Substance use disorder theme: Unintentional misuse of prescription medicines - Peer Group Discussion for Prescribers

The following questions can be used as discussion points for peer groups or self-reflection of practice. The questions for this peer group discussion relate to medicine misuse, a topic within the “Substance use disorder” theme. It is strongly recommended that the linked article is read before considering the questions.

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Unintentional misuse of prescription medicines”, bpacnz, Oct, 2018. www.bpac.org.nz/2018/misuse.aspx

This Peer Group Discussion is intended for prescribers.

If you are a pharmacist see: www.bpac.org.nz/PeerGroupDiscussions/substance-use-theme-pharmacists.aspx

Medicine misuse is generally described as: “using a medicine in a manner or dose other than prescribed”. This definition encompasses people who obtain medicines for the sole purpose of gaining a “high” (i.e. without a legitimate indication for the medicine) or for diversion (i.e. selling to others). However, the more common scenario in a primary care setting is a person who is using a medicine for the purpose it was prescribed, but at a higher dose, increased frequency or for a longer duration than indicated.

Medicines with a higher potential for misuse include opioids (e.g. oxycodone, morphine, tramadol and codeine), sedatives and hypnotics (e.g. benzodiazepines and zopiclone), other CNS depressants (e.g. gabapentin, pregabalin) and stimulants (e.g. methylphenidate). However, almost all medicines have potential for misuse.

The reasons why people misuse prescription medicines are multi-factorial and complex, including psychological and biological factors, coping mechanisms for pain and other symptoms, lack of family and social support, adverse living circumstances and challenging or traumatic life events.

When any medicine is prescribed, especially those that have the potential for misuse, the responsibility lies with the prescriber to set the boundaries for use by ensuring that the patient understands why, how and when to use it and for how long. Prescribing principles can be followed to reduce the risk of medicine misuse, e.g. assessing psychological wellbeing and risk of addiction, establishing goals of treatment, providing a written treatment plan.

Ideally, a practice strategy for prescribing for and reviewing patients taking medicines with a high potential for misuse should be prepared in advance. This strategy should include consideration of:

  • A policy for repeat prescription requests for high-risk medicines, e.g. no early repeats and review of patients in person by a general practitioner at least three-monthly
  • How to manage electronic prescription requests via patient portals
  • Documenting treatment plans in the patient’s notes so other clinicians in the practice can follow the protocol
  • Being aware of pressure to prescribe or prescribing in isolation from practice colleagues
  1. What strategies have you found work well in your practice to help avoid unintentional misuse of medicines? What are the main challenges?
  2. In your experience are there particular situations or characteristics of a consultation that might make you more cautious when prescribing some medicines to some patients?
  3. A scenario that many clinicians encounter is a patient who has been prescribed an opioid for acute pain who continues to re-present requesting further opioid prescriptions when the clinical need has reduced or gone. What is your strategy for managing a situation such as this?
  4. How long do you usually prescribe an opioid for when writing the initial prescription? Were you surprised to read that the initial number of days supply influences the patient’s long-term use of opioids?
  5. When prescribing a medicine such as an opioid or hypnotic, do you create a written treatment plan for patients? If so, do you find that patients are receptive to this idea and find the plan beneficial?
  6. Medicines Control (Ministry of Health) can provide advice for prescribers about the legislative requirements under the Misuse of Drugs Act 1975 and the Medicines Act 1981. A restriction notice can also be issued. Have you ever needed to contact Medicines Control? Or initiate a restriction notice? Do you think these measures help patients and prescribers to address prescription medicine misuse?
  7. Overall, how effective do you feel in being able to prevent unintentional prescription medicine misuse? Has reading this article made you feel more confident in identifying and managing medicine misuse?

Published: 7 December 2018 | Updated:

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