L3 Controlled Drugs - decision-making for prescribing CDs, risks associated with prescribing CDs, Advance Care Planning

Prescription requirements for Schedule 2 and 3 CDs

• Usual legalities - name, address, signature and address of prescriber, date

• Name of the drug

• Formulation

• Strength

• Dose - must state a dosage unit e.g. ‘ONE to be taken as directed’

• Total quantity in words and figures

• Approved wording

Clinical considerations before prescribing

• Patient characteristics - the patient, co-morbidities, allergies, preferences

• Medication regimen - indication, dose, frequency, strength, formulation, interactions, monitoring

• Administration - RoA available/acceptable to patient, aids to administration

• Dependence - reliance on drug

• Tolerance - need higher dose to achieve same effect

• Addiction - drug seeking, compulsive behaviour

• Misuse - use of a drug for a purpose not consistent with legal or medical guidelines

• Overdose - patients could overdose intentionally or unintentionally

• Side effects - opioids can cause respiratory depression, drowsiness, constipation

• Diversion - removal of CDs from supply chain for unauthorised use

What is opioid dependence?

Opioid dependence develops after a period of regular use of opioids, with the time required varying according to the quantity, frequency and route of administration, as well as factors of individual vulnerability and the context in which drug use occurs. Opioid dependence is not just a heavy use of the drug but a complex health connotation that has social, psychological and biological determinants and consequences, including changes in the brain. It is not a weakness of character or will

Prescribing decisions for CD treatment

• Understand own competence and scope of practice

• Benefits vs risks

• Confirm ID of patient

• Detailed medical drug history - access to records

• Establish if opioid naive

• Appropriate route, dose, formulation

• Evidence based guidance - local and national

• Multidisciplinary approach - share relevant information

• Prescribing budget

Information for patients and carers

• Patient’s management plan, next review

• Discuss how long expecting to use controlled drug, how long it will take to work, how it works, indication, how to use, use at recommended dose, only for patient, common side effects, risks e.g. addiction

• Advise patient they may need to show ID on collection of controlled drug – manage expectations so it doesn’t come as a shock

• Dispose of safely - return to pharmacy

Managing risks when prescribing CDs

• Document indication and regime clearly in patient’s record

• Assess patient’s current clinical need and titrate dose

• Frequent monitoring and review, deprescribe

• When required CDs – when and how to take, specify dosage and maximum daily amount on prescription

• If prescribing in hospital/walk in centre – inform GP

• Be vigilant to patients visiting more than one prescriber, forged prescriptions, and fabricated stories

• Quantity – minimal supply initially. Consider existing supplies

• Prescribe no more than 30 days supply

• Must not prescribe CDs for yourself or someone close to you

• Hospital / hospice inpatients – prescribe each controlled drug to be used by different routes separately

• Incident reporting

Safe prescribing - the 5 rights

1. The right drug

2. The right dose

3. By the right route

4. At the right time

5. To the right patient

The unwritten 6^th right is the right of the patient to refuse

• Consider contraindications, appropriate dosage, interactions, adverse effects, allergies

What is palliative care?

Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.

Note: palliative care does not necessarily mean end of life

Prescribing opioids in palliative care

• Oral route preferred choice. Parenteral route if unable to swallow or experiencing nausea and vomiting. Transdermal is an alternative

• Immediate and modified release products

• Formulations – different bioavailability, not interchangeable

• Different durations of action

• Morphine strong opioid of choice

• Breakthrough pain – standard dose is usually 1/10^th to 1/6^th of regular 24-hour dose

• Risk of harm increases if using high doses without increased benefit

• Monitor closely for side effects

• Consider use of stimulant laxatives, antiemetics

• Use recognised opioid dose conversion guide, ensure consider total opioid (and antimuscarinic) load

• Follow local & national guidelines

• Consult with specialist palliative care team

What are some influences on prescribing in palliative care?

• If an Advance Care Plan (ACP) is in place

• Any advance decision or directive

• If someone has been granted the Lasting Power of Attorney (LPA) for the patient or the outcome of ‘best interests’ meetings (where the patient lacks capacity)

• Prognosis – look to deprescribe where possible

Mental Capacity

Governed by the Mental Capacity Act 2005

Assume every adult patient has mental capacity to make decisions about their care, unless establish otherwise

Take practical steps to help the patient to make decisions

Lack capacity if unable to:

• Understand the information relevant to the decision

• Retain that information

• Use that information to make a decision

• Communicate their decision

An unwise decision does not equal lack of capacity

Advance Care Planning (ACP)

Advance statements

• Statement explaining medical care the individual would/would not want in the future, if they were to lack mental capacity as defined by Mental Capacity Act 2005

• Statement of preferences, wishes

• Not legally binding, but must be considered when making best interests decisions should the patient lose capacity

• Should be accessible to those making decisions in the future

Lasting Power of Attorney (LPA)

• The Mental Capacity Act 2005 allows a person to appoint an attorney to act on their behalf to make decisions should they lose capacity in the future

• Two types - Property & Financial and Health & Welfare

• Legal documents that must be registered with the Office of the Public Guardian for them to come into effect

• Can nominate more than one person or different people for different decisions

• LPA comes into effect only when person lacks capacity for decisions that are covered by the document

Advance decisions / directives

• Allow patients to refuse specific medical treatments in they lose capacity in the future

• Legally binding

• Advance Decision to Refuse Treatment (ADRT) e.g. use of cardiopulmonary resuscitation, life saving treatment, blood transfusion

• If clinician satisfied it is applicable and valid, must abide by it

• Whilst patient has capacity their word overrides the advance directive