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Controlled drugs
When was the last time you issued a prescription for a Controlled drug or any other drug that you suspect to be misused/ abused? Probably not that long ago, Right! Let’s find out more:
What do you do when you see: Scenario A
· There is a known and linked Diagnosis
· It seems justified for patient to continue
· Number of dosage units prescribed are in line with the prescribed quantity
· The Rx request history does not indicate over-ordering
How about when you see: Scenario B
· There is no known and/ or linked indication for the drug
· Quantity prescribed is far more than patient would need for a monthly/ fortnightly/ weekly use (whichever applies)
· Rx is being ordered more frequently than set by the prescriber
Surely the scenario B is more often encountered than Scenario A
How about when you see: Scenario B
- There is no known and/ or linked indication for the drug
- Quantity prescribed is far more than patient would need for a monthly/ fortnightly/ weekly use (whichever applies)
- Rx is being ordered more frequently than set by the prescriber
Surely the scenario B is more often encountered than Scenario A
Let’s explore the possible drug groups and reasons for prescribing:
| Therapeutic Drug Category | Examples of the drugs | Possible indication | What type of Prescription is most appropriate |
| Opiates | Morphine Codeine Dihydrocodeine Tramadol Oxycodone Fentanyl Buprenorphine | Acute pain such as postoperative pain
Chronic pain such as Osteoarthritis, Osteoporosis | For acute pain: Acute Rx
For chronic pain: Repeat Rx, given it is regularly reviewed |
| Gabapentinoids | Gabapentin Pregabalin | Chronic and difficult to treat pain, mostly of neuropathic nature; such as Phantom limb pain] Fibromyalgia
Also used for atypical indications such as Migraine prevention, Mood modulators | Repeat Rx, given it is regularly reviewed |
| Benzodiazepines | Diazepam Lorazepam Clonazepam Nitrazepam Temazepam
| Acute muscle spasm: such as LBP, torticollis
One-off use for prevention of anxiety, such as Before flying Before CT / MRI scan / Bereavement / Change in sleep pattern due to long distance flight
Treatment of chronic anxiety, phobias, recurrent spastic disorders | Acute Rx
Acute Rx
Repeat Rx, given that it is regularly reviewed |
| Z-Drugs | Zopiclone Zolpidem | Short term relief from insomniac states
Dyssomnia state secondary to another disorder such as Restless leg syndrome | Acute Rx
Repeat Rx, given it is regularly reviewed |
Please note that certain other drugs / Drug groups are also subject to misuse due to dependency. For example: Sedative antihistamines (Chlorphenamine, Hydroxyzine, Promethazine etc.)
Common dilemmas in primary care:
- The drug in question was started long time ago, even though I do not agree that the ongoing prescribing is justified, patient doesn’t want to come off it.
- Solution: Warn and inform please. It is agreeably a mammoth task to wean a patient off 60mg BD Morphine for hip pain following RTA that happened 15 years ago. This patient is dependent on the medication without a doubt. All our sites are equipped with prompt every time template for such drugs to hold a discussion about such drug(s). Document patient’s response with regards to acceptability of side effects, roadside drug testing, risk of falls and other effects on cognition etc.
- Patient is managing to secure more issues than what they should due to eRx workflow tasks completed by various prescribers.
- Solution: Kindly check when the last Rx was issued before signing. If it continues you may want to provide a set of post-dated Rx for a clinically suitable period.
- Prescribing of multiple opiates together. For example: a patient being prescribed Tramadol, Buprenorphine and Oramorph.
- Buprenorphine has a very strong affinity (up to 100 times more than Morphine) for opioid receptors but only partially activates them. If you are considering adding Buprenorphine to current opiates (Morphine etc.) beware of Opiate withdrawal effects. This is due to Buprenorphine replacing Morphine from the receptors, yet not activating them fully. Therefore, if you are considering replacing current opiate with Buprenorphine, continue with the current opiates for the first 12 hours to avoid withdrawal symptoms.
Ideally If Buprenorphine is being started, the original Opiate should be stopped after 12-24 hours.
- Patient is non-respondent to review request.
- Solution: Please refer to attached step by step guidance on Controlled Drugs review
- Patient keeps asking for higher doses or patient reports taking doses higher than intended.
- Solution: Where codeine/ Dihydrocodeine is being overused, change it to Co-Codamol/ Codydramol respectively (given patient is okay taking Paracetamol). This will ensure a ceiling dose of no more than 8 units of dosage forms/ 24hours
- Solution: Where patient is requesting higher doses and you feel that all options are exhausted, please agree to refer to pain management team. An addition and titration to optimal neuromodulator such as Gabapentinoid/ Duloxetine/ Amitriptyline can be useful. Please beware of Amitriptyline + Oxycodone link to mortality and other contraindications such as Cardiac disease.
For localised neuropathic pain Capsaicin 0.075% is also recommended.
Some Golden Rules:
- If such a drug is being prescribed as one-off, place the drug in past drugs immediately after prescribing to avoid further issues.
- Do not assume that patient is misusing the relevant drug.
- Do not push a drug withdrawal without patients’ agreement.
- Document clear plan of treatment for seamless transfer of care to fellow clinicians.
- Document patients’ acceptability, understanding and decision to continue/ reduce/ Stop (whichever may apply).
- Do provide a regular follow-up support at pre-agreed intervals during withdrawal
- Remember that pain is a subjective experience. Sometimes patients suffer from conditions that can not be proven via a lab test/ scan e.g., Fibromyalgia, Diabetic neuropathy, post-herpetic neuralgia
- Keep revisiting these drugs with patients as circumstances may change over time
- If you consider an immediate harm to patient due to such drug, you may consider withholding with early review: e.g., Acute respiratory depression whilst receiving opiates/ BZ
- If you are considering starting one of such drugs, remember this is not a life-sentence for the patient. Counsel to stay positive and they may be able to break free as their condition improves.
References:
https://bnf.nice.org.uk/drugs/capsaicin/#indications-and-dose
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653099/