Unintentional misuse of prescription medicines

Part 1: Understanding and preventing medicine misuse

In most cases, people do not set out to misuse medicines that are prescribed to them. It may begin with taking an occasional extra dose, taking two tablets instead of one or taking an “as needed” medicine regularly regardless of symptoms, but over time neurological changes occur, and control is lost over these decisions. The medicine is then perceived as a necessary means to function day to day and the person becomes trapped in a cycle of medicine misuse.

Key topics in this article:

Understanding medicine misuse

• Losing control of medicines – understanding the reasons and risk factors for misusing prescription medicines
• Defining medicine misuse – simply put, this is using a medicine in a manner or dose other than prescribed. Substance use disorder is when this use becomes problematic, involving loss of control, cravings and compulsions.
• National prescribing snapshot: medicines of misuse – national dispensing data suggest that there may be a number of patients who are taking these medicines long-term inappropriately

Preventing medicine misuse

• Strategies to mitigate the risk of prescription medicine misuse
• Preparing a practice strategy in advance - primary care practices should agree on a policy for prescribing and reviewing patients taking medicines with a high potential for misuse, and prepare a practice strategy/dialogue for responding to inappropriate medicine requests
• Principles of safer prescribing of medicines with potential for misuse
• Prescribing to patients with risk factors for medicine misuse - depending on the individual scenario, a patient’s risk factors may mean that a certain medicine is not appropriate, or that a medicine can be used but with additional precautions and monitoring put in place
• Reviewing the rationale for continued prescribing - it is never too late to apply the principles of safer prescribing and establish goals for treatment and a strategy to cautiously reduce and discontinue medicines if use is not beneficial
• Legal requirements when prescribing controlled drugs

Part 2: Identifying and managing medicine misuse

Despite following principles for prescribing to avoid medicine misuse, some patients will inevitably still misuse their medicine. This article covers:

• Behaviours or clinical features that may indicate medicine misuse by patients
• Strategies for confirming medicine misuse
• The role of community pharmacists in medicine misuse

When medicine misuse has been identified in a patient, the medicine should ideally be withdrawn gradually over time. Click here to read guidance on undertaking a medicine withdrawal in general practice, including information about determining a tapering protocol, the role of increasing the dispensing frequency, the process of withdrawing more than one medicine and supporting patients throughout the taper.

It can be difficult for patients who have been taking medicines long term to accept the need for deprescribing if they are no longer of benefit or causing harm. Some patients may be distressed, or even become aggressive, when the discussion around deprescribing is raised, which can be challenging to manage. Click here to read about a suggested approach to the conversation of deprescribing.

Specific tapering guidance summaries are available for:

• Opioids
• Benzodiazepines and zopiclone
• Gabapentinoids