Physician Prescribing Practices Program (P4)

A pharmacist contacted the College with concerns about a patient’s prescription. The patient was receiving 200 tablets of OxyContin 80 mg every eight to 14 days -  always paid for in cash. This was equivalent to 2400 mg oral morphine equivalents (OME) on a daily basis. The patient worked out of town, but was always willing to fly home to pick up prescriptions.

Attempts by the pharmacist to communicate his concerns to the physician were not successful. The physician eventually instructed his receptionist to tell the pharmacist that “your job is to dispense the medications and not to question his judgment”. The pharmacist called the College for advice as he was very uncomfortable with the circumstances, but also wanted a good working relationship with this physician in order to provide good patient care.

Some physicians may not be aware pharmacists have their own professional standards to independently determine the appropriateness of each prescription prior to dispensing a medication. There may be situations where a pharmacist requires further information from a physician in order fulfill their professional requirements. The Health Information Act Section 35(1)(a) permits physicians and pharmacists to discuss mutual patients in order to provide health care services without special consent.

Physicians have a responsibility to collaborate with other health care professionals as outlined in the College’s  Standard of Practice, Collaboration in Patient Care. Communicating effectively and respectfully are important aspects of collaboration in order to optimize medical care and to minimize the risk of harm to your patients. It is in the best interest of all involved to have a good working relationship with any pharmacist involved in the care of your patients.

In the situation described above, the College’s Physician Prescribing Program contacted the physician with feedback about his prescribing practice. He admitted he was struggling with the pain management part of his practice and didn’t feel he had the resources to address it. The physician was provided with education and practice tools and made substantial changes to how he approached pain prescribing.

If you have feedback or comments on this month’s Prescribing Corner, please contact Dr. Susan Ulan, Senior Medical Advisor at: 780-969-4930, 1-800-561-3899 ext. 4930 (in Alberta), or email Susan.Ulan@cpsa.ab.ca.

Prescription drug abuse is a significant public health concern in Canada. The first long-acting opioid used as substitute treatment for opioid dependence was methadone. In order to prescribe methadone in Canada, physicians are required to be exempt from section 56 of the Controlled Drugs and Substances Act. To qualify for a methadone exemption for opioid dependence, physicians must:

• apply for a methadone exemption, which requires a letter of support from the College
• attend the Methadone Maintenance Treatment (MMT) Introductory Workshop 

Buprenorphine is a partial opioid receptor agonist available in Canada since 2007. It is most commonly prescribed in combination with opioid antagonist naloxone as Suboxone® in sublingual tablet form. Buprenorphine is as effective as methadone for treatment of opioid dependence but with an improved safety profile. The agonist/antagonist action of Suboxone® creates a “ceiling effect” which makes it less likely to result in overdose and less attractive to abuse.

In order to prescribe buprenorphine for opioid dependent patients in Alberta, physicians must complete an online buprenorphine prescribing course and provide the CPSA with proof of completion. To complete this 6 hour online course, please visit www.suboxonecme.ca.

To initiate buprenorphine (Suboxone®) for opioid dependence physicians must:

• complete online buprenorphine course
• complete the MMT Introductory Workshop
• have the appropriate postgraduate education or experience in a multi-disciplinary setting

To maintain buprenorphine (Suboxone®) in stable dependent patients physicians must:

• complete the online buprenorphine course
• have a letter of support from the initiating physician

Although buprenorphine has an improved safety profile compared to methadone, opioid dependent patients are high risk and must be managed with appropriate boundaries. Monitoring compliance by accessing prescribing databases and consideration of random urine drug screening are recommended. 

• Summary of requirements to prescribe buprenorphine in Alberta
• Summary of requirements to prescribe methadone in Alberta

 If you have comments or questions on this month’s Prescribing Corner, contact Dr. Susan Ulan, Senior Medical Advisor at: 780-969-4930, 1-800-561-3899 ext. 4930 (in Alberta) or email Susan.Ulan@cpsa.ab.ca

Methadone is an oral long-acting synthetic opioid which is effective in treating both opioid dependence and for analgesia in chronic pain and palliative conditions. It has a long and variable half-life with the potential for accumulation which can lead to sedation, respiratory depression and even death. This risk is greater when methadone is combined with alcohol, sedatives or other opioids. It is an important medication but it must be used cautiously and titrated for each patient individually.

For these reasons, there are requirements that physicians must meet before receiving authorization from Health Canada to prescribe methadone. To prescribe methadone for analgesia or for the treatment of opioid dependence, physicians must be exempted under section 56 of the Controlled Drugs and Substance Act which requires the approval of the College of Physicians and Surgeons of Alberta.

To be granted a methadone exemption that permits you to initiate methadone treatment requires appropriate education, experience in a multi-disciplinary setting or post graduate training. If you wish to apply for an exemption to continue prescribing methadone for a patient that has been stabilized by a specialist, you are required to apply for a methadone exemption and to provide a letter of support from the pain, addiction or palliative physician that initiated the patient on methadone. To use methadone for the treatment of opioid dependence, physicians are required to attend the Methadone Maintenance Treatment (MMT) Introductory Workshop to be eligible.

• Summary of the requirements to apply for the different types of methadone exemptions in Alberta
  
  
• More information about the Methadone Program

To apply for a methadone exemption, complete the application and mail the signed original to Health Canada and fax a copy with the appropriate documentation to the College at 780-420-0651. Health Canada will not grant an exemption without support from the College so it is essential that the College receive a copy of your application and any documentation. The application can be downloaded from: http://www.hc-sc.gc.ca/hc-ps/alt_formats/hecs-sesc/pdf/pubs/precurs/methadone_form.pdf

Opioids have a recognized role in treating chronic non-cancer pain. However, many physicians are reluctant to prescribe opioids, because they are concerned about the risk of addiction. This reluctance can contribute to the under treatment of chronic pain.

The risk of addiction or aberrant drug-related behavior is generally reported between 3.7 and 11.5 per cent, depending on the study (Fishbain, 2008). Although the risk of addiction is low, physicians need to know the signs of aberrant behavior, so they can recognize patients’ loss of control over their opioid medications.

Some aberrant behaviors are more predictive of addiction than others (Hojsted, 2007). They include:

• Rapid escalation of drug use
• Deteriorating function despite increasing doses
• Lack of honesty or excessive guilt
• Non-oral route of use
• Active concurrent addiction to alcohol or other substances
• Diversion and other drug dealing behaviour, including “borrowing” medications

A motivated patient can modify an opioid intended for oral use into a more bio-available form, which makes it more prone to abuse. Patients can make physical and chemical modifications to opioids, so they can be injected, inhaled, snorted and even used in rectal enemas. There are also reports of patients steeping transdermal opioid patches to make a “tea”, or cutting them for intranasal use. 

Pharmaceutical companies have developed pharmacological strategies to help deter abuse, although, at this time, it is not known whether these strategies will be effective (Passik, 2009). They have physically modified formulations to make opioids more resistant to extraction, and created agonist-antagonist combinations, which reduce the “reward” at a receptor level. You should be wary if a patient requests an older version of a medication when the formulation changes. 

If your patient appears to have lost control of his/her medication use, or to be at high risk of misuse, use the following strategies to help establish firm boundaries:

• Review non-pharmacologic management strategies
• Use an opioid treatment agreement
• Avoid prn doses
• Fax the prescription directly to the pharmacy
• Prescribe blister pack medications
• Shorten dispensing intervals
• Initiate random urine drug screening
• Establish realistic goals about pain reduction with opioids
• Consider referral to a chronic pain or addiction specialist

Physicians who prescribe opioids to treat chronic non-cancer pain should:

• monitor their patients on a regular basis,
• tailor therapy according to risk of misuse and response to treatment, and
• have an approach for managing aberrant behavior. 

We do not advise relying solely on pharmacological properties of opioid formulations to deter misuse and abuse.

For more information on how to manage prescribing of opioids in high-risk patients and patients with addictions, please refer to the clinical review article Canadian guidelines for safe and effective use of opioids for chronic non-cancer pain: Clinical summary for family physicians. Part 2: special populations.

If you have feedback, comments or would like more information on the references cited in this month’s Prescribing Corner, please contact Dr. Susan Ulan, Senior Medical Advisor, at:  780-969-4930, 1-800-561-3899 ext. 4930 (in Alberta), or susan.ulan@cpsa.ab.ca.