Australia moves to combat the misuse of prescription opioidsBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1345 (Published 28 February 2011) Cite this as: BMJ 2011;342:d1345
Australian authorities are launching an array of initiatives in an effort to prevent the growing problem of the misuse of pharmaceutical drugs from reaching the proportions that now exist in the US.
The country has had a longstanding heroin problem, but hospitalisations for poisoning from prescription opioids have in recent years far exceeded those for heroin, Malcolm Dobbin, senior medical adviser (alcohol and drugs) for the Department of Health in Victoria, told the BMJ.
“We are starting to see rising numbers of hospital admissions, deaths, and pharmacy robberies,” said Dr Dobbin.
Using per capita base supply of oxycodone as a marker, Australia in 2008 was at about the same stage (about 60 kg per million population) as the US in 2000, when deaths from prescription opioids in that country exceeded those from heroin and cocaine, said Dr Dobbin. The gap between the nations has likely narrowed in recent years, he added.
In the US and Australia, the use and misuse of prescription opioids has grown substantially since the introduction of controlled release formulations in the 1990s.
To tackle the problem, the Australian government launched the National Pharmaceutical Drug Misuse Strategy in November, which is scheduled to report later this year. The initiative has momentum since “it has gone through the committee process, the IGDC (Intergovernmental Committee on Drugs) and the MCDS (Ministerial Council on Drug Strategy), so all states and territories and the commonwealth have supported the development of a strategy,” Dr Dobbin said.
Two other reports, one from the Royal Australasian College of Physicians (RACP) in 2009, and one from the Victoria Parliament’s Drug and Crime Prevention Committee in 2007, also highlighted the problems of misuse of prescription drugs.
The second of these reports said that many people did not perceive prescription drug abuse to be a form of drug abuse.
The National Network on Pain Management is also working on guidelines for the country’s 22 000 general practitioners, which it hopes to produce later this year, and in April an advisory committee to the national Pharmaceutical Benefits Scheme is scheduled to meet to discuss restrictions on prescribing opioids for the treatment of severe chronic pain.
Alex Wodak, director of the alcohol and drug service at St Vincent’s Hospital in Sydney, New South Wales, told the BMJ that there is “considerable” discussion about developing a national, web based real time data system for prescription drug monitoring.
But it is the unmet demand for substitution treatment for people who have become dependent on opioids that runs the greatest risk of being neglected, he added. He thought that only about half of those who needed substitution therapy were getting it.
At least six Sydney hospitals are seeing increased medical problems caused by individuals injecting prescription opioids that have been crushed, Matthew Frei, head of clinical services for Turning Point Alcohol and Drug centre, told a recent Melbourne conference. Conditions include endocarditis, abscesses, necrosis and sepsis, and in-hospital treatment is costly, he said.
Experts stress the complexity of the prescription drug misuse, particularly with respect to opioids, because although they are subject to misuse, the drugs can be invaluable for treating pain—particularly acute and malignant pain. “There is both considerable over utilisation and considerable under utilisation of opioids. In terms of numbers, more people may be harmed by under utilisation, but those harmed by over utilisation often die as a result,” says Dr Wodak.
Much of the increase in prescribing of opioids is for chronic non-cancer pain, but Dr Dobbin said there is a lack of good evidence that long term use of opioids is effective for this type of pain. “Never before have so many been prescribed so much opiates for so long,” he said, noting that concerns are emerging about adverse effects associated with this prolonged use, including hypogonadism, osteoporosis, immune suppression, opioid related bowel disorders, and hyperalgesia,” he said. As well, there are risks of overdose, addiction, and diversion to non-patient populations for non-medical use, he added.
The island state of Tasmania has the highest rates of prescribing opioids and benzodiazepines in the country and a rate of opioid related deaths three times that of Queensland, said Adrian Reynolds, clinical director for alcohol and drug services in Tasmania.
In response, Tasmania has taken a lead in developing the first system in the country to give doctors and pharmacists real time access to prescription dispensing information on drugs such as narcotics and benzodiazepines, said Dr Reynolds.
The monitoring system in Tasmania, which cost about $1-million (Aus) to develop, has been “rolled out” to 90% of the pharmacists in the state and, initially, physicians who work in hospitals, he said. Such a system was recommended in the Royal Australasian College of Physicians report and by various coroners’ inquests into prescription drug related deaths in the country.
Reynolds dismissed the argument that privacy legislation is a stumbling block to the introduction of real time prescription monitoring. “I think it is misguided to defer to that excuse . . . indeed duty of care must override such considerations.” Tasmania’s privacy legislation is the same as the national privacy act, he said, and the state had been able to implement the monitoring system.
Dr Reynolds acknowledged that the prescription monitoring system addresses only one aspect of problems with prescription drug misuse. The state is acting on other recommendations from the 2009 RACP report, such as those calling for improved education of health professionals and expanded substitution therapy, he said.
Cite this as: BMJ 2011;342:d1345
Ann Silversides travelled to Australia on a journalism grant from the Canadian Institutes for Health Research