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Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners What is the issue? There are distinct but overlapping populations The 2010 Drug Strategy covers "dependence using these medicines and they may need dif erent on al drugs, including prescription and over-the- counter medicines," and local responses to drug • Those who use prescription and OTC medicines misuse and dependence are also expected to cover as a supplement or alternative to il icit drugs, or dependence and other problems with medicines as a commodity to sel (sometimes cal ed addiction to medicines (ATM) .
• Those who overuse prescription or OTC medicines to cope with genuine or perceived (NTA, 2012) suggested that commissioners ask: physical or psychological symptoms • "Are innovative responses in place or being • Those for whom the prescribed use of a developed to prevent, identify and treat medicine inadvertently led to dependence, evidenced and emerging need in relation to sometimes cal ed involuntary or iatrogenic addiction to prescribed and over-the-counter Problems with prescription medicines occur in And that prescription and over-the-counter (OTC) the community and in secure environments but medicines are included in wider considerations of: the medicines used, populations using them and • Waiting times for community-based interventions reasons for misuse or dependence may dif er.
that provide access within three weeks of referral Health and wel being boards, through their joint • The treatment system's ability to respond rapidly strategic needs assessment (JSNA) and joint health and ef ectively to changing patterns of substance and wel being strategy, wil want to support health and public health commissioners to understand local need in relation to addiction to medicines, so What medicines and who is using them? that together they can commission appropriate responses. Health commissioners wil likely Although dependence on prescribed include both NHS England local teams and clinical benzodiazepines in the community receives most media attention, health and public health commissioners wil want to ensure that local y Understanding local need appropriate responses are available for problems with a ful range of prescription and OTC medicines, Commissioners wil want a ful picture of who is including, but not limited to: misusing or dependent on what medicines from which sources in order to commission appropriate • Benzodiazepines and z-drugs, prescribed mainly local responses.
for anxiety (benzodiazepines only) and insomnia • Opioid and some other pain medicines, both Date on prescriptions dispensed in the community prescribed and bought over-the-counter is made available to local partnerships via the • Stimulants, prescribed for ADHD or slimming prescribing toolkit provided by NHS Prescription Services. There is more information in the NTA's • Some OTC cough and cold medicines, and anti- Addiction to medicine report (NTA, 2011) and from histamines and stimulants.
There is a ful er list at appendix A.
Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners Public health commissioners can ask clinical Commissioners might also request practice or commissioning groups (CCGs) for information on the service-based audits of case notes to inform future prescribing patterns of GPs.
Consultation with those af ected by addiction to – sent to every partnership – includes local NDTMS medicines or likely to encounter it in their work data on people in treatment for prescription and OTC is an invaluable source of additional information. medicines, and drug users who have a problem with Appropriate local consultees might include service these as wel as il icit drugs (see below).
users (drug & alcohol treatment, mental health), treatment and other service providers, peer mentors and volunteers, pharmacy groups, police, probation, on presenting substance that can be used to primary and social care staf , tenancy and housing track changes in the profile of medicines causing support services, etc.
It has been agreed national y that the However, NDTMS data only covers those seeking specialist treatment so may not be most useful for are not suited to improving benzodiazepine gaining an understanding of people who do not approach treatment services or as a source of early intel igence on developing problems with medicines.
What's different about prisons and other secure environments? Other useful local data sources may include any local ATM and primary-care services that do not The medicines used, and reasons for their use, in report to NDTMS.
secure environments general y mirror those in the general population although the scale and nature Other ways of finding out may dif er. Prisoners may be more likely than the general population to suf er from conditions such monitor, audit and ensure the safe management as insomnia, anxiety and pain that lead them to and use of drugs controlled under the Misuse seek medicines liable to dependence. They may of Drugs Act. CDAOs in NHS England local also be more likely to claim these conditions as a area teams are the accountable officers for their way of obtaining medicines for personal misuse or CD local intelligence networks and they have a as currency. They wil also have less access to OTC surveillance role over community prescribing and pharmacies. NHS trusts and independent hospitals PHE wil publish a guide on managing persistent are also required to appoint CDAOs. Many of the pain in secure environments, in June 2013. This will medicines listed in appendix A are controlled drugs complement Safer Prescribing in Prisons (RCGP, so will be considered by accountable officers in Figure 1: Example of JSNA data PRESCRIPTION ONLY MEDICINE/OVER THE COUNTER MEDICINE (POM/OTC)
People in treatment for prescription-only medicines (POM) or over the counter medicines (OTC), and drug users who have a problem with these as wel as il icit drugs are presented below. The drug strategy encourages local areas to ensure their services have the capacity to help people get the support that they need for POM and OTC dependence.
Proportion of
Proportion of
Proportion of treatment
treatment
treatment
population citing POM/OTC
Number of adults
citing POM/OTC use
Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners Responding to local need for co-occurring and emerging mental and physical health problems PreventionThis guide is concerned with the treatment of • Where and when interventions should be problems of dependence that have arisen in people provided. Patients may be uncomfortable sharing prescribed certain medicines or buying them. space with those using il icit drugs and – whether However, commissioners wil also want to consider ultimately this should be accepted or chal enged how problems can be prevented. Primary and – responses need to focus on engaging and secondary healthcare, public health and social care retaining people, which may mean them can together contribute to: providing (and commissioners funding) separate ATM sessions, premises or services.
• Ensuring that psychological and other treatments are available as alternatives to prescribing These specialist responses may be in existing or medicines, including through the Increasing newly-commissioned services that deal with a Access to Psychological Therapies (IAPT) range of drug and alcohol issues or they may be complemented or better provided by separate, dedicated, ATM services and support groups. This • Ensuring that the public and patients are aware is necessarily a local decision in response to local of the problems that can arise with these need, history and context.
medicines, and understand why their availability may be limited in duration or quantity This guide is not intended to provide clinical advice on withdrawal from long-term benzodiazepine • Ensuring that doctors, pharmacists, social care dependence. However, commissioned treatment staf and others are aware of current guidance on wil be based on clinical advice, which you can these medicines and are alert to any developing read more about in the publications listed in ‘further problems in patients reading' below.
• Monitoring and responding to prescribing and Commissioners wil want to ensure that commissioned services include appropriate clinical governance mechanisms to ensure safe Primary care wil be the first port of cal for most and ef ective prescribing of medicines liable to patients dependent on prescription or OTC dependence and for the treatment of dependence, and to prevent and detect diversion of prescription medicines by patients.
If patients are not comfortable returning to the GP who prescribed the medicine on which they have become dependent, they have the right to see Primary care practices can be expected to respond another GP or register with another practice.
to ATM problems as part of their regular patient care, within the terms of the General Medical Services Patients, and sometimes their GPs, may be unaware (GMS) contract.
that there is a problem with a prescription or OTC medicine. ATM outreach services in primary care Specialist responses wil usual y be commissioned practices can help to identify problems and link as part of the drug and alcohol misuse treatment patients to appropriate treatment.
system, from one or more of the fol owing, as local y appropriate: Specialist responses can support and advise GPs to provide treatment and to recognise when a • Primary care (providing an enhanced service) patient needs more specialist care, and can treat • A provider of integrated drug and alcohol patients who cannot be treated in standard primary treatment services care. Commissioners wil need to ensure that those providing specialist responses consider: • A dedicated (often voluntary sector) ATM provider.
• The knowledge and expertise needed to treat It wil also be important to ensure that pain patients, some of whom may have been using management, mental health, and drug and alcohol medicines for many years and may need long- treatment services work together and provide term withdrawal and extensive support, including coordinated and integrated responses to patients.
Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners Voluntary sector responses – which can range from consideration of the extent of dependence and informal support groups to ful y-fledged service harm. London: National Addiction Centre.
provider organisations – may have arisen and been supported in a number of ways, including: Further readingThe has published • From member support and donations • Fundraising and charitable trust funding Commissioners wanting to better understand • Directly commissioned local y: the clinical issues involved in treating addiction to medicines can refer to the fol owing: As part of drug treatment by the NHS or • The contains current advice on appropriate prescribing and on As part of mental health treatment by the NHS or local authority • Funded as part of local authority support for the benzodiazepine and z-drug withdrawal provides voluntary and community sector.
an accessible summary of the evidence base Commissioners contracting with voluntary sector and guidance on best practice for primary care providers wil want to consider and honour between government and the voluntary and community sector so that, for instance, services is principal y concerned are given multi-year funding where possible.
with the treatment of those dependent on il icit A checklist for consideration of addiction to drugs but also covers benzodiazepine misuse medicines in needs assessment is included as • The describes a widely- supported protocol for withdrawal from long-term References and further reading • The publishes a Home Office (2010) – Reducing on clinical and other pain Demand, Restricting Supply, Building Recovery: Supporting People to Live a Free Life. London: Home Office.
A range of guidance covers the use of medicines for insomnia, anxiety, pain, etc that are NTA (2011): an investigation liable to misuse and dependence. into the configuration and commissioning of treatment services to support those who develop problems with prescription-only or over-the-counter medicine. London: National Treatment Agency for Substance Misuse.
NTA (2012) of recovery in communities 2013. London: National Treatment Agency for Substance Misuse.
RCGP (2011) London: Royal Col ege of General Practitioners.
Reed K, Bond A, Witton J, Cornish R, Hickman M & Strang J (2011) The changing use of prescribed benzodiazepines and z-drugs and of over-the-counter codeine-containing products in England: a structured review of published English and international evidence and available data to inform Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners Appendix A. Some medicines liable to misuse or Opioid pain medicines • The proper or generic medicine name is fol owed • Methadone [Physeptone] notes or other names, including those used • Oxycodone [OxyNorm] in medicine combinations, in brackets () • Tramadol [Zydol] example brand names, some no longer available in UK, in square brackets [] • Codeine (with paracetamol = co-codamol) • The list does not distinguish between medicines that are prescription-only or available over- • Dihydrocodeine (with paracetamol = co- the-counter without a prescription (either from dydramol) [Paramol] pharmacies only or from any shop, often only in limited quantities). For more information, see the Epilepsy and pain medicines • Pregabalin (also licensed for anxiety) [Lyrica] • The remit of this guide is restricted to medicines with psychoactive properties, as is this list. Other medicines, such as, for example, laxatives and anabolic steroids, may also be liable to misuse but are not included here.
• Methylphenidate [Ritalin] • A comprehensive list of medicines recorded in • Dexamfetamine the National Drug Treatment Monitoring System is contained in annex 1 of the NTA's 2011 Addiction to medicine report.
• Caf eine [Pro-plus] Benzodiazepines and z-drugs Some cough and cold, anti-diarrhoea, and anti-allergy medicines • Benzodiazepines • Opium tincture [Gee's linctus] • Codeine linctus Diazepam [Valium] • Anhydrous morphine [J.Col is Browne's Mixture] • Kaolin and morphine Lorazepam [Ativan] • Sedative antihistamines such as promethazine Nitrazepam [Mogadon] [Phenergan] and diphenhydramine [Benadryl, Some people also report problems withdrawing from antidepressants (e.g. amitriptyline, fluoxetine [Prozac], paroxetine [Seroxat], venlafaxine [Efexor]), • Z-drugs (although z-drugs dif er chemical y and it is general y best to taper of the dose of from the benzodiazepines, they have the same an antidepressant rather than stop it suddenly. However, there is no clear evidence that these medicines can produce dependence according to Zaleplon [Sonata] international y accepted criteria.
Zolpidem [Stilnoct] Zopiclone [Zimovane] Commissioning treatment for dependence on prescription and over-the-counter medicines: a guide for NHS and local authority commissioners Appendix B. Commissioning for addiction to medicines: needs assessment checklist Range of medicines: • Benzodiazepines and z-drugs – prescribed and • Clinicians (doctors, pharmacists, nurses, etc and il icitly obtained their local groups) • Opioid and some other pain medicines – • Current, potential and past service users prescription, OTC and il icitly obtained • Control ed drugs accountable officers • Stimulants, prescribed for ADHD or slimming• Other OTC medicines Joint work between HWBs and local and national commissioners, specifying their current and desired provision, etc.
• Prescription and OTC medicines as a supplement or alternative to il icit drugs, or as a commodity to sel • Overuse of prescription or OTC medicines to cope with genuine or perceived physical or psychological symptoms • Inadvertently dependent fol owing prescribed use Range of environments:• Community• Hospitals• Secure environments Existing services/responses:• Primary care• Specialist treatment• Voluntary sector support groups and services Data sources:• NHS Prescription Services• JSNA support data from NDTMS• Quarterly (Green) NDTMS reports• Local ATM and primary care services Gateway number: 2013052

Source: http://qna.files.parliament.uk/qna-attachments/454667%5Coriginal%5Cpheatmcommissioningguide.pdf

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GREEN MEDICINE: USING LESSONS FROM TORT LAW AND ENVIRONMENTAL LAW TO HOLD PHARMACEUTICAL MANUFACTURERS AND AUTHORIZED DISTRIBUTORS LIABLE FOR INJURIES CAUSED BY COUNTERFEIT DRUGS Stephanie Feldman Aleong* The majority of the American public would be astonished by the frequency with which counterfeit prescription drugs appear on reputable drugstore shelves. In 2004, the Food and Drug Administration (FDA) noted thatthose who counterfeit prescription drugs "deny ill patients the therapies thatcan alleviate suffering and save lives."1 In 2006, the World HealthOrganization (WHO) estimated that there exists a $30 billion market in fakedrugs.2 Although the FDA has tried to characterize the incidence of

Doi:10.1016/j.jamcollsurg.2006.01.018

Green Tea, the "Asian Paradox,"and Cardiovascular Disease Bauer E Sumpio, MD, PhD, FACS, Alfredo C Cordova, MD, David W Berke-Schlessel, BS, Feng Qin, MD,Quan Hai Chen, MD Archeologic findings have revealed that infusions of 75% to 80%of the 140 million cups of tea consumed leaves from various wild plants, including the tea plant, might have been consumed for more than 500,000