Drug misuse and abuse remain a serious issue in this country. In 2006, there were 4.6 drug-induced deaths per 100,000 people (excluding deaths related to drug use in a surgical procedure and those exclusively due to alcohol). This figure increased significantly to 7.5 per 100,000 people in 2016 which equates to 1,808 lives.
The majority of drug-induced deaths (71.3%) were noted to be accidental overdoses. Suicides came in second (22.7%) with the remainder made up of chronic complications of drug abuse and addiction, homicides, and undetermined intent. Contrary to popular opinion, prescription drugs are actually responsible for more drug-induced deaths in Australia than illicit substances. According to the Australian Bureau of Statistics, the most likely profile of a person succumbing to a drug-induced death in 2016 is a middle-aged male, living outside of a capital city, who is misusing prescription medications in a polypharmacy setting.
For over 20 years, opioids have been the drug class most commonly implicated in drug-induced deaths. While opioids include licit and illicit substances, prescription opioids appeared in the toxicology reports of 41.9% of drug-induced deaths in 2016 compared to 20% for heroin. Some caution does need to be applied when interpreting statistics for heroin-related deaths as heroin is rapidly metabolised to monoacetylmorphine and then morphine. Identification of monoacetylmorphine is indicative of heroin use, while the identification of just morphine at death would lead to a coding for “other opioid.”
Polypharmacy is a significant issue with 59% of all acute drug deaths involving more than one substance. When a single agent is implicated, benzodiazepines have consistently been the most common drug class. Benzodiazepines are also commonly taken with other drugs including alcohol which increases their toxicity. Other significant classes of prescription medication involved in these deaths are antidepressants and antipsychotics, as well as paracetamol.
Drug-related deaths in Australia
In addition to the 1,808 drug-induced deaths, 2016 saw a further 1,387 lives lost to drug-related causes. Drug-related deaths can be divided into external causes (72.6%) and natural disease drug-related deaths (27.4%). The most common cause of external drug-related deaths is suicide, followed by transport accidents, assaults, drownings, and falls. Natural drug-related deaths were predominantly made up of circulatory disease, cancers, respiratory diseases, and digestive system diseases. The contribution of transport accidents and assaults to these statistics really highlights the significance of drug misuse as a community-wide issue.
Strategies to curb drug misuse
While these figures are concerning, they may just be the tip of the iceberg. The incidence of non-fatal overdose events from prescription opioids may be up to 11 times higher than the rate of fatal overdoses. These sobering statistics should give all healthcare professionals reason to pause. While much has been done at a national level to tackle drug misuse, including the up-scheduling of codeine earlier this year and investment in the development of a real-time prescription monitoring system, much can also be done at a local level.
Opioids beyond discharge
A recent retrospective cohort study demonstrates that the duration of opioid usage in the postoperative period is more strongly associated with ultimate misuse than the dosage used. In this study, each prescription refill was associated with a 44% adjusted increase in the rate of misuse. As surgical patients are more likely to be discharged with opioids than non-surgical patients, improved medication management in this population could significantly reduce opioid misuse. If opioids are to be supplied for discharge, the cease date or date for review should be clearly communicated to the patient’s general practitioner along with a discharge analgesic plan.
Patients’ own medications in hospital
A recent Coroner’s inquest has highlighted the issue of returning patient’s own medications (POMs) at discharge as a significant area of concern. Patients are encouraged to bring POMs with them when presenting to hospital. This assists healthcare professionals when undertaking a best possible medication history (BPMH) and supports accurate medication reconciliation. These medications may then be administered to the patient during their inpatient stay. This helps to minimise dispensing costs, reduces the risk of the patient having duplicated medications upon discharge, allows the patient to continue using the brands they are familiar with, and prevents any delays in the provision of medications not routinely stocked in the hospital. However, there are a number of issues that must be considered before choosing to administer a POM, including:
- The medication must have been prescribed for that patient;
- The medication must be identifiable from the original packaging or the name and strength visible on the foil strip;
- Medications not contained within the original packaging (e.g. in a dose administration aid, pill box, or a mixed supply in a bottle) must not be administered to the patient;
- Where applicable, the dispensing label should be legible and state the supplier details, patient name, quantity dispensed, date dispensed, and drug name, form, strength, and dose;
- If the dose instructions have changed, the medication should be re-labelled by the pharmacy;
- The medication must be within the expiry date printed on the pack. Items with specific storage instructions (e.g. refrigerated items, or medications with shortened expiry dates once opened) should only be used if they have been stored if no expiry date is visible, the medication should not be used;
- The packaging must be in good condition with no signs of damage or contamination;
- If the patient is part of a clinical trial conducted at another institution, the principal investigator must be notified of the patient’s hospitalisation. If treatment is to continue, the patient’s own supply of clinical trial medication must be used; and
- All POMs must be stored appropriately on the ward e.g. all scheduled medicines must be stored securely, Schedule 8 and Schedule 4 recordable items must be stored in the relevant safe, and refrigerated items kept refrigerated.
Returning patients’ own medications
A review of POMs must occur prior to discharge to ensure that only clinically appropriate medications are returned to the patient. Patients should always be encouraged to leave their ceased or expired medication at the hospital for safe disposal by the pharmacy department. Excessive quantities of a continuing medication may also be grounds for concern.
To ensure compliance with the National Safety and Quality Health Service Standards (NSQHSS), particularly Standard 2 (Partnering with Consumers) and Standard 4 (Medication Safety), patients should be actively involved in the decision to leave POMs at the hospital. Educating patients is crucial so that they are empowered to make safe and appropriate decisions regarding their health care. However, it is important to remember that POMs remain the property of the patient. Therefore, consent must be obtained from the patient or carer before any POM is confiscated for destruction. If the patient does not consent to the destruction of an inappropriate medication, it should be returned to the patient with the label crossed out, dated, and marked as ceased. These patients should then be encouraged to present their redundant medications to their local community pharmacy for destruction under the national return unwanted medicines (RUM) project.
While returning clinically inappropriate POMs to a patient always carries a risk, there are situations where this risk is heightened. Schedule 8 medications are of particular concern due to their high potential for abuse, misuse, and dependence. These drugs include opioids such as morphine, oxycodone, and codeine, medications commonly implicated in drug-induced deaths and non-fatal overdose events. In addition, there are patient groups at greater risk including those with diminished decision-making capacity, cognitive impairment, and a history of intentional self-poisoning. If these patients do not consent to the destruction of a POM that has been deemed inappropriate, the issue should be escalated to a suitably qualified medical officer. The ensuing risk assessment should focus on the decision-making capacity of the patient and, where appropriate, the risk of self-harm. It may be necessary to consider treating the patient under the relevant state or territory mental health acts or guardianship acts.
Individuals and health care professionals concerned about drug misuse and abuse are encouraged to call the National Alcohol and Other Drug hotline for free and confidential support, information, and counselling. This hotline can also refer callers to appropriate services available in their state or territory.
- Australian Bureau of Statistics. Drug Induced Deaths in Australia: A changing story. Belconnen: Australian Bureau of Statistics; 2018.
- Brat GA, Agniel D, Beam A, Yorkgitis B, Bicket M, Homer M, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018; 360: j5790.
- Government of South Australia. Patients’ Own Medications Policy Guideline. Version 1.1. Adelaide: SA Health; 2018.
- NSW Government. Safety Notice 008/18: Return of Patients’ Own Medications. Sydney: NSW Health; 2018.