Not what the doctor ordered

Recent studies show that misuse of prescription drugs is as much a problem in New Zealand as anywhere else in the world – possibly more so because opioids like heroin aren’t plentiful here. But a full understanding of the problem’s seriousness is still emerging, which means we may not have the structures in place to deal with it. Rob Zorn.

According to an International Narcotics Control Board (INCB) report released in 2007, prescription drug misuse is now a worldwide problem that is increasing rapidly. In fact, in some regions, prescribed medicines are being abused “in quantities similar to or greater than the quantities of illicitly manufactured heroin, cocaine, amphetamine and opioids”.

The Board’s conclusion is borne out by research and reports from various western countries. In the United States, for example, statistics suggest levels of prescription drug misuse are second only to misuse of cannabis. The National Center on Addiction and Substance Abuse (CASA) says 6 percent of Americans (15.1 million people) reported abusing controlled drugs in 2003 – higher than the number of those abusing cocaine (5.9 million),hallucinogens (4 million), inhalants (2.1 million) and heroin (328,000) combined.

Data from the UK are more patchy, though a 2000 report appearing in the journal Addiction described the size of the market for diverted prescription drugs as “substantial”.

In Australia, an increasing number of prescription medicines are being abused. Data from the 2004 National Drug Strategy Household Survey revealed that 7.6 percent of Australians had used pharmaceuticals for non-medical purposes at least once and that the most used substances in the 12 months preceding the survey were painkillers and tranquillisers. In 2006, morphine was the most commonly reported pharmaceutical used by injecting users according to Australia’s Illicit Drug Reporting System (IDRS).

Of particular relevance to us is the Tasmanian component of the IDRS, given that state’s geographical similarity to New Zealand. Heroin has not generally been widely available in Tasmania, and this is one accepted reason why the 2006 IDRS reported it had higher rates of benzodiazepine injection than other Australian states.

New Zealand’s National Drug Policy also acknowledges that our geographical isolation makes it difficult to import bulk quantities of heroin or raw opium into the country, and therefore, like Tasmania, we are more likely to abuse other opioids such as prescription medicines.

Geoff Robinson, Chief Medical Officer at the Capital and Coast District Health Board, has no doubt that New Zealand’s problem with prescription drug misuse ranks up there with other western countries and that a local scarcity of heroin is one main reason why.

“In 1990, New Zealand had 600 people on the methadone programme. Now we have around 4,000! That’s a level similar to that of New South Wales. The difference is that heroin is not available here like it has been there, so these people aren’t on the programme because of heroin dependence, but as a result of prescription opioid problems.”

While such a massive increase in the number of people presenting at clinics makes it clear that prescription drugs misuse is a serious problem, it’s not easy to put an accurate finger on the full extent of that seriousness. There are no published data that would provide an overview, and even what we do know is subject to interpretation.

While the amount of opioids prescribed in New Zealand has more than doubled in the last 15 years, it is very difficult to tell just how much of that prescribed medicine is being used legitimately and how much is being diverted and used illicitly. After all, the same patient may be doing both in many cases.

A recent New Zealand study indicated that 14 percent of people in drug and alcohol treatment were diagnosed with sedative dependence. The 2006 Illicit Drug Monitoring System (IDMS) indicated that opiates were easy/very easy to get, and 50 percent of the injecting drug users taking part in the study said opiates were the drugs most responsible for their drug-related problems.

In April this year, Auckland University’s School of Pharmacy released its report Prescription drug misuse: issues for primary care. Researchers interviewed 51 general practitioners, community pharmacists and other key experts about their experiences with prescription drug misuse. The GPs and pharmacists indicated that, while it is not generally a major disruption to their practices, they are highly aware of it as an issue.

This qualitative study, led by Professor Janie Sheridan, provides an excellent overview, from the coalface, as it were, of what drugs are typically being misused, how they are being obtained, and what is being done – individually and collectively – to deal with the resulting problems.

The sorts of drugs commonly sought fall into three main categories – opioids, benzodiazepines and stimulants – though interviewees differed on which were mainly targeted in their practices or pharmacies.

Opioids are synthetic chemical substances mainly used for pain relief. Those sought include codeine, dihydrocodeine tartrate, morphine (including morphine sulphate) and methadone.

Benzodiazepines are a class of psychoactive drug with varying hypnotic, sedative, anxiolytic and muscle-relaxant qualities. They were reported as widely sought by all interviewees and include diazepam (Valium®) clonazepam (Rivotril®) and temazapam (Normison®, Somapam®, Euhypnos®).

Stimulants cause increased alertness, insomnia and raised heart rate and blood pressure. Those sought include pseudoephedrine-containing products and methylphenidate (Ritalin®).

‘Drug seekers’, as they are known to health professionals, tend to come from all walks of life so it is hard to generalise about their characteristics. While interviewees agreed they were predominantly New Zealand European, some said they tended most to be aged in their 20s and 30s while others indicated they were most often over 50. Only two interviewees were concerned about teenagers abusing their prescription medication.

Males and females seemed to be equally represented, though there were some general differences in approaches. Respondents reported that males were more likely to use standover tactics while females were more successful at fabricating stories as to why they need the medicine. Men were more likely to claim they had physical injuries such as car accidents or that they had been assaulted. Women were more likely to claim emotional anguish, migraines or ‘women’s problems’ in the hopes male doctors wouldn’t ask too many questions.

The researchers also pointed out that one emerging theme was a distinction between two types of drug seekers. ‘Abusers’ are those who seek drugs to use or sell for recreational purposes or to knowingly feed an addiction. ‘Over users’ are drug seekers who originally began using the drug for legitimate purposes such as for chronic pain or anxiety. However, misuse has developed over time and escalated to the point of addiction. ‘Over users’ tended to be considered less of a problem by respondents. They were not perceived to be as ‘underhand’ and didn’t fit the ‘drug addict’ stereotype. They were also thought less likely to sell their medications on the illicit market.

The two main methods of acquiring prescription medications, other than ‘raiding grandma’s medicine cabinet’, are known as ‘doctor shopping’ and ‘pharmacy hopping’.

‘Doctor shoppers’ will visit a number of different doctors in their own area or in neighbouring districts seeking multiple prescriptions that they will then present at a number of different pharmacies. Sometimes, fraudulent IDs are used, but because it is easy in New Zealand to see a doctor on a one-off basis, these are often not needed.

Using different pharmacies, or ‘pharmacy hopping’ helps the user hide the extent of his or her prescription drug use, but ‘pharmacy hopping’ also includes the practice of presenting a prescription at another pharmacy when it is refused the first time due to a pharmacist’s concerns.

The respondents said another way drug seekers attempt to obtain medication is by presenting for repeat prescriptions before they are due. Generally, a reason is provided as to why the medication is needed early. It has been ‘lost’ or ‘stolen’, or the patient says they are going on holiday and needing additional supplies to take away.

While there are regulations around early prescriptions, pharmacists have discretion to fill them early. For example, a 30-day repeat prescription may be collected after 20 days if the dispensing pharmacist believes there is sufficient reason.

Often, fabricated medical conditions are used to fool GPs and hospital clinics, such as invented pain symptoms or fake psychological states (e.g. grief) – the ‘patient’ relying on the fact that most doctors would prefer to err on the side of caution and not deny medication, even if they suspect the symptoms are phoney.

Prescription forging is also reasonably common. This can involve altering an authentic prescription by adding drug names to it or by changing the amount of the medication prescribed – for example, by inserting an additional digit to the correct dose. Computergenerated fake prescriptions have also been used, sometimes even verified with stamps stolen from hospitals or surgeries.

The respondents also discussed specific diversion methods relating to obtaining methadone. Most diversion occurs when takeaway doses are given to patients on the programme. The methadone is sold or given to someone else. One respondent said that, typically, the methadone diverter would return after half an hour claiming their takeaway dose was lost or spilled in the hopes of receiving another.

But diversions are attempted even with supervised doses, with the user sneaking the dose into a hidden container while pretending to drink it. Another method is to hold the methadone in the mouth and spit it into a container upon leaving the clinic.

Most doctors and pharmacists in New Zealand aren’t silly and have become reasonably astute at spotting prescription drug abusers. There are behaviours to watch for including specific requests for a particular drug, a refusal to consider alternatives and agitated behaviour. Drug seekers are most likely to visit surgeries at busy periods such as at the end of the day when doctors are behind schedule and more likely to give the benefit of the doubt to get through their day’s workload. It is also common for drug seekers to target new practices, pharmacies or doctors, including locums.

Under their codes of conduct, both doctors and pharmacists are bound to act within the law and withhold medicines from those who would abuse them. The guidelines may well be very clear, but respondents indicated the reality is often much less straightforward. Even when they are suspicious, there is an understandable reluctance to act. Where doctors don’t know a patient, it can be difficult to be certain they are faking it without direct evidence, and most would prefer to prescribe a small amount of medication than make a mistake and leave someone suffering.

Pharmacists say they can find themselves in a similar situation. They are entitled to refuse a prescription if they are in doubt, and it is common for them to call the prescribing doctor to check that a prescription is legitimate. Even where the pharmacist disagrees with the doctor, there is an understandable reluctance to question that doctor’s professional integrity or competence, especially when the pharmacist does not have access to the patient’s history or reasons for diagnosis.

Ministry of Health figures suggest that, while reckless or criminal prescribing does occur, it is not widespread. Medicines Control, the Ministry’s drug abuse containment arm, actively monitors prescription rates and investigates where a doctor is prescribing unusual amounts of addictive medicines, either in general or to the same persons. Around three or four doctors are approached each month nationwide, but of these, only a few would be referred each year to the Police or Medical Council.

Medical Officers of Health in conjunction with Medicines Control make these decisions on a case-by-case basis, unless there is direct Police intervention.

According to Geoff Robinson, the threshold for what is considered aberrant prescribing may be too low. “While there can be legitimate reasons why some doctors prescribe more addictive substances than others, the fact is that an incredible amount is diverted to illicit use, and we need tighter controls on what is given out and to whom.”

He says that, while there are some doctors willing to supplement their incomes by selling unnecessary prescriptions, the majority who over prescribe would be motivated by a “foolish altruism” where they somehow believe they are helping their patient, or that the patient’s situation would be worse if their addiction was not fed.

As with most professional communities, doctors and pharmacists have their own unofficial support networks and liaise with their peers on issues around prescription drug misuse. This can involve consulting nearby colleagues about suspected drug seekers and the sharing of advice between more and less experienced or knowledgeable doctors and pharmacists. Some have even set up fax trees to quickly disseminate information about drug seeking activity in their area.

There are also professional bodies that can be turned to for help or guidance such as drug treatment agencies that may have specific knowledge about individuals or the general drug scene in the locality. Methadone providers are particularly valuable in this regard.

GPs and pharmacists are able to check a register of known drug seekers published in print form by Medicines Control, but this is only useful when the drug seeker is using his or her real name. Looking up the booklet during a consultation with a suspected drug seeker is also considered impractical by many doctors and pharmacists.

Medicines Control can be contacted directly for advice on what to do about a drug seeking patient or if there is concern about the prescribing habits of a doctor. Suggested additions to the register of known drug seekers can also be made.

If it seems that our institutional response mechanisms to prescription drugs misuse are underdeveloped, that is probably a reflection of the fact that our understanding of the scale and complexity of the problem is still emerging.

Respondents to the University of Auckland prescription drug misuse study identified three broad areas in which developments could be made to better manage prescription drug misuse in the future.

The first was training and education so that all GPs and pharmacists had a minimum level of understanding around prescription drug misuse issues, not just those with knowledgeable colleagues in their support networks. The training would include which medications were most targeted and innovations in drug seeking behaviour (such as forgery techniques), how to identify and manage drug seekers and who to contact when issues arise.

The second area was access to electronic information such as an up-todate national database of known drug seekers/restricted persons, and community databases across pharmacies and practices that would identify a person sourcing potential medicines of abuse from more than one location. Such a system would have immense ethical, privacy and misuse of data implications, however.

The third concern was for improved support systems such as national or regional standard protocols to guide the management of prescription drug misuse. A targeted specialist support body was also suggested, made up of key prescription drug misuse stakeholders such as the Police, AOD treatment representatives and knowledgeable GPs and pharmacists. Lastly, improved support for prescription drug misusers was seen as necessary. Once a prescription has been denied, what then? This is especially relevant to ‘over users’ with legitimate prescribing indications who do not necessarily fit the drug addict mould most AOD services are geared towards.

Interestingly, the Medical Council of New Zealand’s report Strategies for Action on the Misuse of Addictive Prescription Drugs made many of the same recommendations back in 1991. As Sheridan et al. point out, this indicates that “whilst action may have occurred in the intervening period, the problems remain broadly similar and unresolved”.

So what action has occurred in the intervening period, particularly on the part of the Ministry of Health?

One thing that has been done is the introduction of electronic monitoring of controlled drug prescribing, which has made surveillance much easier. Plans are afoot to bring in e-prescribing based on a Swedish model, which will mean prescriptions are no longer given out to patients. Instead, they will reside in an online database where they can be accessed by pharmacists according to the patient’s unique identifier. It is uncertain when this will be a reality.

Regulations have also been altered so that drugs with a high level of addictive potential, such as morphine and Ritalin®, can only be given out in 10-day amounts.

“But actually, there’s not been a lot of change or progress at all,” says Geoff Robinson.

“The National Drug Policy contains exactly nine lines on diverted pharmaceuticals and contains no discernable plan for reducing what has become an epidemic.”

Robinson would like to see the Ministry of Health conduct a formal review of the issue in conjunction with relevant parties such as The Royal New Zealand College of General Practitioners, the treatment sector and the Police.

He concedes, however, that getting the balance right between optimal pain control and over prescribing is always going to be difficult and suggests doctors need more training and better guidelines to increase their awareness and help them get it right more often.

“You can put all the prescribing controls in place that you like, but it’s pretty hard to regulate what happens to the drugs once they’re in the hands of the user.

“It’s essential, therefore, that prescribing doctors make good decisions based on a sound understanding of the nature and extent of the problem, and we’re only going to get that across all sectors if all parties work together.”