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Fixing the prescription opioid problem is simple, but not easy…

This article greeted my tragically decaffeinated gaze this morning as I fired up the computer at work. You’d have to be concerned about a senior drug and alcohol clinician like Alex Wodak saying something like ‘We’ve got a hell of a problem’ with prescription painkillers. Especially when that respected clinician writes for this very website!

As with all medical stories patients ask me about, I thought I’d find the actual source of the reporting. Turns out it was this report from the National Drug and Alcohol Research Centre (NDARC). This is a collation of the deaths in Australia related to opioid overdose over the last few years. It is worth looking hard at the methodology behind such reports, as they are not subject to the same peer review process as journal articles.

Before getting to the conclusions, my usual process is to check whether I even believe the assumptions the researcher has made. If some of them are a stretch, have they acknowledged this? Looking at this report, I see that there are some significant assumptions, and that there is a whole section, entitled ‘Notes on Findings’ with just such a discussion. So far, so good. The notes point out that there have been some changes in the way that overdose deaths are recorded, and that this may mean that between some states and some years, we may not be comparing apples with apples. Leaving these reservations aside, is it possible to get a better feel for the scope of the problem? Are we on the way to a public health disaster like the US?

I have to say I’m concerned about the rate of opioid-related deaths in Australia. But perhaps not as worried as I am about the road toll. The number of deaths from transport accidents in 2011 was 1,291, which represented a fall of 4.4 percent from 2010, and a full third of the total from a much smaller population in the early 1970s. This compares to 551 for opioid-related deaths in 2008, with projected rates of 612 for 2009 and 705 in 2010 awaiting formal confirmation. This also includes a fair chunk of deaths from heroin overdose, at rates that have been stable at a lowish level since the heroin drought of 2001 began.

The highest rate of deaths due to opioid overdose was during the late 1990s from heroin overdoses. Those peak rates were around double the number of deaths that we currently are recording, and are still well below the States where opioid overdoses rank just behind motor vehicle crashes as a cause of death in young and middle-aged adults. The US has around 14 times the population of Australia (311 million vs 22 million) but it has 60 times the number of overdose deaths (37,000 vs 612 in 2009).

So what do we have going in our favour? Stricter advertising and sales controls on prescription drugs for a start. More lenient marijuana and alcohol laws for another, though this is just my speculation.

On the other hand we have thousands of GPs who feel poorly equipped to know how to prescribe these drugs appropriately. We have minimal enforcement of opioid regulations except against those who are already using them legally. We have a lack of community awareness that the right to pain relief needs to be coupled with the responsibility of being an informed and disciplined consumer. We also have a real lack of awareness of the long-term health penalties that go with medium or high-dose opioid use, even for therapeutic purposes.

We have a resounding absence of leadership federally on the issue of centralized monitoring of opioid scripts and who is writing them. Despite much fanfare when announced the $5 million Electronic Recording and Reporting of Controlled Drugs system remains a spectral presence, the merest phantasm of a useful product. Such systems have been shown to be effective at reducing aberrant prescribing while not affecting legitimate pain patients, but it seems that even this basic and comparatively cheap measure is beyond our health bureaucrats to implement. It was supposed to begin in July, but it’s now October and we still don’t have any news about a rollout…

So while I don’t expect this very complex and nuanced problem to be fixed any time soon, it helps to know that we’re not as bad as some news columnists would have you believe. The solutions that will reduce the availability of trafficked prescription opioids are not overly complicated. They do however some money to be spent in an area where there is no real electoral payoff. They also require a culture change in education of health professionals and the community to provide accurate and nonjudgmental information about the potential benefits and harms of medium or long-term use of opioid anagesics.

Addicts, abusers and the anxious will always tend to prefer opioids because of the effects they can have on their brains. Some will demand them to treat pain even when they aren’t helping because they have been raised to believe that there should be a pill for every ill. Most people, in my experience, have a healthy attitude to painkillers. They want them to work when they take them, and they want to be off them when they aren’t necessary anymore. For the minority who can’t control their intake of prescription opioids, the answer is in having GPs who understand these drugs and prescribe them according to best practice, backed up by pharmacists who have the training and electronic capability to monitor their supply and spot those gaming the system for criminal purposes. Penalties for prescription drug trafficking should be harsher than for illicit drugs, to ensure that it becomes a high-risk decision for those better-organized criminal types looking for an easy buck. Potentially unpopular legislation is therefore part of the regulatory solution to the problem.

Simple, isn’t it?

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