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Opioids part1-2010
Opioids part1-2010
Opioids part1-2010
Opioids part1-2010
Opioids part1-2010
Opioids part1-2010
Opioids part1-2010
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Opioids part1-2010

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  • These questions will be addressed in this lecture.
  • Stafford J., & Burns, L. (2009). An overview of the 2009 IDRS: the Injecting Drug User survey preliminary findings. Drug Trends Bulletin, December 2009. Sydney: National Drug and Alcohol Research Centre, University of New South Wales
  • Degenhardt, L., Rendle, V., Hall, W., Gilmour, S. & Law, M. (2004) Estimating the size of a heroin using population after a marked reduction in heroin supply. Sydney, National Drug and Alcohol Research Centre, University of New South Wales.
  • Day C, Degenhardt L, Hall W. (2006) Changes in the initiation of heroin use after a reduction in heroin supply. Drug Alcohol Rev . 25(4):307-13
  • 1http://www.avert.org/transmission.htm Accessed November 2009. 2ASHM and NCHECR (2008) An overview of hepatitis C: Clinical management in opiate pharmacotherapy settings. Australasian Society for HIV Medicine Inc and National Centre in HIV Epidemiology & Clinical Research. 3 Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic. National Centre in HIV Epidemiology and Clinical Research.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic. National Centre in HIV Epidemiology and Clinical Research and ACT-HBV Australia and New Zealand Local Chapter.
  • Dolan, K. (1997) AIDS, drugs and risk behaviour in prison: state of the art. IN NEDLES, J. & FUHRER, A. (Eds.) Harm Reduction in Prison. Bern, Peter Lang. Dolan, K. A. (2001) Can Hepatitis C transmission be reduced in Australian prisons? Medical Journal of Australia, 174, 378-379.
  • Photograph courtesy of Dr Kate Dolan.
  • WHO (2004) Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users. Evidence for Action Technical Papers. World Health Organisation, Geneva, Switzerland.
  • 1National Centre in HIV Epidemiology and Clinical Research (2003) Australian NSP Survey National Data Report 1995-2002. National Centre in HIV Epidemiology and Clinical Research, The University of New South Wales, Sydney, NSW. 2National Centre in HIV Epidemiology and Clinical Research (2009) Australian NSP survey: National data report 2004-2008, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW.
  • 1DOLAN, K. A. (2001) Can Hepatitis C transmission be reduced in Australian prisons? Medical Journal of Australia, 174 , 378-379. 2DOLAN, K. A., SHEARER, J., WHITE, B., ZHOU, J., KALDOR, J. & WODAK, A. D. (2005) Four-year follow-up of imprisoned male heroin users and methadone treatment: mortality, re-incarceration and hepatitis C infection. Addiction, 100 , 820-828.
  • Leong M, Murnion B, Haber PS. Examination of opioid prescribing in Australia from 1992 to 2007. Intern Med J . 2009 Oct;39(10):676-81.
  • Australian Institute of Health and Welfare 2008. 2007 National Drug Strategy Household Survey: first results. Drug Statistics Series number 20.Cat. no. PHE 98. Canberra: AIHW
  • Transcript

    • 1. Opioids Part 1 Epidemiology of illicit use Complications Prescription opioid use © 2010 University of Sydney
    • 2. Learning Objectives <ul><li>To be able to: </li></ul><ul><li>Describe the prevalence of illicit opioid use and dependence </li></ul><ul><li>Understand the complications of injecting drug use, including opioids </li></ul><ul><li>Describe the prevalence of prescription opioid use </li></ul><ul><li>Explain how to prescribe opioids responsibly to reduce risk of iatrogenic dependence </li></ul>
    • 3. Overview <ul><li>Epidemiology of illicit opioid use </li></ul><ul><li>Factors affecting substance use </li></ul><ul><li>Complications </li></ul><ul><ul><li>Psychosocial </li></ul></ul><ul><ul><li>Medical </li></ul></ul><ul><ul><ul><li>Viral infections </li></ul></ul></ul><ul><ul><ul><li>Overdose </li></ul></ul></ul><ul><ul><ul><li>Prevention </li></ul></ul></ul><ul><li>Prescription drug use </li></ul><ul><li>Responsible prescribing of opioids </li></ul>
    • 4. Mr. J <ul><li>Mr J, aged 24 , was recently released from jail </li></ul><ul><li>Commenced illicit drug experimentation at age 12 </li></ul><ul><li>No home or major personal problems, just fell in with friends that were ‘into things’ </li></ul><ul><li>Intermittent heroin use (mainly using stimulants) from age 14 to 19, then daily heroin use; dependence ensued </li></ul><ul><li>Questions: </li></ul><ul><ul><li>How common is heroin use? </li></ul></ul><ul><ul><li>Who is more likely to develop problems with heroin? </li></ul></ul><ul><ul><li>What are the associated risks? </li></ul></ul>
    • 5. Epidemiology of substance abuse <ul><li>Prevalence </li></ul><ul><li>Patterns of use </li></ul><ul><li>Recent trends </li></ul>
    • 6. Assessing Prevalence of Drug Use <ul><li>Household surveys of representative samples </li></ul><ul><li>Illicit Drug Reporting Scheme </li></ul><ul><ul><li>Utilises multiple sources of users and their contacts </li></ul></ul><ul><li>Consequences </li></ul><ul><ul><li>D eaths, treatment seeking, crime </li></ul></ul>
    • 7. Life-time prevalence of drug use in Australia 2007 <ul><li>Note: Heroin: 1.6% (0.3 million); Mean age of initiation of life-time use: 29 years. </li></ul><ul><li>Household surveys underestimate use of stigmatised substances </li></ul><ul><li>Data Source: AIHW (2008) 2007 NDS Household Survey </li></ul>
    • 8. Lifetime use of heroin (by age and gender) Data Source: AIHW (2008) 2007 NDS Household Survey
    • 9. Recent use of heroin Data Source: AIHW (2008) 2007 NDS Household Survey
    • 10. Recent use of heroin <ul><li>Males are more likely than females to have used heroin in the last 12 months </li></ul><ul><ul><li>♂ 0.3% vs ♀ 0.1% </li></ul></ul><ul><ul><li>or ♂ 25,900 vs ♀ 10.300 </li></ul></ul><ul><li>The highest proportion of recent users found among 20-29 y.o. males </li></ul><ul><ul><li>0.7% (10,700) </li></ul></ul>AIHW (2008) 2007 NDS Household Survey
    • 11. Heroin - patterns of use <ul><li>Most users inject heroin </li></ul><ul><ul><li>However, a significant proportion ‘smoke’ heroin, inhaling the vapour. Known as ‘chasing the dragon’ </li></ul></ul><ul><li>Polydrug use is common </li></ul><ul><li>Experimental and recreational use more common than dependent use </li></ul><ul><ul><li>Risks - especially of Hep C and overdose </li></ul></ul><ul><li>Long-term dependent user has the largest impact on public health and order </li></ul><ul><li>Dependent use </li></ul><ul><ul><li>usually daily use by injection (1-2 years from 1 st use to daily use) </li></ul></ul>
    • 12. Heroin use among Injecting Drug Users (IDUs) <ul><li>2009 National sample: N=881 </li></ul><ul><li>Heroin is the drug of choice (52% of IDUs) </li></ul><ul><ul><li>64% of heroin users inject ~ 3 times a week (in the last six months) </li></ul></ul><ul><ul><li>15% use daily </li></ul></ul>Stafford J., & Burns, L. Drug Trends Bulletin, December 2009. (NDARC)
    • 13. Estimated number of heroin dependent users in Australia Data source: Degenhardt et al 2004, NDARC
    • 14. Dependent heroin users <ul><li>Dependent heroin users </li></ul><ul><ul><li>65% male; age varies (median 30-35 years); evidence of aging cohort in Australia </li></ul></ul><ul><ul><li>>90% English speaking </li></ul></ul><ul><ul><li>Indigenous 10-15% </li></ul></ul><ul><ul><li>Imprisonment ~50% </li></ul></ul><ul><ul><li>Unemployment/pension >80% </li></ul></ul><ul><ul><li>Homelessness ~10% </li></ul></ul>Day C, et al (2006) Drug Alcohol Rev. 25(4):307-13
    • 15. Complications Drugs Social Medical Psychological
    • 16. Psychosocial complications of heroin use <ul><li>Generally severe. Why? </li></ul><ul><ul><li>Illicit </li></ul></ul><ul><ul><li>Stigmatized </li></ul></ul><ul><ul><li>Expensive </li></ul></ul><ul><ul><li>Grossly intoxicating </li></ul></ul><ul><li> (contrast with tobacco) </li></ul>
    • 17. Social consequences <ul><li>Illicit nature </li></ul><ul><ul><li>Imprisonment rate up to 50% </li></ul></ul><ul><ul><li>(60% of prisoners are incarcerated for drug-related crime, 20% for alcohol-related crimes) </li></ul></ul><ul><li>Stigmatised </li></ul><ul><ul><li>Alienation from parents, spouse and children </li></ul></ul><ul><ul><li>Discrimination in workplace, health care </li></ul></ul><ul><li>Expensive : $50-200 per day </li></ul><ul><ul><li>Involvement in crime (theft, dealing, importation) </li></ul></ul><ul><ul><li>Prostitution </li></ul></ul><ul><ul><li>Homelessness and debt to unscrupulous drug dealers predispose users to becoming victims of violent crime. </li></ul></ul><ul><li>Intoxication </li></ul><ul><ul><li>Inability to complete education or keep jobs </li></ul></ul><ul><ul><li>Difficulties caring for children; family breakdown may result </li></ul></ul>
    • 18. Medical complications <ul><li>Non-specific to opioids </li></ul><ul><ul><li>Infections </li></ul></ul><ul><ul><ul><li>Viral*, bacterial, fungal </li></ul></ul></ul><ul><ul><li>Vascular damage </li></ul></ul><ul><ul><ul><li>Venous, arterial, pulmonary </li></ul></ul></ul><ul><ul><li>Glomerulonephritis </li></ul></ul><ul><ul><ul><li>Not common, but severe complication of injecting drug use </li></ul></ul></ul><ul><ul><li>Rabdomyolysis and acute renal failure </li></ul></ul><ul><ul><ul><li>Not common, but severe complication resulting from compartment syndrome (caused by prolonged period of unconsciousness) </li></ul></ul></ul><ul><ul><li>Malnutrition </li></ul></ul><ul><ul><li>Trauma </li></ul></ul>* Major causes of harm - discussed in this topic
    • 19. Medical complications (cont) <ul><li>Specific to opioids </li></ul><ul><ul><li>Overdose * </li></ul></ul><ul><ul><li>Dental caries </li></ul></ul><ul><ul><ul><li>Mostly due to suppressed secretion of saliva </li></ul></ul></ul><ul><ul><ul><li>May cause acute or chronic pain, dental infections </li></ul></ul></ul>* Major causes of harm - discussed in this topic
    • 20. Infections due to IDU <ul><ul><ul><li>Viral </li></ul></ul></ul><ul><ul><ul><ul><li>Caused by blood borne viruses (BBV) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HIV/AIDS, Hepatitis C (HCV), Hepatitis B (HBV) </li></ul></ul></ul></ul><ul><ul><ul><li>Bacterial </li></ul></ul></ul><ul><ul><ul><ul><li>Abscess, cellulitis, necrotising fasciitis, thrombophlebitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pneumonia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Endocarditis: R>L sided, Staph Aureus </li></ul></ul></ul></ul><ul><ul><ul><li>Fungal </li></ul></ul></ul><ul><ul><ul><ul><li>Mostly Candida albicans, local or systemic </li></ul></ul></ul></ul>
    • 21. Viral Infections: Prevalence in IDUs
    • 22. Transmission of viral infections: Needle sharing <ul><li>Sharing needles and other injecting equipment or “works” (syringes, spoons, filters and blood-contaminated water) is an important route of transmission of the blood born viral infections </li></ul><ul><ul><li>Is three times more likely to transmit HIV than sexual intercourse 1 </li></ul></ul><ul><ul><li>Is the most common mode of HCV transmission 2 </li></ul></ul><ul><ul><li>Is the most common risk factor for HBV in adults 3 </li></ul></ul><ul><li>Needle sharing has reduced with introduction of Needle and Syringe Programs (NSP) </li></ul>1 Avert.org (2009). 2 ASHM and NCHECR (2008) An overview of hepatitis C: Clinical management in opiate pharmacotherapy settings. 3 Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic. (NCHECR)
    • 23. Needle sharing (2004-2008) Source: NCHECR (2009) Australian NSP survey: National data report 2004-2008
    • 24. HIV antibody prevalence in IDUs (Australia) <ul><li>HIV prevalence low: 1.5% </li></ul><ul><ul><li>Lower that in parts of USA, UK, Europe and Asia </li></ul></ul><ul><ul><li>Reduced due to NSP, peer education and opioid maintenance programs </li></ul></ul><ul><li>Prevalence is higher in: </li></ul><ul><ul><li>Homosexual males </li></ul></ul><ul><ul><li>Predominantly methamphetamine users (reporting as last drug injected), compared to heroin </li></ul></ul>NCHECR (2009) Australian NSP survey: National data report 2004-2008
    • 25. HIV prevalence by gender and sexual identity Source: NCHECR (2009) Australian NSP survey: National data report 2004-2008.
    • 26. HIV prevalence by drug last injected NCHECR (2009) Australian NSP survey: National data report 2004-2008
    • 27. HCV antibody prevalence in IDUs <ul><li>HCV prevalence high, stable at 62% </li></ul><ul><ul><li>Transmission reduced but not prevented by NSP </li></ul></ul><ul><ul><li>Higher prevalence pre-NSP, compared to HIV </li></ul></ul><ul><li>Prevalence higher in users who are: </li></ul><ul><ul><li>Older that 30 years of age and with a longer history of injecting </li></ul></ul><ul><ul><ul><li>20% among those injecting for less than one year </li></ul></ul></ul><ul><ul><ul><li>50% - injecting for 8 or 9 years </li></ul></ul></ul><ul><ul><ul><li>75% - injecting for 20 years or longer </li></ul></ul></ul><ul><ul><li>Using predominantly heroin (reported as last drug injected compared to those reporting methamphetamine) </li></ul></ul><ul><ul><li>Imprisoned in the year prior to survey </li></ul></ul><ul><ul><li>From Indigenous background </li></ul></ul>NCHECR (2009) Australian NSP survey: National data report 2004-2008
    • 28. HCV prevalence by years of IDU NCHECR (2009) Australian NSP survey: National data report 2004-2008
    • 29. HCV prevalence by drug last injected NCHECR (2009) Australian NSP survey: National data report 2004-2008
    • 30. Hepatitis B in IDUs 1 <ul><li>More than 40% of acute hepatitis B cases result from unsafe use of injecting drugs </li></ul><ul><li>Risk related to duration of injecting: up to 50% HBVcAb+ in long term users </li></ul><ul><li>Less government support compared to programs aimed at reduction of HIV and HCV </li></ul><ul><li>Vaccination of IDUs against HBV is available and should be strongly recommended. </li></ul>1 Dore et al. (2005) Hepatitis B in Australia: Responding to a Diverse epidemic.
    • 31. Intravenous Drug Use in prison <ul><li>High risk practices persist </li></ul><ul><ul><li>75% continue some IDU in prison </li></ul></ul><ul><ul><li>80% share needles in prison (cf 20% in community) </li></ul></ul><ul><ul><li>10% of prison-IDU started in prison </li></ul></ul><ul><ul><li>High number of injecting partners </li></ul></ul><ul><ul><ul><li>5 partners inside v 1 outside </li></ul></ul></ul>Dolan, K. (1997) in Harm Reduction in Prison, Nedles & Fuhrer (Eds.); Dolan, K. A. (2001) Medical Journal of Australia, 174, 378-379.
    • 32. IDU in prison: Confiscated needles and syringes
    • 33. Source: Mouzos J and Smith L (2007) Of Substance, 5(4):21. Reprinted with permission.
    • 34. Mental Health
    • 35. Mental Health <ul><li>Mental health problems are common among opioid users. </li></ul><ul><li>Related to dependence and associated lifestyle </li></ul><ul><li>Complex relationship and interaction between mental health and dependence </li></ul>
    • 36. Prevalence <ul><li>Prevalence of mental health problems among opioid dependent treatment seekers </li></ul><ul><ul><li>Suicide </li></ul></ul><ul><ul><ul><li>34% lifetime history of attempted suicide </li></ul></ul></ul><ul><ul><ul><li>13% attempted suicide in the last 12 months 1 </li></ul></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><ul><li>25% reported current major depressive episode2 </li></ul></ul></ul><ul><ul><li>Post traumatic stress syndrome (PTSD) </li></ul></ul><ul><ul><ul><li>92% exposed to trauma </li></ul></ul></ul><ul><ul><ul><li>41% lifetime PTSD3 </li></ul></ul></ul>1 Darke, S. et al (2004) Drug and Alcohol Dependence , 73, 1-10. 2 Teesson, M. et al (2005) Drug and Alcohol Dependence , 78, 309-315. 3 Mills, KL et al (2005) Drug and Alcohol Dependence , 77, 243-249.
    • 37. Opioid Overdose: Risks and fatality rates
    • 38. Opioid overdose <ul><li>Relatively common among heroin and other opioid users </li></ul><ul><li>Life-threatening </li></ul><ul><li>Death from respiratory depression </li></ul>
    • 39. Risk factors for opioid overdose <ul><li>Polydrug use: </li></ul><ul><ul><li>Concurrent alcohol & benzodiazepines use </li></ul></ul><ul><ul><li>Common in fatal and non-fatal overdoses </li></ul></ul><ul><li>Variable purity (not the major factor) </li></ul><ul><li>Reduced tolerance to opioids </li></ul><ul><ul><li>e.g. recently released from prison, not on treatment program </li></ul></ul><ul><li>Injecting alone (common in fatal overdoses) </li></ul><ul><li>Not seeking help </li></ul><ul><ul><li>Absence of others or fear of police involvement </li></ul></ul><ul><li>Ineffective interventions often tried first by bystanders </li></ul>
    • 40. Rates of heroin overdose <ul><li>High in Australia in 1997-1999 </li></ul><ul><li>Significant reduction in 2001, consistent with reduced availability of heroin </li></ul><ul><li>Overdose remains a major cause of heroin-related harm </li></ul>
    • 41. Fatal opioid overdose rate Source: Drug and Alcohol Office, Government of Western Australia (2008) Overview of Trends in Opioid Related Mortality . Statistical Bulletin No. 40, February 2008, p.3.
    • 42. Prevention of medical complications
    • 43. Preventing and reducing harm from injecting heroin use <ul><li>Non-injecting route of administration </li></ul><ul><li>Advice on safe injecting </li></ul><ul><ul><li>Professional or peer education </li></ul></ul><ul><li>Needle Syringe Programs (NSPs) </li></ul><ul><li>Medically Supervised Injecting Centre </li></ul><ul><li>Overdose interventions </li></ul><ul><li>Hep B Vaccination </li></ul><ul><li>Treatment programs </li></ul>
    • 44. Needle and Syringe Programs (NSP) <ul><li>One of the principal harm reduction measures </li></ul><ul><ul><li>Aim to curb the spread of HIV among injecting drug users </li></ul></ul><ul><ul><li>First program established in Amsterdam in 1983 </li></ul></ul><ul><ul><li>Now exist in more than 40 countries </li></ul></ul><ul><li>Provide access to sterile syringes to reduce the risk of IDUs coming into contact with other users’ infected blood </li></ul><ul><li>Reduce the number of new HIV diagnoses without encouraging drug use </li></ul><ul><li>Have potential to increase recruitment into drug treatment and into primary health care </li></ul>WHO (2004) Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users.
    • 45. <ul><li>Commenced 1986 </li></ul><ul><li>Widespread and publicly funded </li></ul><ul><li>Bipartisan support </li></ul><ul><li>General public support 1 </li></ul><ul><li>Fixed site, outreach, vending machines and pharmacy </li></ul><ul><ul><li>Public, private and NGO operated </li></ul></ul><ul><li>Distribution rather than exchange </li></ul>NSPs in Australia 1 Treloar & Fraser (2007) Drug Alcohol Rev, 26: 355-361
    • 46. NSP outcomes in Australia <ul><li>Number of distributed needles and syringes increased during the past decade (from ~27 million to ~31 million) </li></ul><ul><li>Needle sharing by IDUs reduced: </li></ul><ul><ul><li>~30% of users in 1995 1 </li></ul></ul><ul><ul><li>~10-20% in 2004, stable since then 2 </li></ul></ul><ul><li>Effectiveness of NSPs (2000-08) 2 </li></ul><ul><li>NSPs have directly averted: </li></ul><ul><li>• ~30,000 new HIV infections </li></ul><ul><li>• ~100,000 new HCV infections </li></ul><ul><li>Annual national incidence of HIV and HCV among IDUs decreased: </li></ul><ul><ul><li>HIV - from 39 to 24 </li></ul></ul><ul><ul><li>HCV - from ~13,000 to ~8,000 </li></ul></ul>1 NCHECR (2003) Australian NSP Survey National Data Report 1995-2002. 2 NCHECR (2009) Australian NSP survey: National data report 2004-2008.
    • 47. Overdose interventions <ul><li>Peer education </li></ul><ul><ul><li>Avoid polydrug use </li></ul></ul><ul><ul><li>Avoid injecting alone </li></ul></ul><ul><ul><li>Call an ambulance </li></ul></ul><ul><li>Naloxone administration </li></ul><ul><li>Protocols to limit police intervention at overdose resuscitation </li></ul><ul><li>Supervised injecting rooms </li></ul>
    • 48. Treatment Programs in Prison <ul><li>Assessment of dependence </li></ul><ul><li>Management of intoxication and withdrawal </li></ul><ul><li>Education, counselling </li></ul><ul><li>Opioid Treatment Programs (OTP) </li></ul><ul><ul><li>Those who remain in OTP 8/12 post -release have significant reduction in recidivism & mortality 1&2 </li></ul></ul>1 Dolan, KA (2001) Medical Journal of Australia, 174, 378-379. 2 Dolan, KA et al (2005) Addiction, 100, 820-828.
    • 49. Prescription opioid use and responsible prescribing
    • 50. Prescription opioid use <ul><li>Significant increase in number of prescriptions for codeine in the 1990s, peaking in 1999, use now declining </li></ul><ul><li>Dramatic rise in the use of oxycodone between 2001 and 2007 1 </li></ul><ul><ul><li>Increasing steadily (by ~20% per year) since 2001 </li></ul></ul><ul><ul><li>Sharp increase in 2001-02 when generic oxycodone sustained release became available </li></ul></ul><ul><li>Increase in the use of tramadol between 2001 and 2004 (plateau in 2004-2007) 1 </li></ul><ul><li>Major harms: </li></ul><ul><ul><li>Spread of opioid dependence </li></ul></ul><ul><ul><li>Risk of overdose </li></ul></ul><ul><ul><li>Risks associated with non-sterile injection and needle sharing </li></ul></ul>1 Leong M et al (2009) Intern Med J, 39(10):676-81.
    • 51. Illicit use of prescription analgesics, including opioids Data source: AIHW 2008. 2007 National Drug Strategy Household Survey Prevalence of prescription drug use for non-medical purposes (Use in the last 12 months, proportion of the population aged 14 years or older, Australia.)
    • 52. Responsible prescribing of opioids <ul><li>Prolonged regular opioid use leads to tolerance and risk of dependence </li></ul><ul><ul><li>Avoid use for chronic, non-terminal conditions </li></ul></ul><ul><ul><li>Avoid parenteral opioids for recurrent conditions such as migraine, back pain </li></ul></ul><ul><ul><li>Be very cautious in prescribing opioids to patients you don’t know </li></ul></ul><ul><li>BUT: do manage pain compassionately, even in those with opioid dependence </li></ul>
    • 53. Alternative treatments <ul><li>Non-steroid anti-inflammatory analgesics </li></ul><ul><li>Psychological and other management of pain: e.g. via Pain Clinic </li></ul><ul><li>Has the cause been adequately treated? </li></ul><ul><li>Consider a drug and alcohol referral for iatrogenic dependence or mixed iatrogenic/abuse picture? </li></ul>
    • 54. Medical prevention issues <ul><li>Responsible prescribing </li></ul><ul><ul><li>Daily dispensing where potential for loss of control over use </li></ul></ul><ul><li>Recognise and manage drug-seeking behaviour </li></ul><ul><ul><li>Illegal to prescribe S8 drugs to patients with known addiction to these drugs </li></ul></ul><ul><ul><li>Say ‘no’ (promptly and courteously: ‘I’m not allowed’, ‘I don’t prescribe … to patients I don’t know’) </li></ul></ul><ul><li>Early referral to treatment in a D&A service </li></ul>
    • 55. Legal controls on prescribing (NSW)* <ul><li>Cannot prescribe opiates where there is known dependence without an authority </li></ul><ul><li>Methadone and buprenorphine for opioid dependence </li></ul><ul><ul><li>Can only be prescribed by authorised doctors (or nurse practitioners) and with a NSW Health authority for each case </li></ul></ul>*It is important to check your local laws and all laws for accuracy, as they may change.
    • 56. Avoiding deliberate misuse/diversion <ul><li>Scripts for opiates are usually faxed to chemist if there is risk of tampering </li></ul><ul><li>Dose in numerals and words </li></ul><ul><li>Controlled dispensing (daily, weekly or similar) from chemist or clinic makes dose escalation or diversion less likely </li></ul><ul><ul><li>Can be arranged for any medication with a willing pharmacy </li></ul></ul><ul><ul><li>Sometimes a small fee involved </li></ul></ul>
    • 57. Case study: Jane <ul><li>Jane is aged 36, and presents because panadeine forte (contains codeine 8mg) is no longer controlling her back pain </li></ul><ul><li>She is using 40 tablets per day </li></ul><ul><li>Questions: </li></ul><ul><ul><li>What are the risks of her panadeine forte use? </li></ul></ul><ul><ul><li>Can you suggest a better treatment? </li></ul></ul>
    • 58. Jane: Answers <ul><li>40 tabs = approx 7 tabs every four hours </li></ul><ul><ul><li>Risk of paracetamol-induced hepatic damage </li></ul></ul><ul><ul><li>Opioid dependence </li></ul></ul><ul><li>Jane would be better on a long-acting opioid, if she is unable or unwilling to cease: e.g. methadone or oxycontin </li></ul><ul><li>Daily dispensing will help prevent dose escalation </li></ul><ul><li>Authority required </li></ul><ul><li>Pain Clinic referral may be useful </li></ul>
    • 59. Conclusion (1) <ul><li>Prevalence of heroin dependence in Australia is low (<1%) </li></ul><ul><li>Heroin use is associated with significant medical and psychosocial complications, especially when injected. </li></ul><ul><li>Sharing of injecting equipment is the major vector for transmission of blood bourn viral infections. </li></ul><ul><li>Introduction of NSPs has prevented the epidemic of HIV, but did not significantly reduce prevalence of HCV infection in Australia </li></ul><ul><ul><li>Prevalence of HIV antibodies in IDUs is low (1.5%) </li></ul></ul><ul><ul><li>Prevalence of HCV antibodies remains high (65%) but stable </li></ul></ul><ul><li>HBV antibodies are present in up to 50% of long term IDUs </li></ul><ul><li>Vaccination against HBV is strongly recommended. </li></ul>
    • 60. Conclusion (2) <ul><li>Mental health problems are common among opioid dependent people (e.g. depression, suicidal ideations, PTSD) </li></ul><ul><li>Opioid overdose is the major cause of heroin-related harm </li></ul><ul><li>Use prescription opioids with caution because prolonged administration leads to tolerance and risk of dependence </li></ul><ul><li>Recognise and manage drug seeking behaviour appropriately </li></ul><ul><li>Provide adequate pain relief especially in people with opioid dependence </li></ul>
    • 61. Contributors <ul><li>Associate Professor Kate Conigrave </li></ul><ul><li>Royal Prince Alfred Hospital & University of Sydney </li></ul><ul><li>Dr Ken Curry </li></ul><ul><li>Canterbury Hospital & University of Sydney </li></ul><ul><li>Dr Carolyn Day </li></ul><ul><li>University of Sydney </li></ul><ul><li>Professor Paul Haber </li></ul><ul><li>Royal Prince Alfred Hospital & University of Sydney </li></ul><ul><li>Dr Olga Lopatko </li></ul><ul><li>University of Sydney </li></ul><ul><li>Professor Richard Mattick </li></ul><ul><li>National Drug and Alcohol Research Centre, </li></ul><ul><li>University of New South Wales </li></ul>

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