that pharmacist. The other thing he is looking at does he go to the pharmacy every day for observed dosing or can he get some takeaways and we will talk a little bit more about that in a minute.
Moving onto the next slide, one year after starting he is down to 10 mg. He really did not feel that dose decrease. Now he is on fortnightly dispensing so he is going into the pharmacy and he is picking up two weeks worth of medicines. When he first started he would have actually been on daily dosing while he got that dose titrated and probably moving towards some takeaways but now a year after starting he is down to fortnightly takeaways. He has seen a psychologist and he is starting to decrease to work towards completing treatment. Moving forward, two years after starting he is on 4 mg and he has decreased to 2 mg and what we are looking at is further reductions and looking at maybe second or third daily dosing. Some people do fine just stopping on 2 mg, some people need to do that a little bit more slowly but he has also got better skills to manage his emotional space, 2.5 years after starting he has now stopped treatment and is doing really well so for him there was this real sense of just, you know why did I wait this long to get on treatment. This has been brilliant and I have put some work into managing my emotional life and my psychological health and now I am ready to move on from this.
Linda are there any questions? It is a lot to get through. We have only got a little bit of time left, you know, one or two just to make sure I had not missed any important questions.
LINDA: Can I just go back to the issue of the paperwork? The clinical stuff is interesting and we can all get that quick. The paperwork drives us all nuts. I will quote a question, get this straight. If you have a chronic pain patient who is on long-term OxyContin, you need to apply for an authority from New South Wales health as well as a PBS authority. I have been told I did not need to.
HESTER: It depends if they are drug dependent or not. So what I would suggest is go back and look at the website and look at which of the drugs you need to apply for a New South Wales authority for. There is actually a list there on the website. If you want to we can go back to that now, have a quick look, SAMMI can you bring up the website?
LINDA: More questions, more questions.
HESTER: There are more questions?
LINDA: So the next question is about distinction between methadone and Suboxone. Along the lines of methadone is something you seem to use for a very long time, Suboxone not quite so much.
HESTER: Ha, ha. It depends on the patient and so the bottom line is both methadone and buprenorphine are fantastic for helping people with their opioid-use disorder. We do have an issue with both of these medications but they are a replacement. There are still opioids. They are not perfect and they have side-effects like opioids do and cutting down takes time. The group of people that tend to be on methadone tend to be people that are more complex, have more psychological and physical health issues, have a whole heap of stuff in their history, their social history, trauma in their background and so for them getting to the point where they stop their methadone is quite often quite an extended period of time and there will be some of my patients who will and are going into nursing home still on both, either buprenorphine or methadone because they actually have a more severe story with their illness where as others it will be much shorter. The thing with the Suboxone is that it is really useful in this group because it is very long acting and so the cut down is a little bit easier quite often and the other thing is that methadone is a bit sedating so it gives people that nice warm fuzzy feelings so if you are someone that loves your opioids and loves being a little bit sedated buprenorphine can feel like you are really raw. It does not cover you up in your nice blanket of sedation and so it is great for people that are working because you can still think. It is great for people that want to use their brains. I have one of my patients who is an artist who started on methadone and he loved that sedated feeling but he wanted, he knew that it was interfering with his ability to do his art and moved across to Suboxone and got really creative and got working again which was really brilliant.
LINDA: Now there are a number of questions that look at using other kinds of S8 drugs instead of Suboxone to wind people down who are using oxycodone.
LINDA: Do you have any comments about that?
HESTER: The issue here is that you could do that. This man is drug dependent so you would need to apply for an authority. The first thing that PSU will say to you is why do not you start him on Suboxone. It is really long-acting, it is really safe. We can monitor it, you can get it monitored in pharmacy. You need to think about what is the most appropriate thing for your patient and it may well be that you decide because this person has been on oxycodone for a long time and we will just slowly cut it down and once again I would encourage you to go to the ACI or the HIPS website to have a look at their issues and there way that they talk about describing. You can certainly do that. I have to say with Targin it is bit of a trickiness that somehow that is safer. It is not any safer. It is a very strong opioid. It does have some naloxone mixed in that is to manage constipation. You just got to think about what is actually going to be the most effective thing and we know with the Suboxone and methadone that they do really work with people with substance use disorder, opioid use disorder.
LINDA: And my last question is could you just make a comment about the overseas experience after codeine has been de-prescribed? You know put on to prescription only.
HESTER: So most countries have now made codeine prescription only. As far as I know the sky has not fallen and there are lots of other options that people can use to manage their acute pain and that is all I can say. The sky has not fallen. Codeine is not a great medication because it is so variable. It is a pro drug and it does not particularly work very well in many people.
HESTER: Okay so we got three minutes. So in summary ask your patients about their over-the-counter use and prescribed opioid use, assess people’s chronic, non-malignant pain using the five As, the PEG and the Brief Pain Inventory, give them support and inspiration and information around the use and risks and ask those prescribers carefully consider the risks and benefits before the prescribing because we are responsible for their prescribing and if it is not safe you do not have to prescribe. The other thing is that the Opioid Agonist Treatment is a very well evidence-based treatment. It is safe and it is effective. We need to be thinking about this more guys and the guidelines are changing so that we actually can access it. If you are not sure ask for help. The PSU, the website that we put up there as I said the pharmacists are great, they are really happy to help, your local drug and alcohol teams, get that help, do not try and do it on your own. Talk to your colleagues, you will have colleagues that have done more of this and get support around because it actually is a really great treatment that is available and we need to use it on people that need it. Where to ask for help? Do not forget DASAS, as I think sometimes the Drug And Alcohol Specialist Advisory Service is the best kept secret. It is available for patients and the community to ring but also for doctors to ring and when you ring up you will get a really quite knowledgeable intake person who will take the information and then you get a callback from a Drug and Alcohol Specialist and usually pretty quickly. They are usually pretty good and there is a rural number there for us that are outside Sydney. The other thing is the pharmaceutical services unit. They have a duty officer 9-to-5 but I must say DASAS is 24x7 whereas the pharmaceutical unit is 9-to-5 weeks days and they are really helpful. Your LHD, talk to your local drug and alcohol service. There is a lot changing in terms of local drug and alcohol services where we are wanting to step up and support GPs more, talk to your colleagues. If you have got issues around legality MDU, AVANT, NIPS whoever you are with they have a lot of information around this, join the GPSI in addiction group through the RACGP, which I happen to be the chair so that is the GPs with special interest in addiction come and join us, health pathways, more and more health pathways are being developed and we are involved in putting together an opioid pathway at the moment to really start looking at what is available in your local area. The New South Wales clinical guidelines for methadone and buprenorphine treatment, the new guidelines are coming and will be with us soon and there will be some information upon the RACGP website and there will be an attempt by New South Wales health to get information out because this is a big change and it is an important change and it is a timely change given the changes to codeine.
Next page, so the resources, I understand SAMMI you are going to send those out so that everybody has access to those.
HESTER: And I think we have kind of come to the end. Questions? We have got all of no minutes, yeah this presentation was put together over a period of time with many of my colleagues, many of whom are GPs, Dr Suzie Nielsen who is a pharmacist and working at NDARC, Dr Lucy Harvey Dodds who has a GP background in the UK and is also an addiction specialist so my thanks to those wonderful people for helping me put this together. Once again guys think about it, talk to your patients, be kind to yourself, be kind to them, ask for help when you need it, help is available.
SAMMI: And Hester and Linda I just wanted to thank both of you very much for joining us tonight and I hope everybody online has found it really helpful. I would also like to add that the RACGP up scheduling codeine pain now live so you can jump on there to have a look at details and information surrounding that. There is also contact on there from the RACGP that you can get in touch with if you have any questions you want answered. On that note that does bring us to the end of this evening’s session. I would also like to add that to ensure you receive your QI&CPD points you will need to complete the evaluation. There will be an e-mail that goes out in about an hour’s time that will have a link to that so again and thank you all so much for joining us tonight. I hope you found this helpful.