Dealing with drug-seeking behaviour

People who misuse prescription drugs most commonly seek prescriptions for opioids and benzodiazepines. Other prescription drugs that are misused include the newer antipsychotics such as quetiapine and olanzapine, and stimulants such as dexamphetamine and methylphenidate.

Health professionals should be aware of behaviours that may indicate drug seeking, but dependency on prescription drugs can occur at any age, within any cultural group and across any educational class. Patients with dependencies may not necessarily display obvious drug-seeking behaviours.

All general practices should have a practice policy on prescribing drugs of dependence. GPs should register with the Prescription Shopping Information Service.

There is strong evidence in Australia of increasing harms from prescription drugs of dependence, including deaths from overdose. Before prescribing any drug of dependence, health professionals require an understanding of the patient’s biopsychosocial status, and the evidence-based indications and potential significant harms of these drugs.

Increasing harms from prescription drugs of dependence are evident in Australia. Between 2001 and 2012 over 800 Australians died from overdoses that involved the prescription analgesic oxycodone, either alone or in combination with other drugs.¹ People may seek prescriptions for drugs of dependence with the intention of misuse.

Drug misuse occurs when patients consume either prescribed or illicit substances in a manner that is not consistent with legal or medical guidelines. Patients may be seeking drugs for themselves or to pass on to a family member with dependency issues. They may also seek to procure these drugs for diversion and monetary gain.

Drug-seeking behaviour is a commonly used, although poorly defined, term that describes a range of activities directed towards attainment of sought-after drugs. It requires an approach that is mindful of outcomes for the patient, practice staff and the community. General practitioners and pharmacists can be part of the solution to dangerous misuse of prescription drugs.

Benzodiazepines and opioids are the two most common classes associated with drug-seeking behaviour. Opioids commonly misused in Australia include oxycodone, fentanyl, codeine and morphine.

Psychotropic drugs producing stimulant effects, euphoria, sedation or hallucinatory effects are sometimes sought. These include the newer antipsychotics quetiapine and olanzapine, and stimulants such as dexamphetamine and methylphenidate.² Anabolic steroids are also increasingly misused.

The National Drug Strategy Household Survey 2013 found that misuse of prescribed drugs of dependence has increased for many years, while the proportion of people using most illegal drugs has remained relatively stable.³ Opioid misuse in Australia now mainly involves opioids obtained on prescription.⁴ Oxycodone was the seventh leading drug prescribed in general practice in 2014.² Data from needle and syringe programs in Australia show that in 7% of injecting episodes ‘the last drug injected’ by their clientele in 2000 was a prescription opioid. This rose to 27% in 2010.² There have been large increases in opioid prescribing,5 with the total number of prescriptions on the Pharmaceutical Benefits Scheme (PBS) increasing about threefold between 1992 and 2007 (2.4 million to 7 million scripts).⁴

Over-the-counter combinations of codeine with paracetamol or ibuprofen have caused serious harms when misused.⁶ Complications of overdose with the ibuprofen/codeine combinations can be life threatening and include gastrointestinal bleeding, perforation, hypokalaemia, renal failure, anaemia and opioid dependence.

In the last 10 years, benzodiazepine prescribing has increased, but there has also been a dramatic change in the profile of the benzodiazepines prescribed. Over a five-year period the prescription of alprazolam increased by a third, particularly on private (non-PBS) prescriptions.⁷ The PBS-subsidised use of alprazolam, for the treatment of panic disorder, changed from Schedule 4 to Schedule 8 in February 2015 and it is expected that this will result in a decline of prescriptions for alprazolam. However all benzodiazepines can be misused.

Many coroners’ inquests have drawn attention to deaths due to prescription opioids and psychotropic drugs. Most Australian deaths involving oxycodone were caused by combined drug toxicity. The most commonly co-administered drugs included benzodiazepines, alcohol and other opioids which in combination can cause respiratory depression. Approximately 12% of deaths were identified as due to oxycodone toxicity alone.¹

Patterns of drug-seeking behaviour, intoxication and withdrawal states can affect patients’ relationships, employment and finances. Misuse of prescription drugs is associated with crime and consequent incarceration. Harms extend to the wider community and include robbery, theft, identity fraud, extortion and the manufacture of illicit drugs. Traffic accidents and disorganised behaviour can have consequences for both the patient and community. Harms associated with the injection of prescription drugs include an increased risk of acquiring blood-borne viruses and other adverse effects of unsafe injecting.

Dependency on prescription drugs may occur at any age, within any cultural group and across any educational class. GPs should be aware of drug-seeking behaviours (Box 1),⁸ but some patients seeking drugs of dependence may present without these behaviours. Common contexts within which drug-seeking occurs include:

• the development of dependence arising out of the use of prescription and over-the-counter opioids, benzodiazepines and other psychotropic drugs
• the use of prescription opioids by individuals dependent on illegal opioids such as heroin, partly as a result of substantial unmet demand for treatment of illicit opioid dependence. This includes patients who may wish to inject or sell these drugs
• drug diversion by people who want to sell the drugs
• the use of prescription drugs of dependence by patients who would never self-identify with ‘people who use drugs.’ These patients may self-medicate to feel better, and may present without immediately obvious signs of drug-seeking behaviour. Patients may appear to be socially advantaged with high achievements in education, adequate social supports and good incomes.

GPs can seek help from the Medicare Prescription Shopping Information Service by ringing to find out if a patient has been identified as a prescription shopper in the previous three months (Box 2). If the patient meets the program’s criteria, the GP is informed straight away and can request further detail on the amount and type of PBS medicine supplied to the patient. The patient’s consent is not necessary for the inquiry.

There are two caveats about the reports provided by the Prescription Shopping Information Service. Some patients who have met the criteria over a three-month period may not necessarily be prescription shopping. Target drugs include analgesics, antiepileptics, antiparkinson drugs, psychotropics and antidepressants, all of which the patient may need. Conversely, some patients with prescription drug dependency will not be identified by the Prescription Shopping Information Service because the ‘bar’ is set quite high. Additionally, non-PBS private prescriptions are not captured in the Prescription Shopping Information Service data.

If a patient does not meet the Prescription Shopping Information Service criteria, GPs can ask the patient to agree to the release of Medicare and PBS claims information. However, there is a time delay of several weeks before this information is sent and it always requires the patient to sign a release-of-information form (Box 2).

In general practice, managing requests for prescription drugs of dependence requires a team approach involving the whole practice.

Practice policy

All practices need a policy on prescribing drugs of dependence. Team work and consistency of prescribing are essential. Community pharmacists can be made aware of the practice policy and also invited to be part of care planning for patients receiving drugs of dependence.⁹ The practice policy should be comprehensive (Box 3) and understood and applied by all staff.⁸ It should be explained to patients requesting drugs of dependency from the outset. This will diminish the chance of harms befalling the patient and of patients continuing to display challenging behaviours.

The practice policy also needs to be communicated to specialists, particularly neurologists and psychiatrists, who are external to the practice in order to avoid patients receiving mixed messages. The Royal Australian College of General Practitioners has recently released a clinical guideline on drugs of dependence, and practice staff can use this as a reference.⁸ Practices may also wish to consider a sign in the waiting room that explains some basic policies (Box 4).¹⁰

What GPs can do

The practice’s approach to prescribing drugs of dependence should be applied universally and without prejudice towards any group of patients. While there are red alerts within a patient’s history that may indicate an increased risk of dependence,¹¹ any person can potentially become addicted to their drugs.

Some GPs find it too difficult to refuse requests for drugs of dependence. The practice policy can help them to say ‘no’ to such requests. A GP can say ‘I don’t prescribe drugs of dependence’, or ‘It is our practice policy not to prescribe drugs of dependence’, or ‘It is recommended by health guidelines that we do not prescribe these medicines’. Further explanations are not needed. The GP can then suggest that the focus is shifted to seeing what other strategies can be used to help the patient with their presenting problem.

Before an ongoing need for a drug of dependence can be medically justified, a full biopsychosocial assessment needs to be done, contact with the previous treating doctors made, and a treatment plan formulated. Monitoring within frequent review appointments should occur and include assessment of the patient’s function and quality of life, and not just resolution of one symptom. All of this should be clearly documented. Most patients receiving drugs of dependence will have complex problems and require collaborative care and hence should be offered a care plan. Care plans can also be used to encourage patients to engage in active approaches to treatment such as goal setting and the identification, and hence prevention of, triggers to drug use.

It is possible for any person to develop a prescription drug dependence and precautions should be built into a practice policy. Controlled prescribing strategies (Box 5) are part of this approach. GPs should discuss the addictive nature of the drugs, the harms that can ensue, and that these drugs will not be prescribed in the long term, but only until other treatment strategies are put in place. It is important to set clear time boundaries from the outset. Such discussions should occur within a patient-centred framework,¹² hence the GP should talk in terms of judging the treatment and not the patient. Practices should also consider using a contract to inform patients about controlled prescribing, boundaries and the risks and benefits of treatment.¹³ The wording of such contracts should be focused on promotion of patient well-being and safety, and not primarily used for the protection of the prescriber.

If patients present with opioid dependency and are not suitable for a trial of controlled prescribing, they can be offered treatment with opioid substitution therapy in the form of methadone or buprenorphine. GPs can become approved prescribers and are well placed to provide holistic primary health care alongside treatment of a patient’s dependency.

All practitioners have a duty to act within state, territory and national legislative frameworks (Box 6).⁸ There can be medicolegal consequences for not complying.¹⁴

There is strong evidence that serious harms can result from misuse of prescription drugs of dependence. GPs should be aware of drug-seeking behaviours that may indicate a patient has a dependency problem. All GPs should develop practice policies stating their approach to prescribing drugs of dependence.