Unintentional misuse of prescription medicines”, bpacnz, Oct, 2018.
www.bpac.org.nz/2018/misuse.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
- What strategies have you found work well in your
practice to help avoid unintentional misuse of
medicines? What are the main challenges?
- 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?
- 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?
- 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?
- 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?
- 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?
- 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?
