Lecture Notes
Opioid prescribing: Dr Frank McLeod – “The Issues”

Drug dependency and addiction are complex. The terminology can also be inconsistent and confusing, for example we might consider a postoperative patient who gets withdrawls if missing a dose to be dependent, but the legal definition by NSW Ministry of Health is different:

An authority from the Ministry of Health is required to prescribe or supply a drug of addiction for:
– a drug dependent person
– a non-drug dependent person who is prescribed or supplied with the following drugs of addiction continuously for more than 2 months:
– any injectable form of any drug of addiction
– any drug of addiction for intranasal use, or for spray or application to mucous membranes
– alprazolam
– buprenorphine (except transdermal preparations)
– flunitrazepam
– hydromorphone
– methadone

If a person is on an opioid-substitution program, they are defined as opioid-dependent and there are important restrictions on their prescribing. To check if a patient is already known to be drug-dependent, call the Pharmaceutical Regulatory Unit (02) 9424 5923. It is illegal to prescribe drugs of addiction to these people unless in an emergency or an inpatient for <14 days.

Common flags of a patient with a drug seeking problem include knowing the exact drug names, doses and generics, coming in late in the day / out of hours and having run out of medication, may be loud and demanding, anxiety, spurious claims of illness, may have mental health issues or homelessness or have track marks visible, but equally these patients may have none of these signs. Many of these patients have personality disorders and many have been sexually or physically abused.

Non drug-dependent patients

Some patients have inadvertently become drug-dependent. If the patient has not escalated, sought early scripts, lost medication or sought alternative sources, they may not be considered legally drug-dependent. However, if you are not sure, you can apply for an authority to prescribe – especially if the patient is on >100 mg oral morphine equivalent daily dose. (Use the free online Opioid calculator)

Steps for managing opioids in non-dependent patients:

  • Discuss the situation and advantages of dose reduction
  • Advise regarding problems including dependence, overdose risk, side effects (constipation, sweating, libido, thyroid and adrenal problems), hyperalgesia
  • Calculate the total daily dose using an Opioid calculator
  • Encourage and agree to a plan of reduction, i.e. 10% maximum reduction at a time, and agree on a time scale
  • Go slower as you get lower, do not exceed the 10% reduction
  • Manage it with a gentle hand and allow delays
  • If the patient begins to have withdrawls, hold at that level before reducing again
  • Keep the patient in the decision chain and remember they have done nothing wrong
  • Consider staged supply (daily dispensing controlled by pharmacy) if needed

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