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2010 APSAD Conference
Fentanyl abuse in Queensland
Identification of emerging pharmaceutical
drug misuse
Bill Loveday, Abhilash Dev, Rebecca Thompson,
& Dr Sue Ballantyne
Drugs of Dependence Unit
Email:[email protected]
Overview
Fentanyl- cause for concern
Precribing trends in Queensland
Fentanyl misuse- issues & solutions
Conclusion
What is fentanyl?
 A synthetic primary opioid agonist and potent narcotic
analgesic with rapid onset and short duration.
 Clinical setting = fentanyl administered via injection,
gaseous form, nasally or in a lozenge.
 Transdermal patches used to provide consistent, slow
release administration of opioid analgesic for period of
48 to 72 hours.
Why use fentanyl?

Typically indicated for management of persistent,
moderate to severe chronic pain among opioid
tolerant patients

who require continuous, around-the-clock opioid
administration for an extended period of time, and
cannot be managed by other means such as
nonsteroidal analgesics, opioid combination products,
immediate-release opioids
Potency, availability & misuse issues
 Approximately 80 - 100 times more potent than morphine.
 100mcg/hr fentanyl approximately equivalent to 10mg of morphine
and 75mg of pethidine.

The matrix patches contain higher quantities of fentanyl to achieve
the same delivery rate (60–70% more than the reservoir patches)
 August 2006 = Australian Pharmaceutical Benefits Scheme (PBS)
listing for fentanyl patches amended to include chronic non-cancer
pain.
 Result = reduced cost and increased prescribing for non cancer
type pain management.
 High potential for misuse and diversion due to a higher volume of
fentanyl used in the matrix patches.
 Misuse and diversion of used patches which have a high dose of
left over fentanyl (Dumpster diving)
Misuse of fentanyl
 Abusers are distilling fentanyl from patches for IDU.
 Distillate used to ‘boost’ other illicit substances.
 Distillate crystallised to resemble ‘rock’.
 Smoking associated fentanyl derivatives.
 Chewing & ingestion of patches.
 Placement of multiple patches on the body.
 Non-medical use by individuals with no opioid tolerance
is extremely dangerous.
What makes fentanyl appealing to illicit drug
users?

Purity of product = more ‘bang’ for buck

Rapid take-up = immediate euphoria / ‘high’.

A belief that pharmaceuticals are ‘safer’ than street drugs.

Negative opiate screen.
What makes fentanyl appealing to
prescribers?
 Marketing - pharmaceutical companies advertise slow release
transdermal patches as safe, user friendly and effective.
 Transdermal patch technology allows continued analgesia for opioid
tolerant patients
 Fentanyl is the fastest acting opiate available; particularly applicable
when used for break through pain.
 Fentanyl patches can be effective in treating neuropathic pain.
 Patches are useful when oral opioids cannot be used because of
vomiting, difficulty swallowing or inability to administer via IV.
 Fentanyl can be used in severe renal impairment situations
when other opioids are inappropriate. It is metabolised in the liver
and does not have active metabolites.
Concerns around fentanyl use

Fentanyl carries a high risk of dependence and misuse

Can result in fatal and non fatal overdoses due to narrow
therapeutic/toxic window

Deaths related to fentanyl has significantly increased in USA and
Canada over the years ( Wong et.al (2010) , Martin et.al (2006))

Emergency Department presentations for fentanyl have increased
over the years in USA (DAWN, 2008)

There have been 8661 accidental opioid overdose deaths in
Australia between 1988 and 2004 (Degenhardt et.al (2006))
OA Prescriptions in USA – 1998-2007
8.0
oxycodoneER
7.0
fentanyl
6.0
morphine
methadone
5.0
TRx(millions)
hydromorphone
4.0
3.0
2.0
1.0
0.0
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Years
 327% increase in fentanyl prescriptions since 1998
Fentanyl related ED presentations, USA, 1995-2008
DAWN Emergency Department Presentations for Fentanyl
25,000
20,000
15,000
Fentanyl
10,000
5,000
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
0
 3403% increase in ED presentations related to fentanyl since 2000
Fentanyl person and script count, QLD, 1999-2009
120000
100000
80000
Persons
Scripts
60000
40000
20000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
 A three-fold increase in fentanyl prescriptions since 2005/2006.
Fentanyl prescribing by age group, QLD, 1999-2009
Script Count by Age Category
0 to 9
25000
10 to 19
20 to 29
20000
30 to 39
15000
40 to 49
50 to 59
10000
60 to 69
70 to 79
5000
80 to 89
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
90 to 99
100+
 A rapid escalation in prescribing fentanyl patches for an older
age group with a variety of non-cancer or chronic pain issues.
Fentanyl prescribing by gender, QLD, 1999-2009
Count of Persons and Scripts By Gender
70000
60000
50000
Persons MALE
Persons FEMALE
Scripts MALE
Scripts FEMALE
40000
30000
20000
10000
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
0
 It was evident that from 2006, more females than males were
being prescribed fentanyl patches.
Fentanyl prescriptions per person (AVG), QLD, 1999-2009
Scripts per Person
8
7
6
5
Scripts/person
4
3
2
1
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
 In Queensland, the number of prescriptions per person per
year continues to steadily increase.
OTP patients obtaining fentanyl, QLD, 2000-09
Count of Fentanyl Prescriptions for Program Patients
20 -29 yrs
600
500
400
40-49 yrs
300
50-59 yrs
200
60-69 yrs
100
70-79 yrs
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
30-39 yrs
80-89 yrs
 In Queensland, fentanyl is actively being sought and obtained by
individuals with prior or current OTP registrations.
Note the reverse trend where a younger age group is seeking
fentanyl…not necessarily for therapeutic purposes.
The Queensland Story began when…
 DDU became aware of an increasing number of individuals
on the Sunshine Coast presenting at hospital ED’s with
apparent fentanyl overdose.
 QAS subsequently reported an increase in call outs to
narcotic overdoses where the patient’s presented with
extreme respiratory depression and reduced response to
naloxone.
and then…
 March 2010 police (QPS) advised DDU of two IDU
deaths in the Bayside area where misuse of
pharmaceutical drugs were suspected.
 Initially, police thought the deceased had injected
contents of ‘morphine patches’ – suspected to be
fentanyl
 Princess Alexandra Hospital ED reported increase in
narcotic overdoses with severe respiratory depression –
at least 2 more fatalities.
 Some aged care facilities in the Greater Brisbane and
Gold Coast area, reported persons ‘dumpster diving’ for
used fentanyl patches.
Fentanyl Scripts per Person (AVG) by Region, QLD, 1999-2009
Fentanyl Scripts per Person by Region
8
scripts/person
7
6
Statewide
5
4
3
Brisbane
Gold Coast
2
1
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
0
 7.4 scripts/person for Sunshine Coast in 2009
Sunshine
Coast
Fentanyl Scripts per OTP Person (AVG), QLD, 2005-09
Fentanyl Scripts per Program Person by Region
12
scripts/person
10
Statewide
Brisbane
8
Gold Coast
6
Sunshine Coast
4
OTP_SW
2
OTP_SC
0
2005
2006
2007
2008
2009
 The OTP patients in the Sunshine Coast region were on an
average getting more scripts per person compared to State wide
trend AND…
OTP patients on an average getting more scripts per person
compared to non OTP patients
Proportion of OTP Clients dispensed fentanyl by Region, QLD,
2005-09
Program clients dispensed fentanyl by region
35.0%
30.0%
25.0%
Brisbane
20.0%
Gold Coast
15.0%
Sunshine Coast
Linear (Sunshine Coast)
10.0%
5.0%
0.0%
2005
2006
2007
2008
2009
 30% OF THE OTP patients seeking fentanyl in QLD
were from the Sunshine Coast Region
Observations
 Persons living in the Sunshine Coast region getting on an
average more scripts/per person for fentanyl in comparison
to neighbouring regions
 Increase in fentanyl scripts for OTP patients in the
Sunshine Coast region since 2007 (higher than State wide
average)
 Nearly 30% of OTP patients who were dispensed fentanyl
were in the Sunshine Coast region ( Sunshine Coast region
usually makes up 11% of the OTP population)
What we did
 Fentanyl alert cards for NSPs
 Review of fentanyl scripts to identify
any concerns
 Official correspondence sent to
doctors prescribing fentanyl in the
Sunshine Coast area advising on the
situation
 Research and analysis of population
trends relating to fentanyl
prescriptions
Prescription Drug Misuse: Issues
 Illicit drug use transcending to opportunistic
prescription drug misuse
 Doctor/prescription shopping
 Diversion to illicit markets
 Iatrogenic (doctor caused) dependence
 Overdose and death
 Injecting Related Injury and Disease (IRID)
 Chronic pain and addiction management
 Legal and professional responsibilty of GPs
Solutions
 Improved Pain Management practice (alternative pathways, multidisciplinary approaches) to decrease prescription drug use
 Real Time Reporting between prescriber, pharmacist and regulatory
body and dedicated prescription information service (e.g. DDU 24/7
enquiry service)
 Improving co-ordination between GPs, pharmacists, specialists, and
pain & addiction management services
 Preventing drug overdose and other drug use related injuries (better
education & access to support networks), e.g. fentanyl alert, overdose
and vein care resources
 Partnership and information sharing between treatment provider,
regulatory and enforcement bodies to prevent misuse and diversion
 Increased accountability and ownership from pharmaceutical
companies through responsible marketing and better research and
funding initiatives focussing on dependency and misuse linked to
pharmaceutical drugs.
Conclusion

Prescription drug misuse is increasing and National Public Health
surveillance systems similar to Drug Abuse Warning Network
(DAWN) and Researched Abuse Diversion and Addiction- Related
Surveillance (RADARS) system will be useful.

National surveys like the National Drug Strategy and Household
Survey (NDSHS), National Survey for Mental Health and Wellbeing
(NSMHWB) and other drug surveys need to focus more on
prescription drug misuse.

Nation wide real time reporting system that is consistent across all
state and territories to be set up to prevent diversion and to improve
patient management

Multi-pronged approach to tackle prescription drug misuse through
partnership between public and private clinicians and allied health
professionals involved in treatment and rehabilitation with regulatory
and enforcement bodies to ensure ongoing sustainable long term
solutions to prescription drug misuse issues.
Drugs of Dependence Unit
Locked Bag 21
Fortitude Valley BC
QLD 4006
Tel: 07 3328 9890
Fax: 07 3328 9821
Email: [email protected]