Co-ordinated approach to illicit
prescription drug abuse
Dr Greg Lydall
Consultant Psychiatrist, HSSD Guernsey
SSA York, 2015
What we will cover
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Small island context
Problems
3 datasets
Findings
Action plan
Results
What we will cover
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Intro
Method
Results
Discussion
Conclusions
What we will cover
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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
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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
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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
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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%
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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)
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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
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Conclusions
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Conclusions
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Conclusions
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Conclusions
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Conclusions
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Conclusions
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Conclusions
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Results (2): changes in prescribing
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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)
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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
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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%
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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