With independent public policy thinktank Australia21 publishing a landmark report Monday calling for a complete overhaul in the nation’s approach to illicit drugs, Professor Dan Lubman and Christian Smyth argue that the current system is broken.
In this piece for Croakey coinciding with the Australia21 release, Lubman and Smyth from Turning Point and Monash University warn that fatal overdoses in Victoria now exceed the number of road deaths and this is just the tip of the iceberg.
Professor Dan Lubman and Christian Smyth write:
Australia’s record on drug-related overdose deaths makes for uncomfortable reading – 88.1 per million of population, compared to 44.6 per million in the UK, 10.2 per million in the Netherlands and 3 per million in Portugal. There has also been a 61% increase in the number of accidental overdose deaths from 2004 to 2014.
Australians aged 40-49 are the most likely to die, with prescription medication being responsible for more overdoses (69%) than illicit drugs. Indeed, over the period 2008-2014, there has been an 87% increase in prescription opioid deaths.
So when we think of drug overdoses, we have to move away from the stereotype of the inner-city, alleyway heroin user, maybe destitute and probably young, and we have to wake up to the fact that in Victoria, overdose deaths now exceed the number of road deaths.
Policy crisis
Victoria has a looming crisis in pharmacotherapy policy. Governance is unchecked and there is a disproportionate balance of opioid management in the hands of a diminishing number of GPs.
All patients on opioid maintenance therapy for addiction have to have a permit before the doctor starts prescribing and there are about 13,500 active permits, with limited review once approved. There are no limits on dosages prescribed or the number of patients allowed in a single prescriber’s caseload, meaning that there are a small number of prescribers who hold hundreds of permits, and others that prescribe well above current clinical guidelines.
This is a system that would not be tolerated in other areas of health.
Victoria has rested on a tired assumption that its system is superior by pointing out that states like NSW have long waiting lists for opioid maintenance treatment and that Victoria’s system is cost effective and normalises treatment of opioid addiction.
The reality is that after decades of underfunding addiction training and specialist support for doctors, the majority of GPs feel unskilled in this area of medicine, and hence are reluctant to get involved, meaning that Victoria has few GPs and pharmacists who are able to manage the number of Victorians needing opiate pharmacotherapy.
Community concern
Last year there were 172 heroin-related overdose deaths in Victoria, many of which occurred in the City of Yarra, concentrated around North Richmond and Collingwood. This has led to a high degree of community concern, with a growing coalition of residents, health professionals, business associations and local government calling for the introduction of a supervised injecting facility to reduce deaths.
Similarly, community concern about public injecting and overdose in the Footscray area has been growing in recent years, whilst both local media and community health organisations continue to raise concerns about a paucity of drug services throughout the western suburbs more broadly.
In 2001, the Sydney Medically Supervised Injecting Centre (MSIC) commenced operation on a trial basis. Operating within a clinical model, the Centre’s primary objective was to reduce the morbidity and mortality associated with drug overdose. Staff included nurses who were authorised to administer naloxone.
In 2010, the New South Wales Government announced it would continue funding the MSIC on an ongoing basis after three comprehensive evaluations which were positive and broadly comparable with evaluation results of other similar supervised injecting drug facilities, mostly located in European cities. Among other things, the MSIC had treated a substantial number of overdoses that would otherwise have occurred in public places and without medical support, thereby increasing the risks to drug users and others.
The challenge for the major political parties is to reverse fifty years of ‘tough on drugs’ policy and to implement strategies that work.
The reality is that people are dying and families and the wider community, especially in North Richmond, are calling for solutions. And things could soon get much worse.
Tip of the iceberg
In New York State, where real time prescribing has been operating since they introduced the Internet System for Tracking Over-Prescribing (I-STOP) in 2012, heroin overdoses have increased by 25%.
Last week, New York’s Mayor Bill de Blasio announced that all 23,000 city patrol officers would be given naloxone to use on overdose victims, and that it would be available through pharmacies without prescription. He vowed to spend $38 million a year on a broad array of services, including expanding methadone and buprenorphine treatment for addicts, focusing on city hospitals on dealing with addiction and overdoses, and a more aggressive prosecution of illicit opioid distributors and heroin dealers.
Victoria will implement its own real time prescribing system within the next 2 years, and the experts are saying that New York’s experience is likely to be followed here in Melbourne. So what we are seeing now is just the tip of the iceberg.
The number of trainees and qualified addiction specialists in Victoria is low, due to a longstanding lack of investment in training and specialist positions. New South Wales, by way of contrast, has almost 10 times the numbers of addiction doctors in training, as well as a number of funded specialist positions within each health service.
The lack of a career pathway for doctors interested in pursuing a career in addiction means that Victoria is facing a future without such expertise, with an exodus of specialists to funded positions interstate in recent years, and many of the remaining cohort of addiction specialists nearing retirement.
Victoria needs to wake up to this crisis before the opioid bubble bursts.
Professor Dan Lubman and Christian Smyth are from Turning Point and Monash University
Some further thoughts on changing the conversation on addiction…
There’s a lot of talk about harm reduction at the moment, with many debating how we can do it better. It’s a tough balancing act trying to implement programs that the community feel comfortable with, that will also genuinely help people struggling with alcohol, drug or gambling problems.
The opportunity to reduce harm can extend beyond clinical practices and programs of addiction treatment. We can reduce harm to people being affected by addiction, by changing the conversation, reducing stigma and letting people know what support is available to them.
To be clear we are not calling for people or organisations to glamorise addictive behaviours, but for the discussion to be more mindful and compassionate of people who are vulnerable.
The imagery and language long associated with addiction has reinforced a stereotype, focusing on the criminal or degenerate image of addiction. People are portrayed as dark and dangerous and there is usually an emphasis on the moral failing of those addicted, regardless of what they are addicted to.
This stereotype is harmful as for some it may prevent people from accessing help, a 2016 study from the University of Western Australia found that ‘the biggest barriers to methamphetamine users seeking treatment are embarrassment or stigma, belief that help is not needed, preferring to withdraw without help and privacy concerns”.
If we can reduce stigma and make people aware of the confidential service available to them, hopefully we can reduce the harm.
Even when there is reporting or promotional health messages that are focused on prevention, they still seem to follow the degenerate rhetoric, rather than focusing on services available or the opportunity to turn lives around.
When creating these messages or articles it would be helpful to give some consideration to how it may affect people in recovery. People who are working hard to change their lives can be particularly vulnerable to triggers especially when including photos of something they are trying to stay away from.
Rapper 360 last year spoke about the government’s anti-ice ads in the SMH. As someone who has openly spoken about being in recovery, he was particularly critical of the government including images of drug paraphernalia in the ads saying “they have zero idea that simply showing a picture of a pipe will have every addict itching”.
Addiction is affecting people beyond the fringes of society, it is touching people in every region and community across this country.
A further difficulty of negative portrayal of addiction is that it not only affects the individual themselves, it also affects the community around them. Family and friends of those struggling with addiction often express that they also feel heavily stigmatised and responsible for the addictive behaviour.
At Turning Point we are seeing increasing numbers of concerned families and friends accessing our services, and there are many more communities we could help, if they knew about the services available to them and felt that they could reach out for help.
In 2016 our Breakthrough program, for family and friends being affected by ice addiction, delivered assistance to over 1500 concerned family members across Victoria, through more than 80 sessions in multiple locations around the state. This is a program that covers one state, for one drug and is really just getting started, if more people were aware of the programs available to them the whole community could be better served..
Talking about life beyond addiction is critical to supporting those seeking treatment and their families and there are examples out there such as http://www.Livesofsubstance.org that show how to provide support for people who consider themselves to have an alcohol or other drug addiction and helps them deal with stigma.
Mental health used to be a heavily stigmatised topic, often with overtly negative representation. Reporting and public health messaging relating to mental health is now handled with much more sensitivity. Trigger warnings, signposting to services, expert advice and accurate and respectful language are a normal part of the conversation now. We should do the same with addiction and we could start by adding signposting to http://www.counsellingonline.org.au, a national support service for anyone concerned about alcohol or other drugs, at the end of all alcohol advertising.
There are lots of different views about next steps in harm reduction and we understand that this is a complex policy area, but while we debate the merits of needle and syringe programs, supervised injecting centres or pill testing we know people and their families are experiencing real trauma and need help now. If one thing we can do is reduce harm to people being affected by addiction by changing the conversation, reducing stigma and letting people know what support is available to them, surely this is something we can all agree on?
If you or someone you care about is concerned about their alcohol, drug use or gambling, confidential help is available 24/7 at:
http://www.gamblinghelponline.org.au http://www.counsellingonline.org.au
Christian Smyth and Cassandra Jovic, Monash University and Turning Point
Many people rely on prescription drugs for pain management. We’ve done a qual study ‘Attitudes Towards Opioids Among Patients Prescribed Medication in Victoria’ (at
http://www.move.org.au/Research/Opioid-Study ) which examines the attitudes of patients on opioids long term. This was part funded by the Victorian Government, to get a better handle on the patient side of prescription drugs before implementing the real time monitoring system.
There are clearly too many opioids prescribed in Australia, with the second highest rate of increase in the developed world (we’ve done a handy infographic at http://www.move.org.au/Research/Useful-Links/Statistics/Stats-Opioids-Use.aspx )
As pointed out by Lubman and Smyth, prescription drug use and misuse is highly damaging, and we need better access to pain management services, as well as addiction services. Self management resources are key for living well with pain.
The New York experience is sobering. We will step up our efforts making sure patients are better informed of their options when the prescription monitoring system is introduced.
Ben Harris
MOVE muscle, bone & joint health
http://www.move.org.au