Coordinated Approach Reduces Illicit Prescription Drug Use

Daniel M. Keller, PhD

March 03, 2014

MUNICH — Illicit use of prescription and over-the-counter (OTC) drugs reaches from big cities to the most rural areas, especially when banned substances are in limited supply.

On the British Protectorate Channel Island of Guernsey, off the southern coast of England, tight border controls and strict prison sentences restrain illegal drug importation and make what is available very expensive.

Speaking here at the 22nd European Congress of Psychiatry (EPA), consultant psychiatrist Greg Lydall, MBBCh, MRCPsych, of the Health and Social Services Department on Guernsey, found that 96% of his substance abuse clients were using prescription-only medications as well as OTC medications.

"What we discovered was that prescription-only medications were the big drug of choice, probably due to low levels of access and availability to illicit drugs in our community," he told Medscape Medical News. "And we found that buprenorphine products [and] diazepam [and] benzodiazepines were very high."

He also noticed that fentanyl misuse was much higher than expected. An injectable concoction "was derived from the transdermal patches, which would then be cut up and cooked up and extracted to get the active ingredient out, much like one would cook up heroin in other places," he explained. The result was a number of overdoses and deaths.

In fact, fentanyl caused the same number of deaths as heroin in this island community of 65,000 people. "That was about a quarter of the number of deaths related to alcohol, which if you think about population exposure to alcohol compared to fentanyl, you can tell that fentanyl is a problematic drug in terms of risk of overdose and death," he pointed out.

Community Effort

The investigators tracked the number of drug- and alcohol-related referrals to the Community Drug and Alcohol Team (CDAT) between 2003 and 2013 and did an audit of unnatural deaths from 2002 to 2011.

After a sharp increase in alcohol-related referrals from 84 to 132 from 2003 to 2004, the alcohol figures were fairly stable from then until 2013, ranging between 118 and 146 per year. However, drug-related referrals mainly increased during the period, rising from 41 in 2003 to 103 by 2013.

The CDAT found that up to half of referrals were for primary drug dependency and that the reported patterns of use followed local availability. Polydrug misuse was very common, mostly of prescription and OTC medications, with a significant amount of buprenorphine abuse.

Table. Clients Misusing Various Drugs (Data for 2011 - 13; N = 198)

Drug Misuse Proportion of Clients (%)
Referrals for primary drug dependency 40 - 50
Polydrug misuse 85 - 93
Prescription and OTC medication misuse 72 - 96
Buprenorphine misuse 26
Fentanyl injectors 6 - 9
Illegal drug users 20

Heroin users

4 - 9

 

Multidimensional Approach

To attack the problem, Dr. Lydall took a multidimensional approach involving the public health service, the pain service, lead family physicians, the prison service, specialists, the police, and the border agency. The first step was to raise awareness of the issue and have a frank discussion about it.

"We then started looking at prescribing practice because we realized that some of that medication had to be coming from ourselves as prescribers," he said. "And so we looked at it from all sorts of aspects ― prescribing, public health, law enforcement ― and we brought these ideas together."

An audit of prescribing practice revealed relatively high levels of fentanyl and other potent opioid prescribing, "perhaps not always following best practice guidelines," Dr. Lydall said. "Subsequent to the audit, we found that our fentanyl prescribing rates went down by 18% over a year period, and we found an increase in morphine substitutes. So that was used more appropriately, probably for the management of pain."

He cautioned that the data are still relatively new. But on the basis of early apparent success of this community-wide effort, he advises physicians to be conscious as to whether they are making the best decisions in what they prescribe. And retail pharmacists should be aware of patterns of OTC drug purchases, which is probably easier to do in small communities where they recognize their customers.

For comparison, Dr. Lydall pointed to data from the US Centers for Disease Control and Prevention showing a similar rising trend in deaths from natural and semisynthetic opioid analgesics. In 1999, there were just under 3000 deaths, but by 2008, the number had risen to about 10,000.

Findings Generalizeable?

Commenting on the findings for Medscape Medical News, session chair Sebastien Guillaume, MD, PhD, associate professor of psychiatry at CHU Montpellier in France, who was not involved in the research, said that the public health approach of this study produced positive results. "It seems OK with the size of the island, I think," he said.

He noted that the island of Guernsey is a small area with a homogeneous population, so it is possible to capture almost all of the people referred for help with substance abuse. Whether that would translate to big cities is hard to know. But for other small areas, the study may give insights into the problem and a part of the solution.

Dr. Lydall reports no relevant financial relationships. Dr. Guillaume reports that he has received research grants from Servier Laboratories and receives honoraria from Servier, Lundbeck, and Bristol-Myers Squibb.

22nd European Congress of Psychiatry (EPA). Session FC01. Presented March 2, 2014.

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