Controlled drugs: What you need to know

Helen Moriarty is the Medical Officer of Health for Medicines Control at the Ministry of Health. This article discusses the role of Medicines Control

It is an offence for any healthcare practitioner to disregard rules surrounding the prescription, administering and supply of controlled drugs; the rules are specific with regards to the circumstances of a consultation – and it is vital that healthcare practitioners are aware of them.

Section 24 of the Misuse of Drugs Act 1975 states that a practitioner must not prescribe, administer, or supply controlled drugs to a person that the practitioner believes to be dependent on that or any other controlled drug, unless treatment is for that dependency. In that instance, (treatment for dependency) treatment must be carried out by a gazetted practitioner (and sometimes at a location) nominated by the Minister of Health, or by a practitioner who has the express written authorisation of the gazetted practitioner.

There are few exceptions – emergency treatment in a hospital care institution for up to three days, treatment in an institution pursuant to the Alcoholism and Drug Addiction Act 1966, and treatment of a person subject to a Restriction Notice.

Upholding the law: Medicines Control The Medical Officer of Health for Medicines Control holds a designation by the Director-General of Health to uphold functions within two major pieces of legislation: the Misuse of Drugs Act 1975 and Medicines Act 1981, and regulations made under these Acts. Medicines Control staff deal with licensing, auditing and drug abuse containment activities in the medicines supply chain. Medicines Control advisers are experienced pharmacists who will liaise with the regulatory authorities for health professionals, particularly where prescribing issues are identified.

Medicines Control drug abuse containment activities include: surveillance of the dispensing of controlled drugs; investigation of unusual prescribing patterns; collation of information on drug abusers or drug seekers from doctors, pharmacists, practice nurses, and Drug and Alcohol clinics; advice to health professionals about drug seekers and trends in the misuse of drugs; issuing and revocation of Restriction Notices; receiving and monitoring of GP Authority to Prescribe Controlled Drugs (eg, authorisation of GPs to prescribe methadone for treatment of dependency).

There are common knowledge gaps for prescribers, which include the addiction potential of prescription medication, complications of longterm drug administration, awareness of controlled drugs prescribing requirements, restricted persons and authorities to prescribe. Prescribing competence issues requiring interface with the Medical Council often relate to an inability to resist inappropriate prescription requests (the doctor with a ‘soft touch for drugs’ reputation).

Prescriber advice is also provided on a one-onone basis to GPs and health services, palliative care and pain clinic clinicians. This advice may include alerts, known past history of a particular individual, issuing of Restriction Notices or Privileged Statements. A Restriction Notice is a legal document issued by the Medical Officer of Health. The restriction limits prescribing to a named person and often one pharmacy for dispensing.

A Restriction Notice is issued in one of two circumstances:

1. Where there is clear evidence that the person has been obtaining medication from a number of different practitioners, over a prolonged period and is likely to seek further supplies, or
2. Is addicted or habituated to a medicine or has been obtaining it from several sources and is likely to seek further supplies. A Restriction Notice relates to the specific conditions for that person.

Approximately twice a year a list of currently restricted persons throughout New Zealand is provided to doctors, pharmacists and appropriate services. A Privileged Statement is a means of notifying others about a person who is, or is likely to become, dependent on any prescription medicine or restricted medicine. The purpose of the Privileged Statement is to prevent or restrict the supply of medicines to that person, require a supply from only a named source, or to assist in the cure, mitigation, or avoidance of the dependence.

Generally there is the expectation that health professionals will only share pertinent information with other health professionals involved in that person’s care. The Privilege extends beyond this, and allows the notification of interested others, not just health professionals. The following case is an example of drug abuse containment in action, where many of the functions described above were put into play (identifying details have been altered).

Hillbilly heroin: a case study

A routine Ministry of Health prescription audit identified that one patient had collected supplies of oxycodone exceeding the prescribed daily dose.

The audit revealed that nine doctors had written overlapping oxycodone prescriptions for this particular patient within a three-month period. The patient had used a different pharmacy to collect the medication from each prescriber, effectively hiding the extent of oversupply from the health professionals. This pattern of over-supply to one person, doctor-shopping and pharmacy-hopping to hide the extent of the duplication of medication is typical of drug-seekers. The sought substance itself also raised alarm bells.

Oxycodone is a strong opiate that has been prescribed at an increasing rate since it was introduced in New Zealand in 2005. Here and overseas, oxycodone has rapidly developed a reputation – illustrated by the street name “hillbilly heroin”. Drug users crush it or chew the tablets for faster effect, or roll the crushed tablet in foil, light the powder and inhale the smoke.

Cutting off the supply

In these circumstances, notification to the pharmacies and prescribers will often put an end to the personal prescription supply chain. In addition, the Medical Officer of Health may write to identified prescribers to offer pertinent advice.

In some instances the drug-seeking behaviour can be a result of stand-over tactics, where the drug-seeker is working for another person who holds some form of control over them. In that instance, when doctor-shoppers can no longer supply prescription medication, they may require additional help to get out of a risky situation. The drug-seeker’s GP is in a good position to offer support and advice in this situation.

Referral could be made to a specialist addiction service or advice given that organisations such as Women’s Refuge or the police, are contacted by the patient. A random drug urinalysis is often of value to document that the patient has consumed some or all of the prescription issued in their name. Unfortunately, oxycodone does not predictably show up in drug urinalysis (a ‘benefit’ that drug-seekers know about and use to their advantage).

However, coincidental use of other drugs (benzodiazepine, cannabis, stimulants and other opiates) may result in a positive urine test for those substances. If the patient is believed to be obtaining the prescription medication solely for their own use, as was the situation in this instance, then the prescribers will be advised to educate the patient against the risks of selfadministering more than the prescriber intended, and also (if urinalysis is indicative) of mixing this strong opiate with other sedatives.

An end to doctor-shopping: Restriction Notices

One GP may agree to become the regular prescriber, and in that case a Restriction Notice may be indicated to ensure that doctor-shopping cannot continue. Restriction Notices can be issued with or without patient consent, but are most effective when the patient has entered an agreement with the doctor to abide by the conditions of the Restriction Notice and use just one prescriber, and just one pharmacy.

However, abiding by a Restriction Notice is a voluntary undertaking and determined patients will change doctors or move to a different locality to avoid the restrictions of a Restriction Notice, and that is what happened in this particular case. Additional information will often flow into Medicines Control in response to the initial advice to pharmacies and prescribers. In this case, the patient had presented with a chronic pain syndrome, which was the rationale for opiate requests, and used patient-held medical documentation to verify this.

The same patient had also accessed prescription benzodiazepines, using the same modus operandi but for alleged epilepsy. Patient-held records can be problematic because it is not always practical to ensure the veracity on the spot. In this instance, the documentation was not a medical report but rather a list of drug warnings, indications and contraindications. Despite this obvious shortcoming, the documentation had convinced many doctors to prescribe over many months.

As time went on, different versions of the same patient-held documentation came to light, some using the name of another person but otherwise identical. Fraudulent use of medical documentation and the use of another person’s identity are crimes and should be reported to the police.

A Privileged Statement is usually issued as a last resort when informing prescribers and pharmacies and issuing restriction notices has failed to contain the doctorshopping problem. In this case a privileged statement was issued to regional pharmacies. The statement described the patient and the modus operandi. That step did result in even more information and, in this instance, that information was used to bring the patient help from appropriate authorities.

Learning points

• Chronic pain is the most common presenting complaint used by opioid drug-seekers.
• Epilepsy is a common presenting complaint used by benzodiazepine seekers.
• Patient-held medical documentation may be counterfeit or otherwise altered and should be verified through an official source wherever possible.
• Restriction Notices are most effective when the patient has undertaken voluntary agreement to comply.
• Regional drug-seeker alert networks can be helpful, but only if the health professionals consult them before prescribing or dispensing. Patients should be made aware of policies to notify other members of the network of drug-seeking behaviours. An easy way to do this is to display a poster in the waiting room.
• Medicines Control can provide additional information or advice to prescribers or pharmacists when drug-seeking is suspected. The Medical Officer of Health for Medicines Control may take additional drug abuse containment actions if necessary.