Co-ordinated approach to illicit prescription drug abuse Dr Greg Lydall Consultant Psychiatrist, HSSD Guernsey SSA York, 2015.
Post on 20-Jan-2016
218 Views
Preview:
Transcript
Co-ordinated approach to illicit prescription drug abuse
Dr Greg LydallConsultant Psychiatrist, HSSD Guernsey
SSA York, 2015
What we will cover
• Small island context• Problems• 3 datasets• Findings• Action plan• Results
What we will cover
• Intro• Method• Results• Discussion• Conclusions
What we will cover
• Intro• Method• Results• Discussion• Conclusions
Introduction
• Island community• Illicit drugs are difficult to import and
expensive• Drug users look to alternative substances
mainly pharmaceuticals• Implications for local prescribers, treatment,
prognosis and prevention
Clinical picture in Guernsey• Very different to UK experience• Anecdotally, little heroin, poor quality.• Pharmaceuticals esp fentanyl and benzos
misused and implicated in ODs & deaths• Fentanyl patches ut into strips and cooked up• Extracted and injected• Street value £200-300 for 100mcg patch• Pre-filled syringes available• Suboxone street value £10/mg (vs £1/mg UK)
Clinical picture in Guernsey
Source: opiophile.org; bluelight.org; drugs-forum.com
Clinical picture in Guernsey
Image sources: opiophile.org; bluelight.org; drugs-forum.com; erowid
Drug treatment in Guernsey• CDAT: NTA tier 2-3; no T4 on island• Charity NTA T1 + NEX• AA active; no NA• OST options are mainly DF-118 (high dose) and Subuxone >
Subutex• Methadone not approved• “NHS” (Mental health, addictions, infectious diseases,
radiology, pathology)• Medical Specialists Group (chambers): all other secondary
care• Primary Care is private • All 3 different systems – including data systems!
Methodology
• 3 Audit results examined:– Unnatural deaths (2002-2011) [States Pathologist]– Substances misused from CDAT referrals (2011-13)– Prescribing data [Prescribing Advisor]
Results (1):Unnatural deaths
• n=106 (suicides, RTAs, etc)• n Alcohol = 20• n Drugs (all) = 25• M:F = 60:40• Small numbers per year - confidentiality
Source: ONS.gov.uk
Different drug death profiles
• Higher proportion of fentanyl, benzo deaths• Fentanyl = Heroin (14%) < Heroin E&W (30%)• DHC/Codeine 17% vs E&W 2%• Methadone 4% vs E&W 12%• Paracetamol 4% vs E&W 11% • Guernsey: no cocaine, amphetamine deaths• BUT: small Guernsey numbers (n=106) vs E&W
(27k)
Results (2)
• 280 drug patients were referred/3 yrs• Buprenorphine (36%), benzodiazepines (30%),
dihydrocodeine (18%), fentanyl (9%), heroin (7%) and codeine (7%)
• 90%+ misusing prescription only medicines (POMs) and over the counter (OTC) drugs, particularly opiates and benzodiazepines
• Reported patterns of use tended to follow local availability and poly-drug misuse was common
(2) Top 10 = pharmaceuticals
NTA data (2011-12)
(3) Drug groups misused at referral to secondary care addictions
Guernsey E&W* Group 2011 2012 2013 Total % %OPIOIDS (all) 65 64 76 205 73 >90%FENTANYL 9 9 6 24 9 ?BENZODIAZEPINES 25 28 30 83 30 25EDOC /NPS 4 5 9 18 6BUPRENORPHINE 26 29 46 101 36HEROIN 11 5 4 20 7CODEINE 6 7 6 19 7DIHYDROCODEINE 22 13 14 49 18
* Addiction to medicines, NTA, 2011/
Class 2011 2012 2013 Total Avg % UK*Drugs Referrals 80 97 103 280POM 75 67 79 221 79 16%*illegal 17 18 13 48 17 90%+OTC 3 5 4 12 4 ?OTC+POM 78 72 83 233 83 16%
* In 2009-10, just 2% (3,735) of those in drug treatment services reported their primary problem was with POM/OTC (referred to as ‘POM/OTC-only’). A further 14% (28,775) whose primary dependency was illegal drugs reported additional problems with POM/OTC (referred to as ‘POM/OTC+’). This means that overall 16% (32,510) of people in drug treatment services reported problems with their use of POM/OTC medicine out of a treatment population of 206,889.
Results (3): Drugs misused by legal class
Implications
• Drug users are creative and will find alternative substances and ways of using them
• Fentanyl-related deaths = heroin-related deaths at post mortem/case review
• A high risk sub-group of substance misusers (9%) injecting fentanyl (derived from fentanyl patches) was identified
• How to address fentanyl and POM availability?
Action Plan
• Discussed with service users, Public Health, Drug & Alcohol Team, and Drug & Alcohol Strategy Co-ordinator in 2011
• Suggested a forum be set up to raise concerns, share info, monitor trends, discuss strategies to address POM availability
Addictive POM Group
• Public Health, CDAT, Border Agency, Primary Care, Pain Clinic, Prison HC
Action Plan (2)
• APOM group met first in 2011 quarterly• Prescribing advisor showed fentanyl px data• Opioid px audit: Primary Care & Pain Clinic• Border agency: aware to look for APOM
imports – changed policy (personal use) and several arrests
• Prenoxad programme for high risk injectors
Results (1)
Conclusions (1)
Conclusions (1)
Conclusions (1)
Conclusions (1)
Conclusions (1)
Conclusions (1)
Conclusions (1)
Conclusions (1)
Results (2): changes in prescribing
• Over 2011 to 2013:• Fentanyl prescribing ↓ by 18% and cost ↓ by 45% • Sedative hypnotics ↓ by 13%• Morphine increased…• Oxycodone and Tramadol increased…• Increased awareness among prescribers• Support for various initiatives incl Community
Supervised Consumption, GP shared care• Annual audit of drugs misused at referral to
continue
Discussion (1)
• High rates of pharmaceutical drug misuse• May reflect the low availability of illicit drugs:
displacement• Increases demand for addictive POMs and OTCs. • Prescribers in isolated communities need to be
more cautious when prescribing addictive POMs• Pharmacists and Prescribing Advisors may need to
monitor for POM and OTC drug misuse particularly of opioid-containing medications and benzos
• Ongoing data monitoring may be helpful
Discussion (2)
• Generalizeable?• Island, small area, homogeneous population• Possible to capture almost all of the people
referred for help with substance misuse• Whether that would translate to big cities is
hard to know. But for other smaller communities, may give insights into the problem and possible solutions
Discussion (3)
• Future?• Ongoing data monitoring• Cross reference with Drug Testing results• …and Prescribing data (2013-)• …and Unnatural Death data (2012-)• …wider than fentanyl: benzos, DHC• Watch Buprenorphine referrals and as Community Supervised
Consumption was strengthened in 2014• Watch if new pain meds appear in referrals
• #1 drug cause of death though = alcohol!
Conclusions
• Creative drug users• Demand high – why?• Supply restriction: borders vs prescribers• Prescribing responsibility: wider than patient• Addictive POM group: co-ordinated approach
may reduce prescribed drugs and hence drug availability – public health initiative
• Questions? Ideas & research links welcome!
Thanks – any questions?
• Service users & carers• CDAT: Michelle Aldridge, Anna Williams, Claire
Peters, Katrina Johnston, Dr Sakhib Rahman• States Pathologist: Dr Catherine Chinyama• Prescribing advisor: Ms Geraldine O’Riordan• Director of Public Health: Dr Steven Bridgeman• Pain service: Dr Yaroslav Stefak, Ms Katie Bassett• All members of Addictive POM group
Results (1)
• Causes of unnatural death (drugs, incl alcohol) in Guernsey vs UK (2002-11)
Drug Guernsey England & Wales
Alcohol 20%
All opiatesHeroinFentanylOther
10%4%4%2%
55%28%?7%
Benzos 6% 9%
Cocaine - 6%
Amphetamine - 3%
Unnatural deaths Gsy (‘02-’11): drugsYear
Total deaths Alcohol Benzo. “Opiates” Fentanyl Heroin
2002 8 0 0 0 0 02003 9 1 1 2 0 02004 17 4 1 1 1 12005 9 2 0 2 0 22006 11 1 0 0 0 02007 12 4 1 3 1 02008 6 1 0 0 0 02009 5 0 0 0 0 02010 11 1 0 1 0 12011 17 6 3 2 2 0
total 105 20 6 11 4 4% 100 19 6 10 4 4
Top 10 drugs of misuse (self report) 2011 2012 2013
Position Drug % Drug % Drug %
1 Diazepam 29 Diazepam 28 Suboxone - illicit 24
2 Suboxone 18 DHC 15 Diazepam 19
3 Subutex 17 Suboxone 15 DHC 14
4 Heroin 14 Cannabis 12 Subutex - illicit 9
5 Fentanyl 12 Fentanyl 12 Tramadol - illicit 9
6 Codeine 7 Subutex 12 Cannabis 6
7 Cannabis 6 Codeine 7 Heroin 5
8 DHC 6 EDOCS 5 Methadone 5
9 EDOCS 6 "Opiates" 5 Codeine 4
10Codeine+
(OTC) 4 Heroin 4 Fentanyl 4
top related