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Opioid prescription agreement form

Date

PATIENT NAME

PRESCRIBER NAME

I understand that ------insert prescriber name---- intends to give me a potent pain medication (Opioid) as part of the management plan for my pain symptoms. It is only one item amongst a range of options for my care.

This medicine is intended to:

1. Improve my level of routine function/ mobility.

2. Improve my quality of life.

3. Reduce (not eliminate) my intensity of pain.

I have read and understand the potential side effects (overleaf).

I understand that this medication if misused can cause grave harm to myself or any other individual who may have access to it.

I will therefore;

1. Keep the medicine in a safe place and not share with others.

2. Take the medicine as prescribed.

3. If I require potent medication from another source I will inform my GP.

4. Agree to not take/use illegal drugs during this treatment.

5. I understand that this medicine may be withdrawn if the intended benefits are not realised.

Patient Name

Patient Signature and Date

Prescriber Name

Prescriber Signature and Date

2 2Page 1 of 2

Adverse effects of opioid use – Patient information

Adverse effects How common? Description of effects

Slowing of your breathing especially while asleep. Respiratory depression 1% per year Can worsen obstructive sleep apnea. Can cause (caused by overdose). death.

Severe cases can cause blockage of the intestine. Constipation and nausea 40-50% This may need hospital treatment

Sedation, dizziness (can cause falls and injuries) depression, anxiety and apathy. Impaired Cognitive impairment 15-40% concentration (driving). Certain people are prone to misuse of opioids specifically if they have a history of depression or mental health issues.

Misuse can occur if other people have access to Addiction, misuse. 5-30% your medication. It can result in overdoses.

Reduced production of hormones controlling Hormonal effects >25% fertility and sexual function, osteoporosis, infertility & impotence.

You may become prone to catching infections. Immunosuppression Pneumonia in the elderly.

Non specific cardiac symptoms, myocardial Cardiac effects infarctions, heart failure, death.

Medication will need to be reduced slowly to Tolerance and withdrawal prevent withdrawal symptoms such as insomnia.

3

3Page 2 of 2

Protocol for opioid prescribing

This protocol is intended for GPs and other specialists working in City & Hackney. It provides guidance on how to manage patients who have inadequately controlled pain where there may be the need for initiation, maintenance or cessation of opioids. Management includes consideration of pain, function and psychological distress.

PATIENT WITH INADEQUATELY CONTROLLED PAIN

MONITORING ASSESSMENT 1. Assess function and pain status routinely.  Medical History – include cause, description and impact of pain; history of depression or suicide This could include an assessment of  Drug history – medications, alcohol, other maintained effect at annual review e.g. drugs, include questions of dependence consider a 10% dose reduction or nearest (see box over) equivalent lower dose.  Examination – area of pain & associated system, 2. Monitor for medication misuse and check injection sites drug seeking behaviours (see  Supporting evidence – imaging, reports warning flags overleaf)  Pain – type/cause. Identify pathology 3. Consider checking compliance with  Co-morbidities e.g. mental health, medical random urine checks for opioid & other  Drug dependency drugs – make patient aware of this  Be aware of safeguarding issues possibility

Early referral or advice  Pain service Management  Referral made by pain service  Physical education o Alcohol and drug service  Physical therapies o Mental health services (including  Non drug approaches community psychologists, psychiatrist) o Psychiatrist, pain medicine  Rheumatologist

Care when crossing the line

Opioid prescribing (check the 7 Cs)

1. Clinical Indication – right pathology vs. right drug 2. Clinical risks – drug & disease interactions, adverse effects 3. Consider warning flags (see box over) 4. Control dose – Use lowest effective dose & don’t exceed max 5. Contract to be signed by patient and prescriber as and when appropriate 6. Contain prescription – by single prescriber & single pharmacy where possible 7. Consensus between parties about outcomes (function, goals)

4

Points to be discussed with the patient before a trial of oral opioids  Stress that oral opioids are only part of the treatment plan  Warn of the potential for cognitive impairment e.g. driving, falls  Explain the indications for ceasing treatment with opioids: o Lack of improvement in function, or evidence of deterioration in function o Unsanctioned dose escalation and requests for early repeat prescriptions o Losing prescriptions o Unapproved use of the drug to treat other symptoms  Set realistic functional goals (e.g. to commence or maintain an exercise program, improving self-care ability, get out to the shops etc).  Explain that the aim is for controlling pain rather than no pain  Explain that dependence is a physiological effect of opioids and that withdrawal symptoms occur if the drug is stopped. (This should not be a problem with medically prescribed opioids)  Stress that patients must accept the responsibility for: o Ensuring their supply of medication does not run out after hours o Security of their medication o Keeping review appointments o Using only one doctor to supply this medication  Discuss side effects and their management (e.g. constipation, nausea, sedation, dry mouth, urinary hesitancy, and depression of sex hormones, with associated risk of osteoporosis with long term use)  After 6-8 weeks opioids often cease to be effective and can lead to Hyperalgesia

Warning flags for opioid prescribing  Deterioration in functioning at work, in the family or socially  Illegal activities e.g. selling medicine, forging prescriptions, stealing drugs from other patients, buying prescription drugs from non-medical sources  Previous treatment on an opioid pharmacotherapy program  Mental health problems  Indeterminate cause of pain  Previous or current opioid or other substance abuse disorder  Resistance to changes in treatment and requesting increases in treatment doses  Refusal to comply with random drug screens  Multiple episodes of lost or stolen prescriptions

Exit strategies Consider weaning off opioids if 1. Completion of time limited maintenance phase 2. Inadequate analgesia or excessive adverse effects 3. Evidence of aberrant drug related behaviour 4. Development of predominance or psychological issues Get advice from substance misuse or pain specialist

Sources of advice (as of January 2013): ELFT substance misuse services: Specialist Addiction Services City & Hackney Centre for Mental Health, Homerton Row, Hackney, London, E9 6SR 020 8510 8629 020 8510 8270

Reference: 1. Goucke, R. MJA Vol 178 5 May 2003 2. The British Pain Society Opioids for persistent pain: Good practice. January 2010 http://www.britishpainsociety.org/book_opioid_main.pdf (accessed 01/05/13) 3. Protocol for opioid prescribing in Tasmania. http://ebookbrowse.com/protocol-for- prescribing- opioids-in-tasmania-pdf-d383728000 (accessed 03/05/13)

5

Prescription drugs and addiction: the interface

Introduction This material has been produced to cover the potential harms associated with prescription drugs (especially opioids), including potential drug interactions, the risk of “addiction” to prescription drugs, and sources of support for patients who may be becoming dependent on prescription drugs. Many of the concerns that apply to uses of prescription drugs also apply to commonly available over the counter medications (especially those containing codeine).

At risk groups The risk of developing Prescription only Medicines (POM) and over the counter (OTC) dependency appears to be low in the population as a whole, but higher in service users with risk factors such as:  depression and other psychiatric illnesses previous substance misuse or dependency and especially where both problems co-exist

Clinically, polypharmacy may be a marker for the development of POM/OTC problems and patients taking multiple medication are at higher risk of overdose and drug related death (see appendix below).

Reference: Brands B et al. Prescription opioid abuse in patients presenting for methadone maintenance treatment. Drug Alcohol Depend 2004;32:199-207.

Boscarino JA, Rukstalis M et al. Risk factors for drug dependence among out patients on opioid therapy in a large US healthcare system. Addiction 2010; 105: 1776-1782.

General Registrar Office for Scotland. Drug-related deaths in Scotland 2011 (Published 17 August 2012. Available from: http://www.gro-scotland.gov.uk/files2/stats/drug-related-deaths/2011/drug-related- deaths2011.pdf

Ghodse H, Corkery J et al. Drug –related deaths in the UK 11th Annual report. National programme on Substance Abuse deaths (np_SAD). International Centre for Drug Policy, St. Georges Hospital Medical School, University of London; 2010

HM Chief Inspector of Prisons for England and Wales Annual Report 2011–12. Published 17 October 2012. Available from: www.justice.gov.uk/...reports/...prisons/hm-inspectorate-prisons-annual-report-2011-12.

Minozzi S, Amato L, Davoli M. Development of dependence following treatment with opioid analgesics for pain relief: a systemic review. Addiction 2012 (forthcoming) doi: 10.1111/j.1360- 0443.2012.04005.x

National Treatment Agency. Addiction to medicine An investigation into the configuration and commissioning of treatment services to support those who develop problems with prescription only or over-the-counter medicine. NTA, DoH, London; 2011

Reay, G An Inquiry into Physical Dependence and Addiction to Prescription and Over-the-Counter Medication. All-Party Parliamentary Drugs Misuse Group; 2008. Available from: http://www.drugscope.org.uk/ Resources/ Drugscope/Documents/PDF/Appgotcreport.pdf

Sproule BA, Busto UE, Somer G, et al. Characteristics of Dependent and Nondependent Regular Users of Codeine, J Clin Psychopharmacol, 1999; 19(4):367-372.

Sullivan MD et al. Regular use of prescribed opioids: association with common psychiatric disorders. Pain 2005;119:95-103.

66

Potential interactions between licit, prescription and illicit drugs by receptor system

Prescription only Illicit drug System Licit / OTC drug Medicine (POM) (or POM used illicitly)

St Johns Wort, Khat, Fluoxetine, Amphetamine, Serotonin / noradrenalin Pseudoephedrine Methylphenidate Ecstasy, Many “legal highs”* e.g. Methcathinone

Dopamine Salvia Divinorum Chlorpromazine, Cocaine, ropinirole Methamphetamine

GABA Alcohol Zopiclone, Baclofen Diazepam, GHB / GBL

Heroin, Dihydrocodein Opioid Nurofen Plus, Kratom Methadone, e, Tramadol Buprenorphine, Tramadol, Oxycontin

Alcohol, Methadone, tramadol, Ketamine, Glutamate/NMDA Dextromethorphan, acamprosate, Pencyclidine, Nitrous oxide, memantine Methoxetamine Ibogaine

Acetylcholine Nicotine Clomipramine, Procyclidine donepezil

Histamine OTC sedatives Clozapine, Imipramine Amitriptyline

Voltage gated Sodium ion channels Valproate, Carbamazepine Cannabis / synthetic Others Caffeine cannabinoids(e.g. Mary Joy)

Acknowledgement Barts Health NHS Trust Approved by the JPG: March 2014 Date of review: March 2016

7