November feature

Difficult Conversations and Decisions about prescribing drugs of dependence

October 24, 2019
By Dr. Jon Cook MBBS, FRACGP, FAChAM

We are working at a time of evolving evidence of benefits and harms, and changing community and professional expectations, around appropriate prescribing of drugs of dependence. These expectations are often cloudy, confusing and conflicting, and there can be long waits for specialist support.

It helps us to have a clear approach in making decisions about prescribing drugs of dependence, and then to be able to be clear in our communication about our decisions. For what it is worth, some aspects of my approach follow:

When considering prescribing drugs of dependence:

  • Be clear about your indications for prescribing specific medications (especially for opioid and benzodiazepine medications).
  • Be clear about your preferred management of relevant presenting conditions (especially for persistent anxiety or pain conditions).
  • Have a conversation about the presenting problem rather than a medication.
  • Only prescribe a medication if it is indicated in your opinion for the presenting problem.

If it is appropriate to decline a request for a drug of dependence, be clear about why: “In my clinical opinion that is not a good medication for your problem, and I don’t prescribe it for that purpose”. “The problem with opioid medications for chronic back pain is that as your body gets used to them they stop working. You need to increase the dose to have the same effect; and then they can be very hard to stop”.
If an individual is already taking a drug of dependence regularly, it can be difficult to stop. Attempts at reduction can result in withdrawal symptoms which may include increased pain or anxiety, and the individual may be very fearful of this experience. It may be reasonable to continue prescribing of drugs of dependence, especially in situations of good effect and low risk.

Some associated risks can be reduced with some structures such as:

  • One doctor, one pharmacy, one benzodiazepine, one opioid medication.
  • Regular collection of medication from pharmacy (fortnightly, weekly, twice weekly, daily).
  • Rotation to a longer acting medication (such as buprenorphine) to avoid contribution of withdrawal symptoms to pain or anxiety.
  • Checking Safescript.
Dr Jon Cook is an Addiction Medicine Specialist, holding Fellowship for the Australasian Chapter of Addiction Medicine. He has a background in Community Health, and also holds Fellowship of the Royal Australian College of General Practitioners.

Dr Cook has experience in Indigenous Health through the Victorian Aboriginal Health Service, and an interest in working with young people developed through working at YSAS (Youth Support and Advocacy Service). His interests developed in supporting health care for people with a range of co-existing psychosocial complexities, with an ultimate focus and specialization in Addiction Medicine.

Dr Cook has been Head of Unit at Western Health since 2017, and is focused on service development, work with young people, and education of junior medical staff.

The Pharmacotherapy Area-Based Networks (PABN) are a Victorian Government initiative to provide opioid pharmacotherapy support for primary care medical practitioners and pharmacists across the state of Victoria including metropolitan, regional and rural areas.

Each PABN provides connections between primary health care, hospitals and Alcohol and Other Drug (AOD) services to create a more cohesive and strengthened pharmacotherapy service system.

What is pharmacotherapy?

Pharmacotherapy is Medication Assisted Treatment of Opioid Dependence (MATOD). It includes treatments such as methadone and buprenorphine (Subutex®, Suboxone®). Pharmacotherapy is also known as Opioid Replacement Therapy (ORT), and Opioid Substitution Therapy (OST). In Victoria, most pharmacotherapy is provided via a community model, mainly via General Practitioner (GP) and pharmacist service providers. Additional services may be provided by nurse practitioners, community health organisations and specialist nurses and AOD workers.

Your local PABN provides local support

There are two metropolitan and three regional PABNs. Each PABN is structured to meet local need and includes highly qualified management and specialist teams such as GPs, Addiction Medicine Specialists (AMS), Clinical and AOD nurses, and pharmacists. These teams recognise the diverse needs of practitioners and patients, and provide innovative and flexible approaches to meeting local needs. See our About page and the contact details for your local PABN.

Victorian Opioid Management Extension for Community Healthcare Outcomes (ECHO) is a PABN program providing specialist no-cost opioid education for all Victorian health practitioners.