The rise of prescription opioids and the promise of medical cannabis
The 2019 Turning Point Oration event focused on the clinical and policy implications of rising prescription medication harms and responses.
Professor Nick Lintzeris delivered the 2019 Turning Point Oration, following the annual Turning Point Symposium which featured national leaders in pharmacy (A/Prof Suzi Nielsen), pain medicine (Dr Malcolm Hogg) and primary care (Dr Dean Membrey). This year’s event focused on the clinical and policy implications of rising prescription medication harms and responses, and was delivered to an audience of 150 clinicians, researchers and policymakers at Turning Point’s headquarters in Richmond. The event included a live twitter feed, there were 150 tweets and retweets using #TPOration and at one point we were trending at number 7 in Australia.
This year’s Orator, Professor Lintzeris, a Turning Point alumnus with more than 20 years experience as an Addiction Medicine specialist, discussed changing trends in prescribing practices related to opioid-related medications, premised on the idea that public policies and regulations had moved in a binary fashion between periods of total ‘phobia’ (e.g., the 1980s) and total acceptability (e.g., the 1990s and 2000s following aggressive marketing by pharmaceutical companies, the establishment of a ‘pain industry’, and a reluctance to acknowledge the risk of addiction).
‘First do no harm’
— Turning Point (@TurningPointAU) December 4, 2019
Opioids have an important place in medicine, however Prof Lintzeris highlighted the challenge of ensuring that prescribing practices and regulation are appropriately calibrated to ensure that patients receive effective and safe care. A/Prof Suzi Nielsen in the Symposium’s opening address provided a critique of how policy responses had failed clinical practice, particularly in North America. Prolific prescribing of these medications has led to an opiate crisis in the US, with more than 130 deaths per day. This public health tragedy has been exacerbated by regulatory changes which have led to deprescribing of opiate medications for pain, an increased reliance on illicit markets and substitution with alternative psychoactive medications by clinicians which bring their own harms
‘Houston we have a problem’
Traditional opioid replacement therapies weren’t designed for working with people with prescription opioid use — it’s hard to sell someone on going to the pharmacy every day when they’re used to getting a whole week or month of opioids for $6. #TPOration— Turning Point (@TurningPointAU) December 4, 2019
A/Prof Suzi Nielsen and Professor Lintzeris detailed the many responses to the opioid crisis that have been trialled in Australia and abroad including: regulatory responses (e.g., re-scheduling, re-formulation of preparations, monitoring systems), and changes in clinical practice (training and education in the transition from acute to chronic use). These changes have met with various levels of success and often involved high levels of expense. Other responses trialled, including holistic treatment teams (e.g., inclusion of psychosocial considerations and multidisciplinary teams), and the provision of take-home naloxone, have demonstrated higher efficacy, and are cheaper to roll out yet haven’t had as broad appeal in the policy space.
To successfully respond to the opioid crisis, Professor Lintzeris identified a series of structural issues that need to be addressed including greater access to health care for socially disadvantaged groups given they suffer the greatest harm, and greater engagement with primary care. This was highlighted in Dr Membrey’s talk in which he discussed the isolation that GPs face as they often manage complex patients alone, the structural barriers to providing opiate substitution treatment in primary care, and the challenges in managing patient expectations around the provision of medication with those of the broader health sector. Dr Hogg discussed the background, development, and complexities of SafeScript, the new Victorian state-wide prescription monitoring system that is being rolled out to assist GPs and pharmacists to make safer clinical decisions, and the challenge of providing a variety of treatment options in a system that is underprepared.
Prof Nick Lintzeris acknowledges the important role of clinical trials, particularly in bringing launches of groundbreaking treatments to Australia. #TPOration— Turning Point (@TurningPointAU) December 4, 2019
An important take-home message from this year’s Oration was directed towards the field of medicine as a whole. Firstly, it is important to recognise that there are no silver bullets to managing patients with complex needs, despite the promise of new medications. As we’ve seen before with the transition from barbiturates to benzodiazepines, and opiates to the new safer formulations, early excitement and overprescribing is often followed by unexpected harms, and the promise of medical cannabis is no exception. Secondly, rather than operating in a siloed manner as has been done in the past, we need to work in a much more multidisciplinary manner when tackling issues of mental health, pain, addiction and related harms, and ensure that there is close integration with primary care.