Victoria drug and alcohol committee


A series of drug and alcohol updates for Victorian GPs

 

Glenda, age 39, presents today requesting help ‘getting off her sleeping tablets’. She provides a history of being prescribed a combination of temazepam, oxazepam and nitrazepam for insomnia by her recently retired GP. She states that her doses have remained stable for around a year and that she hadn’t perceived any side effects until this week, when she had a ‘near miss’ car accident, briefly falling asleep at the wheel, before regaining control. Following this fright, she planned to cease all her benzos ‘cold turkey’ but her neighbour (a patient of yours) suggested “seeing a GP for help first”.

Some questions go through your head, as you hear her story, including:

  • What’s the risk of Glenda having a withdrawal seizure if she was to cease all her benzos suddenly?
  • Is there a role for a benzodiazepine weaning program, and if so what medication/s and timeframe?
  • What withdrawal symptoms could Glenda expect to experience?

As GPs, we often have consultations where the presentation is potentially complex and often unexpected. Drug and alcohol issues particularly can present this way, and questions such as the above can be hard to sort out without more expertise in this clinical area.

Fortunately, we all have a free service available to all of us to assist with these types of challenges. The Drug and Alcohol Clinical Advisory Service (DACAS) is a specialist telephone consultancy service that assists Victorian GPs to respond effectively to individuals with alcohol or other drug use problems. Initial enquiries to the DACAS service are handled by professional drug and alcohol counsellors, who can then refer our calls to the on-call DACAS Consultant who will be paged to provide a secondary consultation. The DACAS Consultants are experienced Addiction Medicine Specialists. DACAS can provide assistance with any drug and alcohol issue including assessment, medical management of withdrawal syndromes, substitution pharmacotherapy and other prescribing issues, medical and nursing management of intoxication and toxicity, management of medical and psychiatric complications associated with drug and alcohol use, drug interactions  and pain management.

The service is a 24 hour, 7 day specialist telephone consultancy service available to all health professionals in Victoria.

Contact DACAS by:

1800 812 804

DACAS website

48 year old Vicki has been referred to see you by your local pharmacist. She has been a regular patient but you haven’t seen her for a number of months. The pharmacist’s letter states that Vicki has been attending more frequently over the past six weeks requesting increasing amounts of pharmacist-only (S3) ibuprofen/codeine analgesia packets. On inquiring about this, Vicki informs you that she initially started taking the tablets 3 months ago for ‘period pains’, but then admits that she has struggled with controlling this medication since her partner left her six weeks ago. She experiences ‘gut aches’, muscle cramps and agitation within half a day of not taking a dose, and has failed three times in attempting to cease her medication use, after realising she was taking higher doses for far much longer than she had initially intended.

Vicki also describes a daily headache for the past fortnight, which the analgesia only partially helps for 1-2 hours. The pharmacist wrote that she had purchased a packet of twenty-four tablets over each of the past five days, which she confirms she has been taking 4 tablets every 4 hours, including overnight. She had been embarrassed to see you, as she thought you would “tell me off for getting so many medications from the chemist”. She is pleased to see you again and hopes you can help her.

Through your assessment, you conclude that she is opioid (codeine) dependent and has possibly developed a medication-overuse headache. After reading a recent article about the increased overdoses from prescription opioid misuse, you are aware that the treatment for opioid dependence is with either methadone or buprenorphine/naloxone, through a Medication-Assisted Treatment for Opioid Dependence (MATOD) program, but you haven’t done any training in this area.

In Victoria, all GPs may now prescribe buprenorphine/naloxone (Suboxone®) for up to five patients without the need to attend the one-day Accredited Pharmacotherapy Training for GPs workshop. A patient like Vicki would benefit greatly from having her opioid dependence stabilised on medication by her own GP, whom she trusts and has access. Whilst the medication is fairly straight-forward, there are a few aspects of providing this treatment that differ from our usual prescribing.

GPs may refer to the following  guide from the Department of Health for advice on the key regulatory and policy requirements for prescribing buprenorphine/naloxone: A-brief-guide-to-prescribing-buprenorphine-naloxone . There is also an online video produced by Networking Health Victoria

Jacob, aged 42 presents with his partner Mary, requesting help following his third relapse back to heavy drinking. He has previously undergone two outpatient alcohol withdrawal programs and one inpatient detox in the past six months. He has lost his job, his license and his marriage is now under threat. Jacob states that he wants to undergo a residential rehab program following another detox, otherwise “Mary might leave me, as she’s sick of me going back to heavy drinking and ignoring her and our kids most evenings.” You spend the remaining part of consultation assessing his mental and physical health for any complications, and then consider the referral options for Jacob.

As of 1 September 2014, there have been a range of changes to Victoria’s Alcohol and Drug Treatment System Agencies are now located within 16 Victorian catchments. GPs can no longer refer patients directly to a service as we may have previously been able to do. If you are looking to refer a patient, like Jacob, for Drug and Alcohol Care Coordination, Counselling, Non-Residential Withdrawal or Rehab services, we must now refer to our local catchment’s intake and assessment service. These changes have been made to ensure a more person-centred and family-inclusive approach that had been done previously.

An outline of the different Victorian catchments and the organisations / contact details for intake and assessment referrals.

Visit the Victorian Aboriginal AOD services website to find out more about accessing these services.

 

Mavis is a 69 year old retiree, who has transferred to see you from another clinic after her GP recently retired. She is on a waiting list for a knee replacement (severe osteoarthritis) and presents for a repeat for her sustained-release opioid, amongst other medications, which was commenced 4 weeks ago. In taking a further history, she describes tolerance to her opioid (“the effect seems to wear off after a couple of weeks and my GP increased the dose to obtain similar pain relief, but that effect seems to be wearing off now too”) and withdrawal (“I missed two doses last week after I left my medication at home when on on a weekend away at the beach and I felt it: my knee pain spread to my muscles, I experienced gut cramps and couldn’t sleep. Thankfully, all that settled when I returned home to my medications!”

You decide you need more time to assess Mavis’ chronic pain and arrange to see her in a fortnight. When considering the need to apply for an S8 permit, you are aware that one isn’t usually needed until she reaches 8 weeks of treatment*, but are unsure about whether she has developed ‘dependence’ to opioids (where you would need to apply for a permit immediately, as the 8 week rule doesn’t apply for drug dependant patients*). You decide to look this up. DSM-V describes the criteria for ‘Opioid Use Disorder”**.

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. Opioids are often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain or use the opioid, or recover from its effects.
  4. Craving, or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfil major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance (This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision)
  11. Withdrawal

You conclude that Mavis is in the ‘mild’ category of severity (eg 1-2 of the above criteria). Assuming that only the ‘moderate or severe’ categories (≥ 3 criteria) equate to ‘dependence’ a permit application isn’t strictly currently required. Nevertheless, you decide to apply for a permit anyway, as you don’t feel you’ll be weaning her off prior to the 8 week mark.

* for Victorian S8 permit information: 

Jackson, a 20 year old panel beater apprentice, presents today requesting your opinion regarding whether an arm wound (sustained playing football) needs antibiotics or not. You look at his abrasion and happily reassure him that it’s healing well and if not infected. With some extra time before your next patient arrives, you delve into his medical record to see if there are any past issues that might need reviewing.

You discover that Jackson was admitted to your local hospital a year ago following a near fatal overdose. He was given naloxone (narcan) by the ambulance, before being transferred and monitored in the emergency department overnight. He was discharged the next day after the CAT team deemed his presentation a non deliberate overdose. The discharge summary states a combination of diverted prescription opioids and alcohol were the likely factors in an accidental overdose. You realise that this event puts Jackson at high risk of a further overdose and would like to do as much as possible to help him reduce his risk of a further potentially fatal event. Jackson denies any current drug use, but appears to shift uncomfortably in his seat without eye contact when stating this. You wish to provide Jackson some information to consider, relating to opioid overdose prevention.

According to Coroners Court data, almost 400 Victorians died of opioid‐related overdoses in 2014, with majority involving prescription opioids. In response to this startling statistic, the Victorian Government has established the Community Overdose Prevention and Education (COPE) initiative. COPE aims to prevent opioid‐related overdoses through educating individuals who are potential overdose witnesses around how to prevent, recognise and respond to an opioid overdose, including the administration of naloxone via intra‐muscular injection.

As GPs, we regularly see patients who are at higher risk of overdose, often without thinking of out patients’ risk at the time of our consultations. This information from COPE outlines the patients that would be suitable for preventive intervention, as well as outlining the role, use and issues with prescribing naloxone to those patients who are higher risk. Available through the PBS, provision of a naloxone script, along with some training on how to recognise an overdose, administer the injection and arrange urgent ambulance support, can save lives. It is a Schedule 4 prescription medication that can be legally prescribed by a doctor to a person at risk of overdose.

Patients like Jackson, and others with risk factors such as renal, hepatic, respiratory impairment who are prescribed opioids are common. Some of these may die of an overdose in the next year. Whilst there are many factors that contribute to these deaths, GPs can reduce opioid overdoses by circumspect opioid prescribing and provision of naloxone mini‐jets for patients who are at increased risk.

Further information, training, and resources for patients, family and friends can be found on the  COPE website

Trevor and Marion have come to see you. They apologise for ‘wasting your time’ and then explain the difficulties they are having with their daughter, Stacey, who has “run into trouble with the ice thing that’s going around.” After reassuring them that their concerns are valid and thanking them for sharing their concerns with you, their trusted GP, you further explore what’s happening.

Marion begins by describing how her 19 year old daughter is ‘throwing away her life’, having quit her university studies, spending time with “so called friends day and night.” When you ask how/why they suspect Stacey is using ice (methamphetamine), Marion begins to cry and Trevor takes over describing their concerns. It turns out that a close friend also has a daughter in Stacey’s peer group, who admitted to her parents that they have been smoking ice a few times a week, for months now.

With further history, it appears that Stacey is not at all interested in seeking any help, having bluntly refusing (by verbally abusing her parents) to come in to seek your help, yelling that she doesn’t have a problem, they do. You realise that both Marion and Trevor need some further information and support, and wonder if there are any services that can help people who are concerned about a loved one’s drug use.

Drug use is common, especially in late adolescent / early adult years, such as in the case of Stacey.

One of the major effects of drug use is that which affects families. Often deeply concerned about their family member’s use and the potential (or real) negative effects, parents and/or siblings of a drug user are often unsure about where to go to for help and often will then present to their GP for advice.

Family Drug Help is an organisation which aims to provide peer support and access to reliable information about alcohol and other drugs as well as available treatment options.

Family Drug Help have a number of services which aim to reduce the alcohol and drug related harm experienced by families and friends of a person misusing these substances and to strengthen families in their support of that person:

  • Family Drug Helpline – a state-wide 24 hour helpline available for immediate and ongoing support
  • Action for Recovery Course (ARC) – a six week family education course to learn skills and strategies in coping with a loved one’s addiction
  • Support Groups – available across Victoria where family and friends can gain support educational resources and share their experiences with others
  • Family Counselling – provides a supportive environment to help families develop their relationship by building upon their skills and strengths
  • Siblings Support – interactive online support and information.
  • You discuss these resources with Trevor and Marion and they leave very thankful for your help, pleased they aren’t alone with their struggles and hopeful that Stacey will eventually seek the help they believe she needs.
 

 

Drug and Alcohol Webinars

Opioids dependence: assessment and management for GPs


The above video is a recording of the webinar session held on Wednesday 2 December 2015, organised and presented by the RACGP Victoria Drug and Alcohol.

Presenters: Dr Paul Grinzi, Dr Michael Aufgang, Dr Cameron Loy

Facilitator: Dr Paul Grinzi

The committee meet quarterly.



Enquiries

If you wish to receive further updates on any related topics, or are interested in attending a committee meeting, please contact:

 (03) 8699 0591 (Stacey McInnes )

 vic.faculty@racgp.org.au