B-QuiCK: Prescription medicines misuse
Preventing medicines misuse
Have a clear and open discussion with the patient when first prescribing a medicine with high potential for misuse (e.g. opioids, sedatives, hypnotics, quetiapine and gabapentinoids) and at subsequent reviews
- Ensure the patient understands why, how and when to use the medicine and for how long. Set the expectation that treatment is temporary until functional goals have been achieved and outline the potential for harm/misuse.
Agree on a practice policy for prescribing and reviewing patients taking medicines with high potential for misuse, e.g.
- No early prescriptions
- Set number of patient portal or phone repeats allowed before in person review (may differ depending on medicine), e.g. patients who require opioids long-term must be reviewed in person every three months
- Prepare a strategy/dialogue for responding to inappropriate medicine requests; having a script can reduce anxiety about this situation, and allows the clinician to provide a neutral statement with little room for debate from the patient, e.g. I am unable to do that as it is not in the best interests of your medical care. What I can do is....
When prescribing a high-risk medicine, follow the principles of safe prescribing (open here), and consider the following points:
- Limit the initial supply, e.g. one to three days, to a new or unfamiliar patient without having the opportunity to comprehensively assess the rationale for this medicine and their current treatment
- Establish contact with the dispensing pharmacist to seek information about any early requests for repeats and to receive feedback about future dispensing (if there is suspicion or high risk of medicine misuse)
- Be aware of pressure to prescribe, prescribing in isolation from practice colleagues, or repeating a prescription from another prescriber without reassessment of need
- Be satisfied that ongoing prescription of a medicine with potential for misuse is clinically indicated and evidence-based
A patient’s risk factors may mean that a certain medicine is not appropriate (e.g. if they have developed a substance use disorder to a controlled drug; discuss treatment options with a pain or addiction medicine specialist), or that a medicine can be used but with additional precautions and monitoring in place, e.g. restricting supply to a few days’ only before review
- To avert misuse in people with risk factors, prescribe using close dispensing arrangements, e.g. annotating “weekly dispensing” on the prescription
- Document strategies relating to minimising the risk of medicine misuse in patient notes
Regularly assess progress and review the need for ongoing medicine use
- It is never too late to apply the principles of safe prescribing, establish goals for treatment and a strategy to cautiously reduce and discontinue the medicine if use is not beneficial
Pharmacists also have a role in preventing and identifying prescription medicine misuse and guiding patient’s decisions when purchasing over-the-counter medicines with potential for misuse
Identifying medicines misuse
Be clear about the difference between medicine misuse and substance use disorder; there are certain requirements under the Misuse of Drugs Act 1975 for managing patients who have developed a substance use disorder to a controlled drug
- Key features of a substance use disorder include loss of control, cravings, compulsive use and continued use despite adverse consequences. It is distinct from physical dependence.
Behaviours or clinical features that may indicate misuse by patients include:
- Requesting a specific medicine and being unwilling to accept an alternative
- Being more concerned about the medicine than the condition it is prescribed to manage
- Self-directed dose escalations
- Early requests for repeats or new prescriptions
- Claims of lost prescriptions (can be mitigated by using electronic prescriptions direct to the pharmacy) or medicine supply
Strategies to help detect medicine misuse: (use with caution and judgement of the individual clinical scenario)
- Medicine counts – ask the patient to bring in their supply of medicine and check this against the expected number of tablets remaining
- Utilise electronic databases such as Testsafe or HealthOne – to track the prescription and dispensing history of the patient
- Formal treatment contract (as opposed to a general treatment plan) – specifying that the patient agrees to receive prescriptions from only one prescriber and one pharmacy (necessary if prescribing a restricted medicine), not to divert the medicine and not to request early repeats
- Direct communication with the dispensing pharmacist – e.g. sharing information about potential medicine misuse, communicating if there is a reason for a repeat prescription to be released early
- Increasing the dispensing frequency to weekly (or more frequently) may assist pharmacists in detecting misuse if patients request earlier repeats because their medicine supply is not lasting as long as expected
- For fentanyl patches, an option for pharmacists to deter or identify potential misuse is to date the patches and request that the patient return used patches to exchange for new ones
- Urinary drug testing – this is generally not useful or practical to detect prescription medicine misuse as it will simply demonstrate if a patient has taken that medicine (if included in the assay). However, it could be considered if there is a need to detect use of other medicines or illicit substances or to confirm that the medicine is being taken (and not diverted).
Managing medicines misuse
Initiate a conversation with the patient if there is evidence of medicine misuse
- Support them to stop the medicine through gradual dose reduction and provide reassurance that their condition will be managed; several conversations may be required before the patient is ready to begin the taper
Familiarise yourself with local referral protocols to specialist alcohol and drug services
- Patients with a substance use disorder to a controlled drug should be referred for treatment to a gazetted addiction service under the Misuse of Drugs Act 1975. Opioid substitution treatment (OST) is usually initiated for patients with an opioid use disorder.
- Consider referral to a specialist service for patients who have had a previously unsuccessful taper attempt in primary care or have a significant or untreated psychiatric co-morbidity
- Referral to addiction services for OST may be needed for some patients taking opioids who do not meet criteria for an opioid use disorder, e.g. those taking high doses, signs of aberrant behaviour
- Other patients can be managed in primary care, provided they have adequate support at home
Avoid abrupt discontinuation due to the risk of severe withdrawal symptoms (e.g. seizures with benzodiazepines), unless patient safety is at risk (e.g. high risk of overdose). Aim for full cessation, but any reduction in dose is still beneficial.
Reduce one medicine at a time if patients are misusing multiple medicines. The optimal order of deprescribing is uncertain in the literature, so this decision can be made pragmatically.
Individualise the dose taper
- There is little evidence of how frequently doses should be reduced, by how much and over what time frame, and it also depends on the medicine being tapered. This should be individualised depending on the patient’s clinical circumstances; a decrease of 10% per week or month is a reasonable initial step. Actively involve the patient in decision-making about the withdrawal regimen.
- Contact the local pain or addiction medicine service for advice and support as needed
Increase the dispensing frequency of the medicine, e.g. to weekly, set days of the week or daily, if appropriate. If possible, avoid Mondays and Fridays for medicine collection as public holidays generally fall on these days.
Review frequently throughout the dose tapering process
- Assess symptoms and signs of withdrawal, adjust the tapering schedule as needed, and assess the patient’s mental health and wellbeing
Recommend concomitant non-pharmacological and self-management strategies throughout the dose tapering process for continued management of the underlying condition or withdrawal symptoms (as needed), e.g. cognitive behavioural therapy, relaxation/meditation/mindfulness, exercise
Adjunctive pharmacological treatments are not routinely required and introducing more medicines to a person during withdrawal is generally not encouraged. However, they may be necessary in some cases, e.g. NSAIDs for pain or antidepressants for patients experiencing anxiety or depression.
- Benzodiazepines, clonidine and some opioids (e.g. buprenorphine) may have a role in opioid withdrawal but should not be prescribed to manage withdrawal symptoms without specialist advice
Withdrawing a patient from a misused medicine may take a significant amount of time
- Be prepared to maintain patients on low doses for an extended period of time if they are unable to complete the taper
Specific tapering guidance summaries are available for:
