Drug of dependence policy

Welcome to Alfa Medical and Skin Clinic - Cairns one stop Medical Centre

Drugs of Dependence Prescribing Policy

Intended Audience:

This policy is intended to be available to patients, people comprising their support network,

and the Alfa Medical and Skin Clinic staff. It is to be encouraged as a publicly available

document to promote transparency of our activities. It incorporates practice procedure

information for staff.

Intention:

This policy is intended to inform patients of the practices standards and processes regarding

the initial prescribing, review of use, and continual prescribing of drugs hat have the potential

for dependence and related serious harm.

This policy is intended to promote patient safety and high-quality primary health care.

The policy is an instructive guide for doctors who are ultimately responsible for the direct

provision of medical services to patients. It aims to support their decision making and clinical

governance when considering the use of and monitoring of therapy that includes drugs of

dependence. This policy acknowledges the importance of clear, safe, and professional

boundaries with patients, and includes comments on patient responsibilities. Doctors must

maintain professional boundaries or consider ending the therapeutic relationship if it is not

able to be safely maintained.

Context:

Addiction is a serious chronic illness for many people in Australia. Our clinic has a

responsibility to support people who may experience addiction to prescription drugs.

Not all people prescribed drugs of dependence will experience difficulties of addiction. Patients who experience drugs of dependency addiction are welcome to attend this clinic.

This policy will explain some of the responsibilities that apply to all patients. Addiction and dependency are different clinical conditions.

At times, patients are prescribed strong and potentially addictive medication that may result

in dependency and increase the risk of serious harm. These medicines include opioid

mediations, benzodiazepine class medicines, gabapentinoids (e.g., Lyrica), sedative hypnotics, central nervous system stimulants, and other. This is not a complete or exhaustive list.

These medicines can sometimes be used by patients in hazardous ways outside of the

intended therapeutic recommendation, which at times can increase the risk of serious harm,

and death. There is a well-established body of literature in the Australian Context of

increased patient harm and death from prescription medications of dependence where these

are commenced or continued in general practice, even when they are used in accordance with

the intended prescribing parameters. The risk increases significantly where multiple

medications are prescribed, and where patients use alcohol or illicit drugs in combination

with prescription medications.

To minimise the risk of patient harm, which can include hazardous use of prescription drugs,

this practice has established this policy that incorporates evidence informed best practice

care.

Principles:

All patients deserve the highest level of care.

The patient is central in determining the care that they desire and accept. The doctor is

responsible for explaining options of treatment and their risks, benefits, and safe monitoring

requirements, and is ultimately responsible for ensuring safe provision of treatment.

Patient functioning should be regularly measured using the whole person concept framework

of wellbeing.

Patients will be honest and provide full information.

Patients will manage their behaviour so as not to harm others during engagement with this

clinic.

All parties acknowledge there are serious harms, including death that are possible outcomes

from failure to follow this policy and a related prescribing agreement.

Patients are responsible for managing their clinic appointments, prescriptions, medication

dispensing (which may include a staged supply managed by their pharmacist), referral

appointment bookings, and communicating with this clinic to allow partnership with their

doctor and the clinic staff in managing their health needs.

The prescribing and monitoring of drugs of dependence involves the use of a multifactorial

risk analysis in a highly person centric context. Complex clinical reasoning frameworks will

be applied. Experienced rational use of medicine prescribing skills are utilised for each

patient required to deliver safe care.

The doctor has the unfettered discretion to provide any healthcare service they are capable to

offer. Patients who breach this policy, and or their prescribing agreement should be aware that

ongoing consultations may be ceased. The doctor may still be able to facilitate handover of

care to another provider in most settings, however this is dependent upon patient preferences,

service capacity, and other factors outside of the doctor’s control.

Prescribing New Patients:

It may take time to obtain accurate history for new patients, particularly where past medical

care has been complex. Until such information is available, doctors may elect to defer any

treatment including with a prescription drug of dependence. It is our policy that doctors do

not prescribe drugs of dependence until they appreciate the full context of the patient, their

goals and supports, and that safe monitoring systems are able to be in place.

It is our policy that doctors do not prescribe drugs of dependence solely because previous

prescriptions were considered clinically appropriate by other doctors.

Doctors will evaluate the clinical situation for each patient and only prescribe a drug of

dependence in a strength minimally necessary, if at all. This may be different to another

doctor for the same patient condition, even at this clinic. Each doctor must be satisfied that

the benefits outweigh the risks of any healthcare treatment plan, The doctor is ultimately

responsible for prescribing safely.

Long-term Patients:

If the decision to prescribe a drug of dependence is taken after a shared discussion of goals,

plans, risks and benefits, patients may be required to confirm their acceptance of a significant

risk and their ongoing responsibilities in writing.

Patients may be asked to sign a prescribing agreement that details expectations of care and

specific patient responsibilities when being prescribes drugs of dependence. This agreement

may include advice on taking the medication regular monitoring and the standards of

behaviour expected. This agreement is not a legally binding contract and should be read in

conjunction with this policy where appropriate. Patients may be required to acknowledge that

their care requirements are complex, and that referral for ongoing care for al or part of the

management of their condition may be required. It is our practice policy that patient care is

matched with the level of complexity that is clinically required.

Patients must arrange for regular appointments at the clinic to allow for safe drug of

dependence monitoring and prescribing. These should be maid well in advance and are the

responsibility of the patient.

Doctors should be prepared to use specialist clinical support to help manage circumstances

where problematic drug use is suspected, for patients with more complex issues, or if the

clinical situation deteriorates.

All Patients:

Individual patient responsibilities will be detailed in the prescribing agreement where used.

These will usually include a commitment to:

Provide full and honest information.
Disclose lifestyle habits that may be sensitive or embarrassing.
Accept any restrictions required on the ability to drive, work, operate machines or preform other tasks that may be important to the patient and their family.
Undertake urine illicit drug screening at any time without prior announcement.
Attend appointments and undertake activities with allied health providers and comprehensive pain management care teams.
Authorise contact, disclosure of personal health information, and requests for any information, from pharmacists, allied health professionals, family members, employment managers, legal authorities, and any other person as required to verify the safe ongoing provision of treatment.
Book and manage their appointments in timely ways that allow for continuation of any ongoing medication.
Acknowledge that a clinical review is required each time a drug of dependence is expected/sought to be prescribed.
Inform the doctor of any non-prescribed substances that are being used, including alcohol and tobacco.
Use only one pharmacy for all prescriptions, including medications that are not drugs of dependence.
Accept responsibility for all prescriptions. Lost prescriptions will not be replaced.
Contribute to detailed goal setting – treatment success will be measured against
specific goals. If goals are not being reached, treatment may be considered unsuccessful.

Patients are reminded that we have a zero-tolerance policy on issues relating to staff abuse.

Any threatening, intimidating, aggressive or inappropriate behaviour to staff will not be

tolerated and may result in the immediate transfer of your care and inability to see a doctor at

this clinic in the future, without any additional warning.

Classes of Dugs of Dependence:

Some drugs of dependence can be very dangerous in combination. These medications can

increase the risk of falling, result in the development of psychiatric conditions and medication

misuse behaviours, and may accumulate to potentially toxic levels in the body causing

different organs to be under stress, including the brain. They all require frequent monitoring

when being co-prescribed.

Opioids:

Opioid analgesia medication is usually used for acute severe short-term pain and for severe

cancer related pain. Evidence shows that the other pain condition can be worsened with long

term opioid medications. They can result in the phenomena of the loss of pleasurable

experiences in some people.

Opioid medications may improve pain in the short term; however, the evidence suggests that

they do little to improve chronic, recurrent, persisting pain in most people without cancer.

Opioid medications are all highly addictive, often result in withdrawal symptoms that can be

unpleasant when stopped abruptly and will usually result in tolerance (needing more

medicine to have the same effect) very rapidly.

The use of these medicines in combination with other drugs of dependence, antipsychotic

medications, mood stabiliser medications, and some other prescription medications increase

the risk of harm and death. Many patients with complex persisting pain can experience co-

morbid psychiatric conditions, making combinations of medications common, and the need to

be vigilant in safe prescribing very important.

Patients should be counselled that there is an increased risk of dying from adverse medication

effects in some contexts when prescribed opioid drugs, and that the risk may require careful

assessment of patient capacity to make informed decisions about their healthcare by the

treating doctor. This is particularly relevant where high doses of opioids are used in patients

with pre-existing and/or co-morbid conditions involving their cardiorespiratory systems (e.g.,

CPAP machine use, known heart or lung disease), their neurological systems (e.g.,

neuropathy, dementia), or they may be physically incapacitated (e.g., following surgery, or

during an infective illness period).

Benzodiazepines:

These medications may be prescribed for a wide range of health conditions.

They also produce rapid tolerance and can have unpleasant withdrawal symptoms when

stopped abruptly.

They often impact alertness and cognitive functioning in many patients, as with opioids,

careful assessment of patient capacity to make informed decisions about their healthcare must

be evaluated at every clinical encounter. Alprazolam has significant toxicity implications

when co-prescribed with opioid drugs, and the combination should be avoided.

These medications along with opioid medications, strongly interact to increase the

impairment effects of alcohol. Patients should be cautioned against using alcohol while using

drugs of dependence. These combinations can increase the risk of depressed breathing coma

and death.

Gabapentinoids:

These medications are indicated only for the treatment of persisting neuropathic pain and in

patients with seizure disorders.

They carry similar risks to the medicine groups mentioned above. They specifically increase

the risk of suicidal thoughts and behaviour and must be used with great caution in patients

with existing or past depression.

They can significantly impair motor skills, result in a reduced level of consciousness, and

impair decision making and cognitive functioning. These effects are increased with higher

doses and when used outside of the recommended maximum amount. They are more likely to

result in harm in older patients.

There are increasing reports of serious harm, and cases of death in Australia related to the

overuse of Gabapentinoids. These are to be used in extreme caution in patients with a history

of addiction and/or drug dependence due to the risk of overuse.

Seeing the same doctor:

Seeing the same doctor is very important for any chronic health condition, particularly for

chronic, recurrent, and persisting pain, epilepsy, cancer, and psychiatric conditions where

drugs of dependence may be prescribed.

The is expected to monitor:

The patient’s capacity for decision making.
Any co-morbid mental and physical health conditions.
Patient support networks and their utilisation.
Progress towards previously established goals.
The emergence of any new health conditions.
The development of medication tolerance or other direct medication related harms.
Any harm related to risky behaviours (including illicit substance or alcohol use).
How any medication reduction is progressing (including any withdrawal symptoms).

Our doctors understand the importance of how the patient and their community supports

interact and work together overtime to enhance the health of the patient.

Regulation and Compliance

Many drugs of dependence are managed under state government regulation frameworks.

These frameworks dictate the rules around prescribing medicines of dependence.

Patients should be supported to understand the rules and time frames around requesting and

obtaining authorities to prescribe. It is usually the treating doctor who is best placed to

explain this process.

In most jurisdictions it is called a criminal offence to seek possess or distribute prescription

medications of dependence for manners outside the treatment of a legitimate medical

condition by a medical practitioner. This practice is obligated to report any suspicion of

criminal behaviour immediately to the police.

Many medications may impair skills required to operate a motor vehicle and other complex

tasks. Doctors are responsible for providing this advice and monitoring patients for any

impairments that may place the patient or the public at risk of harm from prescription

medication effects. This is an important reason for seeing the same doctor. Impairments may

be subtle, and not obvious to the patient themselves. Doctors may need to contact the relevant

road transport licencing authority if they are aware a patient is not following medical advice

on driving restrictions. This is a serious offence. Doctors may be required to advise a third

party to protect the public of medical advice on activity restriction if not being followed.

Doctors may be required to apply for a permit, or authority from the relevant state or territory

health department when prescribing certain drugs in certain circumstances. Complex funding

regulations also exist under the Pharmaceutical Benefits Scheme for Medicare card holders

and for DVA patients. Patients should be informed when a non-funded medicine is likely to

be provided.

Doctors must always maintain professional boundaries with patients. This is especially

important to monitor when prescribing drugs of dependence to patients where the risk of

developing addiction exists.

Doctors may be required to terminate the therapeutic relationship if they become aware that a

patient is not attending the same doctor for important medical treatment monitoring and

oversite. This is usually included in the prescribing agreement and may be a sign of a

breakdown in the therapeutic relationship, or medication misuse.

Doctors should keep comprehensive notes that support their clinical reasoning and decision-

making.

State and Territory Legislative Frameworks and Clinical Advisory Services

QLD

Legislative Framework Contacts:

Queensland Medicines, Regulation and Quality - Qld Health 07 3328 9890