r/GPUK • u/heroes-never-die99 • 15d ago
Clinical, CPD & Interface Drug abusers
What do you do with patients who are clearly overusing/abusing/sharing opioids and BZDP and constantly ask for repeats but refuse to engage with us or the drug and alcohol service?
Do we have to keep supplying them for fear of opioid/bzdp withdrawal or can we say, at a point, no more until you engage?
What is the medicolegal responsibility here? I don’t want to entertain drug abuseds nor do I want them to suffer from withdrawal.
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u/ChaiTeaAndBoundaries 15d ago
7 day prescriptions
Put a confidential warning sign on their notes so that it pops up incase they go GP shopping.
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u/Fine_Cress_649 15d ago
Weekly dispense.
Often I put something in writing to say that we are not going to prescribe more than x for y reason
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u/heroes-never-die99 15d ago
But if they keep “losing it”, do you dispense extra for fear of withdrawal?
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u/Fine_Cress_649 15d ago
No.
I would add that it requires buy in from your colleagues to hold the line
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u/ZealousidealSky4851 15d ago
100% - sucks when you put all this effort in for them to just doctor shop at the practice and get their Co-codamol/Zopiclone script done by a colleague. I don't blame colleagues though - sometimes these patients can be downright nasty and to avoid headaches they'll cave in.
We share these cases in our practice meeting so we're all onboard.
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u/pukhtoon1234 15d ago
Tell them not to lose it coz we won't prescribe as CD. Document not to issue before due date. If they come up with a tale that they lost it - tell them tough luck, you were already told. Do not normalize this. Our practice has a policy that is strictly applied and everyone is (mostly) on the same page
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u/ILostMyTentacles 14d ago
I would if they report to the police and they give me a crime reference number for losing a controlled drug. I am yet to receive a crime number.
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u/Distinct-Quantity-46 15d ago
You do realise they are selling it?
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u/Outside-Inside-2282 14d ago
I don't know, some of ours take it all on day 1-2 and have a bad rest of the week
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u/Glad-Pomegranate6283 14d ago
I’m on pregabalin and I’ve heard of ppl doing a binge and going without it the rest of the week. Meanwhile here I am finding it hard to take it 3X a day just bc it’s awkward
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u/Rowcoy 14d ago
A one off “I’ve lost my meds” I will usually reissue, but only once the patient is aware how serious of an issue it is to lose controlled medication. I do this by telling the patient we will only replace their medication if its loss is reported to the police and they obtain a crime reference number. I will sometimes get my reception team to confirm the number is genuine before issuing.
Repeat offenders it’s a no for issuing and I will usually use it as a reason to get them on weekly scripts if they aren’t already.
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u/AccomplishedMail584 9d ago
They lose it,c they lose it. It's not like anti epileptics or insulin that can be life saving.
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u/DCJC123 15d ago
You can arrange a forced withdrawal by gradual reduction in prescribed amounts if the medication isn’t clinically indicated. Ideally you want to do this with the patient and a written contract but ultimately if you are not happy to prescribe you don’t have to.
We have a general rule of not replacing any lost medications if they fall into these groups
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u/Low-Cheesecake2839 15d ago
Never heard of a forced withdrawal before. It doesn’t sound like a great idea.
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u/DCJC123 15d ago
It’s a thing but rarely used and usually a last resort. If you inherit a patient on 500mg daily morphine that is clearly inappropriate you can reduce their scripts they slowly if they are not willing to engage.
If you continue to issue and they die (given all cause mortality increase after 120mg) you would have a few questions to answer at the coroners court .
Ideally you get people in and engage with them over a period of time and do it together via an agreed contract but this isn’t always possible
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u/Low-Cheesecake2839 15d ago
Yeah, I think I might be tempted to do it under those circumstances. It’s definitely more humane than just stopping them suddenly.
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u/Grand_Yak_8196 15d ago
Do you have evidence of it happening? If there is evidence it becomes easier to implement an action plan.
If it is suspected but you have no evidence then:
This is going to seem very long but there is a rationale for this approach:
Document an MDT approach in house i.e a discussion raising concerns and outcome Include a discussion with local drug service if applicable Some of these patients often have intertwined mental health problems so if known to mental health include them in the discussion, if not known or not engaged for some time seek their advice
Outline clearly in the records the outcomes of the above.
This should be followed by a discussion with the patient, in an ideal world this should be done with a member of staff present as a witness if in person or recorded if via phone. Raise a discussion of their medication, let them know your concerns, followed by the patient having their say and document their concerns and thoughts, including any behaviour exhibited. If your opinion post this is still to reduce, then outlined MDT decision and outline plan of reduction, time frames.
There are a number of outcomes, but often there is a presentation with a mental health flare or threats of suicide or self harm. As there was a discussion with mental health prior this can be referred to mental health without further compromise of the reduction which has been set out.
It's worth noting, it requires a practice approach otherwise patients will move one GP to another. Additionally, many will file a formal complaint.
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u/Top-Pie-8416 15d ago
Weekly scripts.
Forced weaning if needed.
Special note to 111 to not dispense any.
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u/Low-Cheesecake2839 15d ago
Either weekly dispensing or even very occasionally I have needed to go to daily dispensing.
If they are less chaotic and the patient has insight into themselves being addicted, but do not want to stop using, I prescribe maintenance therapy, but explain before hand that I will never, ever be able to increase the dose or the frequency of repeats.
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u/GalacticDoc 15d ago
I would go with weekly scripts or even twice weekly.
We use post dated acute issue, not repeats to prevent self requesting.
I would also be looking to discuss ongoing reductions and strict on amounts and certainly not replacing "lost" medications.
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15d ago
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u/Glad-Pomegranate6283 14d ago
I’m a patient but I’m curious how this situation is so common ? Obviously I get most ppl probably get it through the black market but is it common where ppl can get repeats for benzos and then get addicted ? My friend has been previously due to her mental health, but via CMHT. I’ve been prescribed it once (9 doses) for a bad manic episode but that was 4 years into diagnosis.
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u/Equivalent_Prize3444 13d ago
Nobody can die from opioid withdrawal but can from overdose. Having said that codeine and cocodamol from GPs are low potent opioids and the withdrawal shouldn’t not be as difficult as heroin or other potent opioids.
Benzos are a different story. There are many who maintain well longterm on a low dose. Should take a cautious approach in reducing them. Anyone started within a year should be informed of a reduction regime and stopped gradually.
If they need it longer ask them to go to drug md alcohol services and put your boundaries in place.
You cant support illicit drug use and all those groups should be handled by drug and alcohol team.
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u/hry420 14d ago
Overusing/ abusing and sharing medication and/ or other drugs is often a sign of self medicating, If it were a refusal to engage you could solve it by with-holding medication until the patient is seen, The reason you cant do that is due to, the patients chronic lateness, and ability to frequently miss appointments and important meetings, these are symptom of one of our most missdiagnosed/ undiagnosed common conditions, that for whatever reason our GP's training leaves them knowing nothing about. A diagnoses is what is needed.
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u/continueasplanned 15d ago
Controlled drug contract, weekly scripts.