Application of Guidelines

1.

This set of guidelines applies to the use of opioids, such as methadone (Physeptone), dipipanone (Wellconal), fentanyl (Durogesic, Fentanyl) and benzodiazepines, such as diazepam (Diazemuls, Valium), triazolam (Halcion), flunitrazepam (Rohypnol), midazolam (Dormicum), and other psychoactive agents, such as phentermine (Duromine), ketamine (Ketalar), with known potential for abuse.
(Note: Medical practitioners should be alert to the updating of classification of drugs which will then come within the application of these guidelines.)

2.

These guidelines reflect currently accepted professional standards on the use of such agents in the local context, and are intended to provide general guidance to medical practitioners for the promotion of good clinical practice.

3.

The Practice Directions under Section (E) should be followed. Breach of these directions may be construed as improper use of dangerous drugs.

1.

The medical practitioner should be familiar with updated knowledge and guidelines on the use of dangerous drugs.

2.

The medical practitioner should abstain from prescribing at the sole request of the patient any psychoactive drug that is not medically justified by his/her condition.

3.

Psychoactive drugs with potential for abuse should be prescribed with due caution in order to avoid abuse and/or iatrogenic dependence.

4.

Such drugs should only be prescribed after proper clinical assessment and diagnosis.

5.

These drugs should be prescribed only in the dose and for the duration as necessary for the clinical condition being treated.

6.

Simultaneous use of multiple psychoactive agents should be properly assessed and justified. Justification should be clearly documented.

7.

The prescription, dispensing and/or administration of such drugs should be carefully organized so as to avoid stock piling, resale or other inappropriate use by the patient.

8.

An adequate and proper medical record should always be kept concerning the treatment provided to the patient.

9.

Special clinical problems deserve expert advice. Appropriate referral to specialists or programmes should always be considered.

10.

All medical practitioners should comply with all the provisions in the Dangerous Drugs Ordinance and Regulations

Doctors who use opioids or other psychoactive agents for the management of patients dependent on such drugs should ensure the following:

1.

They should have relevant training or experience in the management of drug dependence.

2.

They should keep themselves updated with relevant guidelines/information published by appropriate professional bodies e.g. "Advisory Committee on the Use of Psychoactive Agents" of the Hong Kong Medical Association.

3.

Adequate resources and support are made available to provide a comprehensive care, including physical, psychological, and social aspects, for their patients.

4.

Patients dependent on psychoactive agents should be ensured attentive and conscientious care by the attending medical practitioner. Medical practitioners must know their limitations.

5.

In every case, the attending doctor should assess the patient thoroughly, formulate a suitable management plan, keep an adequate medical record concerning the treatment provided to the patient and monitor the outcome.

High-Volume Consumption

Significant social harm can be caused by abuse of psychoactive drugs supplied by medical practitioners or the inadvertent flow of such drugs into the "black market". These are especially prone to occur, when such drugs are used in large quantities on out-patient basis in non-programme settings. To fulfil our social obligation and to avoid disrepute to our profession, the following measures are considered essential for all medical practitioners regularly prescribing large quantities of psychoactive agents:

1.

The use of psychoactive agents should be reviewed regularly to ensure that their use meets the standards as stipulated in sections B and C. In every case, the use or continued use of such drugs should be adequately accounted for. These drugs should be withdrawn appropriately wherever their use is considered ineffective, inappropriate, or unnecessary.

2.

Careful measures should be taken to guard against abuse of psychoactive drugs so supplied. Examples of such measures may include:

a.

regular follow-up assessment, preferably monthly. Exceptions with appropriate justification could be allowed.

b.

minimize the quantity of drugs dispensed per visit, bearing in mind that the practitioner has the responsibility to decide the proper medication with appropriate duration. The duration should not exceed a month although exceptions with appropriate justification could be allowed.

c.

detail record of justification and prescription.

d.

direct supervision of drug-taking where possible.

e.

random urine checking (for opioid dependence). Abuse.

f.

notification to Central Registry of Drug

g.

other measures as appropriate, e.g. referral to appropriate specialists (e.g. to pain clinic for patients in chronic pain), regular checking of unfinished drugs.

3.

If a medical practitioner is not satisfied with the measures he has taken in relation to D.1 and D.2, he should seek advice and assistance from the Advisory Committee on the Use of Psychoactive Agents of the Hong Kong Medical Association. Continued use of large quantities of psychoactive agents cannot be accepted as proper medical practice, unless reasonable measures have been taken against possible abuse.

Practice Directions for Selected Agents

The following Practice Directions for selected agents should be followed.

1.

Practice Directions for use of benzodiazepines

a.

Initial assessment of the patient should include: i. proper history and examination; ii. appropriate investigation; iii. proper diagnosis and/or diagnostic formulation; iv. education and counselling.

b.

Patients on benzodiazepines should be informed of the following:

i.

Drugs are only part of the management plan;

ii.

Drug dependence is likely to occur with improper use;

iii.

Various adverse effects, which include impairment of the performance of skilled tasks and driving;

iv.

Interactions with drugs and alcohol are potentially dangerous.

c.

The lowest effective dose which can control the symptoms should be used.

d.

In general, initial prescription and/or dispensing of benzodiazepines should be kept to the minimum appropriate dosage and duration.

e.

For repeated and/prolonged prescription, there should be a clearly documented management plan.

f.

If the duration of initial treatment is likely to be prolonged, the patient should be properly reassessed periodically. Alternative methods of therapy, if any, may be offered. In case of clinical problems which cannot be adequately dealt with, expert advice should be sought, or patients be referred to appropriate specialists or programmes.

g.

Benzodiazepines should be prescribed with caution especially to patients under 18 and the elderly in which cases the prescribing doctor should fully justify the use. Such justification should be documented.

h.

Caution should be exercised in the use of benzodiazepines in the treatment of major depression.

i.

Caution should be exercised in prescribing benzodiazepines for patients where there is a history or evidence of substance abuse (particularly alcohol or sedative-hypnotic drugs).

j.

Caution should be exercised in the use of benzodiazepines for bereavement-related problems. A tapering-off regime should be used to minimize benzodiazepine withdrawal symptoms.

k.

Simultaneous use of multiple benzodiazepines should be prescribed with caution and its justification should be documented.

l.

An adequate and proper medical record should be kept concerning the treatment provided to the patient.

m.

In addition the medical practitioner shall comply with all the provisions in the Dangerous Drugs Ordinance and Regulations.

2.

Practice Directions on the use of substitute drugs for opioid dependence

a.

Initial assessment of the patient should include:

i.

proper history and examination; ii. appropriate investigation;

iii.

proper diagnosis and/diagnostic formulation;

iv.

education and counselling;

v.

promotion of detoxification programmes.

b.

The medical practitioner should inform patients of other treatment modalities available in the community before putting them on long-term maintenance therapy.

c.

Treatment of opioid dependence should be prescribed only after accurate diagnosis. There should be a proper documented management plan given to the patient and accordingly recorded. In the management plan for the use of substitute drugs for opioid dependence, holistic care is important and success of therapy is highly dependent on the trust between the physician and the patient.

d.

The attending doctor should ensure that he/she is fully competent to provide proper care of patients under his/her care. Specific training in the management of drug dependence is strongly encouraged for all doctors involved in such work.

e.

The patient should be informed that drugs are only part of the management plan, and should be put in touch with available support for proper social and psychological management.

f.

The patient should be warned of risks of concurrent heroin/drug use. He should be informed of the need for random urine checking.

g.

The prescription, dispensing and/or administration of substitute drugs should be organized in such a way as to avoid stock piling by the patient, resale or other illicit usage. The minimum amount of such substitute drugs as necessary should be supplied.

h.

The patient should be regularly monitored, and an adequate and proper medical record should be kept concerning the treatment given to the patient.

i.

Simultaneous use of other psychoactive agents should be justified and used with caution. Clear documentation is required.

j.

In addition the medical practitioner shall comply with all the provisions in the Dangerous Drugs Ordinance and Regulations.