Recognising and handling drug dependent patients
Routine inspection of dispensing records by officers of the Drugs of Dependence Unit have resulted in the detection of prescriptions for drugs of dependence written by prescribers for persons known to the Unit to be dependent on opioids or other drugs.
Drugs obtained on such prescriptions do not help dependent persons overcome their dependency; they delay or disrupt proper treatment and add to the pool of illicit drugs traded and used. Dependent patients regularly ‘do the rounds’ of prescribers to obtain additional supplies and frequently attend two or more prescribers concurrently.
Dependent persons usually present as:
- A new patient; and/or
- A young person.
The dependent person may admit dependence and offer one or more of the following reasons in support of his or her request for treatment:
- Has just arrived from the country or interstate and needs to continue treatment. A letter of introduction, often forged on letterhead may be presented. (If this claim were true, proper arrangements should have been made prior to departure).
- Is awaiting admission to hospital. (There is no delay for acute cases).
- Cannot afford to go to hospital yet.
- Is on bail or bond following conviction.
- Has lost a prescription or tablets.
- Doesn’t want to attend a clinic because of pressure from other patients there. Arrangements can be made for minimal contact with other patients at clinics, or treatment from a Medication Assisted Treatment for Opioid Dependence (MATOD) prescriber if necessary.
- Wants to ‘get off heroin’.
Patients may feign pain and request a particular drug (by name, by description or by exclusion of other drugs).
The drug requested is usually a short-acting drug, injectable drug or preparation that can be injected.
Requests are commonly for methadone, pethidine, Endone®, OxyContin®, morphine, Kapanol®, MS-Contin®, codeine linctus, Dilaudid®, Ritalin®, dexamphetamine or Hypnodorm®. S4 drugs include the benzodiazepines (especially alprazolam), codeine-containing preparations, anticholinergics, anabolic steroids and stimulants.
The pattern of presentation may include:
- A convincing description of symptoms.
- Exhibition of old scars or other signs of injury or physical defect.
- Production of a report and/or x-ray from a hospital or another doctor or clinic in support of the request. (These should be checked for authenticity.)
The results of prescribing a drug of dependence for a dependent person can include:
- Forgery of prescription by adding drugs, changing quantities or forgery on forms stolen during consultation.
- Over-dosage, leading to hospital admission or death as a result of drugs freely available.
- No improvement in patient by any measure of drug use or social integration.
- Disregard of any referral for assessment or management while drugs remain freely available.
- Disruption of treatment under official MATOD as patients either supplement medication given on the MATOD or drop off the MATOD altogether when they see their friends obtaining supplies of drugs of dependence without any restraint or commitment.
- Trafficking in prescriptions and drugs obtained on prescription.
- Intravenous injection of tablets or capsules intended for oral use.
- Pressure to supply further prescriptions by use of a threat, for example physical violence or reporting of earlier prescribing to SA Police or Drugs of Dependence Unit.
- Other drug dependent persons attending the surgery with a similar story.
- Non-payment of accounts.
Apart from the foregoing reasons for not prescribing drugs of dependence for dependent persons or persons suspected of being dependent on these drugs, there is a further reason: It is illegal.
Section 18A of the Controlled Substances Act 1984 (SA) provides that a medical practitioner must not prescribe a drug of dependence for a non-dependent person for more than two months without written authority. For dependent (or suspected dependent) persons, drugs of dependence may not be prescribed or administered at all without the authority of the Minister responsible for the Act (through the Drugs of Dependence Unit).
It is also not permitted, without state authorisation, to prescribe or supply a Schedule 2, 3 or 4 product that contains a Schedule 8 drug to treat drug dependence. Examples of these products are Panadeine Forte®, Mersyndol Forte® and Doloxene®.
When consulted by a dependent or suspected dependent person seeking the administration of, or a prescription for, a drug of dependence:
- Suspicions may be confirmed or refuted by:
- Firmly refuse to prescribe any drug of dependence. Even one prescription may have harmful consequences.
- Non-opioid drugs, particularly clonidine, will give symptomatic relief of withdrawal symptoms and may be prescribed in acute situations. Care should be taken to avoid prescribing drugs that may be abused or produce dependence such as a benzodiazepine. Where a suspected dependent person feigns pain, a non-narcotic analgesic may be offered but is unlikely to be accepted.
- Refer dependent persons to a specialist clinic or an accredited MATOD prescriber for assessment and management (see box below). It should be noted that with opioid dependent persons real physical emergencies are rare (unless an emergency is identified such as advanced withdrawal during pregnancy). Most have experienced one or more extended periods of withdrawal already.
- Keep prescription pads and letterhead out of patient access to prevent theft and forgery.
- Ask the patient whether he or she has been given any drug of dependence or a prescription for such in the last two months and note reply in patient record.
- Call the Drugs of Dependence Unit if in doubt about a particular patient or if further information or advice is needed.
- Remember that dependent persons may be adept manipulators and can be either persuasive or threatening in their efforts to obtain drugs.
Who to call for help
Advice on whether or not a patient is known to be dependent on prescription drugs can be sought by contacting Drugs of Dependence Unit.
Advice from the Medicare Australia on patients who may be obtaining PBS items in excess of therapeutic need. Registration with the project is required and covers PBS prescriptions.
Advice from drug and alcohol specialist medical officers on clinical aspects of treatment of drug dependent patients may be sought from Drug and Alcohol Clinical Advisory Service.
If dependency is confirmed, the patient may be referred for assessment to:
- Central Drug and Alcohol Services South Australia
- An accredited MATOD prescriber.