Where are we going with pharmaceutical opioids?

At the 2017 Turning Point symposium Jeremy Dwyer, Senior Case Investigator at the Coroner’s Court Victoria argued that we need more evidence to inform policy for RTPM implementation. With the looming shadow of the United States’ prescription opioid crisis, opinion leaders are concerned we may follow the same trajectory. Will Australia’s adoption of real time prescription monitoring simply turn off the tap and drive the problem underground, leading to a surge in heroin use?

Dr Matthew Frei, Turning Point’s clinical director talks about Australia’s perfect climate for the opioid crisis.

‘Australia is fortunate to have a universal health insurance system envied by the rest of the world. Non indigenous Australians expect to live and work longer than previous generations. We assume we will not suffer untreated chronic illness and pain. We can source a second opinion and treatment plan from a GP at any time. A wide range of the newest opioid analgesic formulations are affordable and accessible. ‘

However, Dr Frei notes that our Medicare system may have had unforeseen negative consequences: ‘Unfortunately, this model often mitigates against continuity of care and even supports “shopping” for the desired medical opinion and treatments. This climate has been ideal for the development of Australia’s opioid misuse problem’.

Other factors have also contributed to opioid problems in Australia. Dr Frei believes that addiction medicine services have been neglected by health departments over the past 2 decades. GPs managing substance use are isolated, and have limited opportunities for early intervention. Evidence-supported treatment options for opioid addiction—methadone and buprenorphine maintenance—are expensive for patients and remain underutilised in our fee-for-service medical system.

‘We can go some way to reduce risk in prescribing opioids, such as screening for a history of mental illness and substance use and identifying aberrance’, says Dr Frei, ‘However, there are some clinical thinking processes that are missed, such as whether we should be prescribing opioids at all, particularly long term and in high doses, in the management of persisting non cancer pain’.

Dr Frei highlights the lack of studies of the benefit of opioids in the treatment of conditions such as spine pain, fibromyalgia or chronic headache, conditions for which opioids are often prescribed. ‘There’s limited evidence for benefit beyond a few weeks and growing evidence for dose-related problems with longer term therapy’. In addition to opioid related constipation, hormonal disturbances, and mood and cognitive disorders, Dr Frei is worried about neurological sequelae of opioid use: ‘Opioid-induced hyperalgesia, where there is an increased sensitivity to pain, is very difficult to manage’.

The central nervous system reward and pleasure that opioids deliver can lead to repeated use and dose increments. ‘This is the foundation for opioid use disorder or addiction which we know is associated behavioural changes and, sometimes, tragic outcomes, such as toxic overdose and collapse,’ notes Dr Frei. ‘As Tom Frieden (the former Director of Centers for Disease Control and Prevention (CDC)) said, “There are few treatments with so little evidence of effectiveness that kill so many people.”’

Given this clinical evidence, the reaction to plans for national and jurisdictional real time monitoring of opioid and other drug prescriptions has been largely positive. However, given the North American experience, some senior clinicians are concerned about the “downstream” effects of increased visibility of people misusing prescription drugs. In New York State, where real time prescription monitoring has been operating since they introduced the Internet System for Tracking Over-Prescribing (I-STOP) in 2012, heroin overdoses have increased by 25%.

Earlier in 2017, New York’s Mayor Bill de Blassio 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.

Some experts are concerned that the New York experience may be replicated in some Australian cities given that, so far, we have tracked quite closely the disastrous public health journey of the North Americans. ‘Like the US, we have had increased uptake of opioids in Australia into the first decade or so of the 21^st century and have similarly responded by regulating, educating, changing formulations and most recently, building real time monitoring systems. It is a reasonable expectation that this may go the same way as seen in New York and other cities, with a boom in heroin availability and use’.

Given the potential for real time monitoring to increase demands on treatment services, investment in an addiction medical specialist workforce is now a priority. Addiction medicine and psychiatry trainee numbers disproportionately low in Victoria and those qualified addiction specialists retiring from the workforce are not being replaced with new graduating Fellows. New South Wales has almost 10 times as many addiction doctors in training as Victoria. Some Sydney area health networks have more staff specialist positions than are funded in the entire state of Victoria. (Several NSW addiction services are led by Victorian doctors who fled north some years ago). We must ensure Victoria has a robust career pathway for addiction doctors, or we will find ourselves in a crisis when the opioid bubble inevitably bursts.