Analysis released this week by the National Drug and Alcohol Research Centre showed that the rate of accidental deaths due to opioids is increasing and has more than doubled among Australians aged 35 to 44 since 2007.
It particularly attracted headlines with the news that more than two thirds of the deaths are due to pharmaceutical opioids rather than heroin.
The analysis follows the release in the United States earlier this month of a report by the National Academies of Sciences, Engineering, and Medicine, in response to a request by the US Food and Drug Administration (FDA) to update the state of the science on pain research, care, and education and to identify actions the FDA and others can take to respond to the opioid epidemic.
The Academies reported that the ongoing opioid crisis in the US “lies at the intersection of two public health challenges: reducing the burden of suffering from pain and containing the rising toll of the harms that can arise from the use of opioid medications.”
In the post below, Dr Bridin Murnion from the University of Sydney, examines the US report and considers its lessons for Australia.
Dr Bridin Murnion writes:
This week the National Drug and Alcohol Research Centre (NDARC) at the University of New South Wales reported on a dramatic increase in death rates in Australia from prescription opioids since 2007.
Both Canada and the United States have been struggling with rapidly escalating harms from prescription opioids for over 20 years. This has now reached epidemic proportions with deaths from prescription opioids outstripping motor vehicle accidents in many US states, and over 2 million Americans suffering from an opioid use disorder. This epidemic is infiltrating groups such as Mormons not often impacted by alcohol or drug abuse.
While typically Australia has been perceived to be lagging behind North America, the NDARC report suggests we are not far enough behind.
How has this situation evolved? Chronic non-cancer pain (CNCP) affects around 1 in 5 Australians. Before the late 1990s opioids did not have data supporting their use as treatment for CNCP, and were reserved for the management of acute pain or cancer pain. Some short term trials in the late 1990s identified some improvement in CNCP. A limited study, often misquoted, reported very limited risks of addiction when using opioids There was then aggressive marketing, particularly of oxycontin.
This has resulted in a quadrupling of the rate of opioid prescribing in Australia. Time and again we see reports showing the rates of harm are correlated to the availability of these medicines in that population, so predictably we now see the harms increasing.
This really highlights the limitations of clinical trials, particularly applying data from short term trials to long term use in the real world setting, often with populations very different to the study population. Pain doctors are increasingly agreeing that function is a more important outcome than pain per se, so pursuing only a pain outcome in a study or in the real world doesn’t help patients recover. Looking at harms in the short term can in no way be representative of longer term harms.
The response to the North American epidemic has not stemmed the tide.
Abuse deterrent formulations that are not crushable have been brought to market, but people still manage to inject these preparations, sometimes with dire consequence, or turn to heroin or fentanyl. Other abuse deterrent preparations contain an opioid antidote, naloxone, that can precipitate withdrawal if injected rather than ingested. Prescription monitoring systems do not have robust evidence of effectiveness.
Purdue Pharma, the manufacturers of oxycontin, have been pursued in class actions, paying $630 million in fines in 2007 to resolve criminal and civil charges related to the drug’s “misbranding”, and recently another $20 million to settle a class-action lawsuit that accused the company of misleading the public about the addictiveness of the drug.
Recommendations from the US report
The FDA requested that the National Academies of Sciences, Engineering and Medicine compile a report on the status of ”science on pain research, care, and education” and “identify actions the FDA and others can take to respond to the opioid epidemic”. The report, which was released on July 13, recognises the challenges of alleviating the suffering of chronic pain, while not increasing the harms from prescription opioids.
Its recommendations form a multi-faceted approach, and include:
- enhanced research in pain and addiction
- increased post-marketing surveillance of opioids by the FDA to more accurately identify harms
- FDA consideration of public health impact of opioids in future regulatory decisions
- access to multi-disciplinary pain treatment
- improved access to addictions treatment
- education for prescribers to improve prescribing
- consumer education to modify expectations of pain management
- harm reduction strategies:
- peer-administered naloxone as a lifesaving antidote for opioid poisoning (opioid users are given an injectable antidote to opioids, similar to an “Epipen”, and trained in its use and CPR)
- needle syringe exchange programs to reduce transmission of blood borne viruses such as Hepatitis C and HIV.
A glaring omission in the report is preventing the development of chronic pain. As with other developed world epidemic health problems, the importance of maintaining a healthy weight and activity cannot be over-emphasised.
Lessons for Australia
Parallels with the US are evident in the Australian health care system where remuneration in primary care favours prescribing over complex bio-psychosocial assessment and treatment, and access to specialist addiction and multi-disciplinary pain services is limited. Workplace responses to injury and CNCP may not facilitate return to work and may even reinforce disability.
Educational interventions have been developed in Australia and some are available for free. For example, the Agency for Clinical Innovation’s Pain Management Network has resources for both health care practitioners and consumers. The ANZCA Faculty of Pain Medicine’s Better Pain Management is a modular online resource for health professionals. A number of peak bodies have developed guidelines and policy statements on opioid use in CNCP.
Australia is a world leader in the provision of needle syringe exchange programs, and peer administered naloxone is increasingly available. However regulatory processes around opioid prescribing vary state by state, may not be robust, and require a consistent approach and adequate resourcing. Prescription monitoring systems similarly vary, and a cohesive, funded approach is needed.
At a Commonwealth level, the Pharmaceutical Benefits Advisory Committee, Therapeutic Goods Administration and their subcommittees need to consider inclusion of potential and real public health implications in registration and scheduling of currently available and newly marketed opioids.
The opioid harm and death tally is one competition in which we don’t want to get high marks, and there is still opportunity to turn the tide. For this, educated prescribers and consumers with access to evidenced based treatments and adequate regulatory support are needed.
Dr Bridin Murnion is Clinical Senior Lecturer, Discipline of Addiction Medicine, Faculty of Medicine, University of Sydney. She is a Fellow of the Royal Australian College of Physicians, a Fellow of the Faculty of Pain Medicine and a Fellow of the Chapter of Addiction Medicine.