Guidelines for the good practice of medical doctors when prescribing addictive drugs
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Physicians must always use the Prescription Medicines Register when prescribing and reviewing patients' medication. Prescriptions that have not been dispensed must be reviewed and voided if applicable. This applies to all medicines, but especially addictive drugs. See the regulation on prescriptions and delivery of medicines, no. 740/2020 (Icelandic). If an addictive drug is available for dispensing, it is not permitted to prescribe the same medication unless the existing prescription is invalidated. The prescribing physician in each case is responsible for ensuring that this is done.
Violations of the rules on the prescription of addictive drugs may result in the restriction of authorisation to prescribe certain medicinal products or categories of medicinal products. Repeated or serious violations may result in the revocation of a license to practice in accordance with the Medical Director of Health and Public Health Act.
About the prescription of addictive drugs
All addictive drugs are administered by the physician, not by the patient. The physician decides which drug is used and gives instructions about its use. For example, the Patients' Rights Act does not give patients the right to choose medicine or require a physician to prescribe certain drugs or dosages. The physician critically assesses, based on the best knowledge, which drugs an individual needs and in what doses and regularly reviews medication use. A physician is, therefore, obliged to refuse prescriptions that they consider to conflict with good medical practice.
Prescriptions of high-risk medicinal products should be in the hands of the treating physician or consultation with the physician. Particularly in the case of addictive drugs, where a patient has received higher doses than stipulated - or drugs that should not be used concurrently.
Medical students with temporary licenses are not authorised to prescribe drugs subject to control. They may not prescribe addictive drugs unless in consultation with a physician, provided that the physician has a valid medical license. Doctors responsible for medical students with temporary licenses must enforce these rules.
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Addictive drugs should only be prescribed or renewed after a discussion between the physician and the patient and when there is a clear plan on the duration of treatment (when to stop taking drugs) and the dosage. Indications and duration of treatment are discussed in the special drug register.
Information on prescriptions shall be entered in medical records, cf. Article 6 in Health Records Act, no. 55/2009. The extension of short-term treatment and the increase in the dose of addictive drugs shall always be recorded in the medical records.
A good therapeutic relationship between the physician and the patient is very important during treatment with addictive drugs. Physicians should meet the patient regularly to assess the effectiveness of the medication. This applies especially when long-term drug treatment is needed.
The following issues must be considered:
Potential adverse reactions, such as life-threatening sedative effects, as well as the risk of drug dependence, shall be discussed and explained to patients. Patients should also be warned about driving under the influence of addictive drugs.
Physicians should not prescribe addictive drugs to patients who do not belong to their practice.
If individuals are on higher doses of addictive drugs than the physician considers appropriate, a treatment plan or treatment agreement should be made with the patient aimed at either restoring doses to normal or completing medication. Good guidelines on safe prescriptions and tapering have been published.
Doctors should always prescribe addictive drugs for as short a period as possible. The physician may prescribe a smaller quantity of medicine than the smallest available package. It is permitted in a pharmacy to break packages and deliver parts of them, but then only according to the specific instructions. Physicians are encouraged to use this authority whenever they deem it appropriate.
Alcohol, even in moderate amounts, can increase the effects of sedatives, creating a dangerous situation. This must be explained to the patient.
Addictive drugs are generally not desirable for dosage or multiple dispensing. For example, sleeping pills and sedatives are not intended for long-term use. It can also be dangerous to have addictive painkillers in dosage for a long time. Treatment with this type of drug requires close monitoring of its effectiveness.
All medications require a physician to have an overview of individuals in dosage and that other doctors' prescriptions are checked.
If a patient is admitted to a medical facility, care must be taken to ensure that in-patient drug treatment does not add up to the patient's dosage or total volume. Upon admission and discharge, the physician shall familiarise himself with the patient's medication history.
If a patient who is being treated with addictive drugs does not show up repeatedly for the scheduled appointment, the treatment must be reviewed.
Doctors should avoid prescribing addictive drugs to themselves, their friends, and members of the family. All prescriptions must be entered in the medical record of the person in question.
The physician who prescribes medicine must be familiar with their effects and side effects. Patients must be informed of possible effects on their ability to drive vehicles, and it must be recorded in the medical record that this has been done. The physician shall urge patients to follow the rules in all respects.
Suppose a patient shows signs of being at risk from the use of addictive drugs (e.g. falls, respiratory depression, impaired consciousness, risky driving, or drug-related traffic accidents) or shows signs of dangerous use of the drugs (use of excessive doses, use beyond medical guidelines, concurrent drug use). In that case, the benefits of the medication probably do not justify the patient's risks of continued use. In such cases, the physician should not renew medication for continued unchanged use but should inform the patient of possible withdrawal symptoms and ways to manage them and even refer to addiction treatment if appropriate.
If a patient is likely to experience withdrawal symptoms, a physician should help them by tapering the medication.
Before starting treatment with addictive drugs, non-medical measures should be evaluated. Treatment is carried out in collaboration with the patient, but the doctor directs it.
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The patient is abnormally preoccupied with discussing certain medications with the physician, which takes up considerable time during the doctor's visit.
The patient repeatedly requests the renewal of the prescription before the scheduled renewal time or increases the dose themself without any evidence that the condition has worsened.
The patient claims to have lost medication, vomited medication, or been robbed of the medicinal products.
When a patient consults several doctors, even with different indications, to obtain similar drugs.
When multiple prescriptions for the same drug are dispensed.
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A good review of medical treatment for pain can be found in Handbók í lyflæknisfræði (Ari J. Jóhannesson et al., University Press, 2015) where, among other things, the pain rating scale is discussed and which drugs should be chosen at each stage.
Suppose a doctor is to take over prescriptions for painkillers from another doctor. In that case, they must get the original indication from the doctor who initiated the administration of the medication and instructions on when to re-evaluate the indication and use of the drug. The doctor who takes over the prescriptions must be given time to evaluate the medication and have the opportunity to communicate with the doctor who started the medical treatment.
Doses of opioids in the treatment of acute pain should be based on the lowest possible dose and only for a short time (< 5 days). Do not prescribe more.
Long-term treatment with opioids for chronic pain is undesirable and results in tolerance, addiction, and severe side effects. Likewise, long-term pain treatment with opioids rarely improves patients' long-term pain experience. Long-term use of opioids can even promote hyperalgesia.
Concurrent treatment of opioids and benzodiazepines is dangerous.
The same doctor should administer all the patient's pain medication.
Special care should be taken when more than one opioid is used concurrently.
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Diagnosis and treatment of ADHD are the roles of specialists in mental health (see clinical guidelines - Icelandic). If the follow-up is transferred to the general practitioner, it shall be done in consultation and with his consent. General practitioners are encouraged to seek advice from the prescribing psychiatrist or consult with psychiatrists in mental health teams.
In the instructions for using a long-acting form of methylphenidate, it should be mentioned that the medicine should not be taken later in the day than at noon if the daily dose needs to be split in two.
Concomitant use of benzodiazepines, Z-drugs, opioids, or pregabalin is unfortunate due to antagonism to stimulants.
If sleep problems occur after the prescription of stimulants, reducing the dose or moving the intake earlier in the day should be considered rather than adding a sleeping pill. It is possible to consider giving medication before going to bed that does not lead to addiction or dependence.
Before a doctor applies for a drug certificate to prescribe stimulants for ADHD, the prescriptions of other addictive drugs must be examined and assessed if there is a reason to revise those prescriptions before prescribing stimulants. In adults, this is especially true for sedatives.
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Research shows that both pregabalin and gabapentin are addictive, and the special medication register warns against abuse. It is believed that the abuse of these drugs is mainly based on the fact that they are concurrent with other addictive drugs and thus increase intoxication. This should be kept in mind when prescribing these drugs.
As with the prescription of other addictive drugs, doctors must check whether other doctors have also prescribed the drugs.
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Key points to keep in mind when prescribing benzodiazepines and Z-hypnotics:
The use of other drugs, which do not entail the risk of addiction and dependence, or other remedies should be considered before deciding to prescribe benzodiazepines and related drugs.
Sleeping pills and sedatives should always be used in the lowest possible doses and usually no longer than 2-4 weeks at a time; tolerance will develop if this is not considered, and the effectiveness of the drugs will wane, among other things, due to the development of tolerance.
Sleeping pills with the shortest half-life should be chosen, i.e. Z-sleeping pills.
Sleeping pills and sedatives are especially dangerous in older people, as they often cause drowsiness and increase the risk of falls. Large doses should be avoided, especially for older people.
Benzodiazepines can be a beneficial short-term treatment for anxiety.
With long-term use of benzodiazepines, their usefulness decreases, but the risk of dependence and addiction increases.
Patients who have taken sleeping pills in the evening should be instructed not to take sleeping pills again if they wake up during the night. They should wait until the following evening.
For individuals who feel anxious and have sleep problems, it may be enough to prescribe one benzodiazepine, such as oxazepam 10 mg in the evening. It can reduce anxiety during the day and improve sleep at night.
Concomitant use of many benzodiazepines and related drugs
Prescribing more than one drug in the group of benzodiazepines/Z-hypnotics for concomitant use should be avoided because their clinical activity is almost the same.
Tapering of benzodiazepines
When it has been decided to stop the use of benzodiazepines after long-term use, it is necessary to gradually taper the drugs over a sufficiently long period, sometimes months. Stopping too quickly can cause rebound anxiety or insomnia. It should be borne in mind that benzodiazepine withdrawal can cause seizures and delirium and be life-threatening. There is no need to taper off if treatment has lasted less than two weeks.
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Medicines containing testosterone should not be prescribed without regular hormonal tests. Diagnosing hypogonadism is complex and should be performed by a specialist in endocrine diseases. Therefore, it is inappropriate for anyone other than endocrinologists to start this treatment.
At least two tests that are low in testosterone or free of testosterone are required to initiate medical therapy.
There are many contraindications to testosterone drug therapy that a doctor must consider.
In some instances, lifestyle changes are recommended rather than medication.
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The guidelines were first issued on March 16, 2017, by the Directorate of Health. The following took part in the revision of these guidelines, which were published in June 2023.
Martin Ingi Sigurðsson, professor and chief physician in anesthesiology and intensive care medicine, Landspítali
Jón Steinar Jónsson, chief physician, Development Center for Icelandic Health Care.
Ólafur B. Einarsson project manager, Directorate of Health.
Björn Blöndal, general practioner, Heilsugæslan Efra-Breiðholti.
Linda Kristjánsdóttir, general practioner, Heilsugæslan Urðarhvarfi.
Aðalsteinn Guðmundsson, internist and geriatrician, Landspítali.
Sigurður Örn Hektorsson addiction psychiatrist, chief physician, Directorate of Health.
