Co-ordinated approach to illicit prescription drug abuse Dr Greg Lydall Consultant Psychiatrist, HSSD Guernsey SSA York, 2015 What we will cover • • • • • • Small island context Problems 3 datasets Findings Action plan Results What we will cover • • • • • Intro Method Results Discussion Conclusions What we will cover • • • • • Intro Method Results Discussion Conclusions Introduction • Island community • Illicit drugs are difficult to import and expensive • Drug users look to alternative substances mainly pharmaceuticals • Implications for local prescribers, treatment, prognosis and prevention Clinical picture in Guernsey • Very different to UK experience • Anecdotally, little heroin, poor quality. • Pharmaceuticals esp fentanyl and benzos misused and implicated in ODs & deaths • Fentanyl patches ut into strips and cooked up • Extracted and injected • Street value £200-300 for 100mcg patch • Pre-filled syringes available • Suboxone street value £10/mg (vs £1/mg UK) Clinical picture in Guernsey Source: opiophile.org; bluelight.org; drugs-forum.com Clinical picture in Guernsey Image sources: opiophile.org; bluelight.org; drugs-forum.com; erowid Drug treatment in Guernsey • • • • • • • • • CDAT: NTA tier 2-3; no T4 on island Charity NTA T1 + NEX AA active; no NA OST options are mainly DF-118 (high dose) and Subuxone > Subutex Methadone not approved “NHS” (Mental health, addictions, infectious diseases, radiology, pathology) Medical Specialists Group (chambers): all other secondary care Primary Care is private All 3 different systems – including data systems! Methodology • 3 Audit results examined: – Unnatural deaths (2002-2011) [States Pathologist] – Substances misused from CDAT referrals (2011-13) – Prescribing data [Prescribing Advisor] Results (1):Unnatural deaths • • • • • n=106 (suicides, RTAs, etc) n Alcohol = 20 n Drugs (all) = 25 M:F = 60:40 Small numbers per year - confidentiality Source: ONS.gov.uk Different drug death profiles • • • • • • • Higher proportion of fentanyl, benzo deaths Fentanyl = Heroin (14%) < Heroin E&W (30%) DHC/Codeine 17% vs E&W 2% Methadone 4% vs E&W 12% Paracetamol 4% vs E&W 11% Guernsey: no cocaine, amphetamine deaths BUT: small Guernsey numbers (n=106) vs E&W (27k) Results (2) • 280 drug patients were referred/3 yrs • Buprenorphine (36%), benzodiazepines (30%), dihydrocodeine (18%), fentanyl (9%), heroin (7%) and codeine (7%) • 90%+ misusing prescription only medicines (POMs) and over the counter (OTC) drugs, particularly opiates and benzodiazepines • Reported patterns of use tended to follow local availability and poly-drug misuse was common (2) Top 10 = pharmaceuticals NTA data (2011-12) (3) Drug groups misused at referral to secondary care addictions Group OPIOIDS (all) FENTANYL BENZODIAZEPINES EDOC /NPS BUPRENORPHINE HEROIN CODEINE DIHYDROCODEINE 2011 65 9 25 4 26 11 6 22 2012 64 9 28 5 29 5 7 13 Guernsey 2013 76 6 30 9 46 4 6 14 Total 205 24 83 18 101 20 19 49 * Addiction to medicines, NTA, 2011/ % 73 9 30 6 36 7 7 18 E&W* % >90% ? 25 Results (3): Drugs misused by legal class Class 2011 2012 2013 Total Avg % Drugs *Referrals 103treatment 280services In 2009-10, just 2%80(3,735) of97 those in drug was with POM/OTC (referred POM reported their primary 75 problem67 79 221 79 primary 17 illegal to as ‘POM/OTC-only’). 17 A further 1814% (28,775) 13 whose 48 dependency was illegal drugs reported additional problems with OTC POM/OTC (referred to 3 as ‘POM/OTC+’). 5 12overall 4 This4means that 16% (32,510) of people treatment services reported OTC+POM 78 in drug 72 83 233 83 problems with their use of POM/OTC medicine out of a treatment population of 206,889. UK* 16%* 90%+ ? 16% Implications • Drug users are creative and will find alternative substances and ways of using them • Fentanyl-related deaths = heroin-related deaths at post mortem/case review • A high risk sub-group of substance misusers (9%) injecting fentanyl (derived from fentanyl patches) was identified • How to address fentanyl and POM availability? Action Plan • Discussed with service users, Public Health, Drug & Alcohol Team, and Drug & Alcohol Strategy Co-ordinator in 2011 • Suggested a forum be set up to raise concerns, share info, monitor trends, discuss strategies to address POM availability Addictive POM Group • Public Health, CDAT, Border Agency, Primary Care, Pain Clinic, Prison HC Action Plan (2) • • • • APOM group met first in 2011 quarterly Prescribing advisor showed fentanyl px data Opioid px audit: Primary Care & Pain Clinic Border agency: aware to look for APOM imports – changed policy (personal use) and several arrests • Prenoxad programme for high risk injectors Results (1) Conclusions (1) Conclusions (1) Conclusions (1) Conclusions (1) Conclusions (1) Conclusions (1) Conclusions (1) Conclusions (1) Results (2): changes in prescribing • • • • • • • Over 2011 to 2013: Fentanyl prescribing ↓ by 18% and cost ↓ by 45% Sedative hypnotics ↓ by 13% Morphine increased… Oxycodone and Tramadol increased… Increased awareness among prescribers Support for various initiatives incl Community Supervised Consumption, GP shared care • Annual audit of drugs misused at referral to continue Discussion (1) • High rates of pharmaceutical drug misuse • May reflect the low availability of illicit drugs: displacement • Increases demand for addictive POMs and OTCs. • Prescribers in isolated communities need to be more cautious when prescribing addictive POMs • Pharmacists and Prescribing Advisors may need to monitor for POM and OTC drug misuse particularly of opioid-containing medications and benzos • Ongoing data monitoring may be helpful Discussion (2) • Generalizeable? • Island, small area, homogeneous population • Possible to capture almost all of the people referred for help with substance misuse • Whether that would translate to big cities is hard to know. But for other smaller communities, may give insights into the problem and possible solutions Discussion (3) • • • • • • • Future? Ongoing data monitoring Cross reference with Drug Testing results …and Prescribing data (2013-) …and Unnatural Death data (2012-) …wider than fentanyl: benzos, DHC Watch Buprenorphine referrals and as Community Supervised Consumption was strengthened in 2014 • Watch if new pain meds appear in referrals • #1 drug cause of death though = alcohol! Conclusions • • • • • Creative drug users Demand high – why? Supply restriction: borders vs prescribers Prescribing responsibility: wider than patient Addictive POM group: co-ordinated approach may reduce prescribed drugs and hence drug availability – public health initiative • Questions? Ideas & research links welcome! Thanks – any questions? • Service users & carers • CDAT: Michelle Aldridge, Anna Williams, Claire Peters, Katrina Johnston, Dr Sakhib Rahman • States Pathologist: Dr Catherine Chinyama • Prescribing advisor: Ms Geraldine O’Riordan • Director of Public Health: Dr Steven Bridgeman • Pain service: Dr Yaroslav Stefak, Ms Katie Bassett • All members of Addictive POM group Results (1) • Causes of unnatural death (drugs, incl alcohol) in Guernsey vs UK (2002-11) Drug Guernsey England & Wales Alcohol 20% All opiates Heroin Fentanyl Other 10% 4% 4% 2% 55% 28% ? 7% Benzos 6% 9% Cocaine - 6% Amphetamine - 3% Unnatural deaths Gsy (‘02-’11): drugs Total deaths Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 total % 100 8 9 17 9 11 12 6 5 11 17 105 Alcohol Benzo. “Opiates” Fentanyl Heroin 0 0 0 0 0 1 1 2 0 0 4 1 1 1 1 2 0 2 0 2 1 0 0 0 0 4 1 3 1 0 1 0 0 0 0 0 0 0 0 0 1 0 1 0 1 6 3 2 2 0 20 6 11 4 4 19 6 10 4 4 Top 10 drugs of misuse (self report) 2011 2012 2013 Position Drug % Drug % Drug % 1 Diazepam 29 Diazepam 28 Suboxone - illicit 24 2 Suboxone 18 DHC 15 Diazepam 19 3 Subutex 17 Suboxone 15 DHC 14 4 Heroin 14 Cannabis 12 Subutex - illicit 9 5 Fentanyl 12 Fentanyl 12 Tramadol - illicit 9 6 Codeine 7 Subutex 12 Cannabis 6 7 Cannabis 6 Codeine 7 Heroin 5 8 DHC 6 EDOCS 5 Methadone 5 9 EDOCS 6 "Opiates" 5 Codeine 4 10 Codeine+ (OTC) 4 Heroin 4 Fentanyl 4