What to do about opioids

Opioids have caused immeasurable harm the world over.

Pushed by pharmaceutical companies, prescribed by doctors and taken by patients needing pain relief, opioid drugs have ensnared countless people in the traps of addiction – none more so than in the United States and Canada, where opioid deaths have soared in waves over three successive decades.

In 2016, the Australian Institute of Health and Welfare reported legal or pharmaceutical opioids (including codeine and oxycodone) are responsible for far more deaths and poisoning hospitalisations than illegal opioids (such as heroin). Every day in Australia, nearly 150 hospitalisations and 14 emergency department (ED) presentations involve opioid harm, and three people die from drug-induced deaths involving opioid use.

Australia has introduced a raft of policy changes to restrict the supply of opioid medications and reduce harm, but finds itself in a precarious position: possibly on a different path to that of North America, but still teetering on the edge of an escalating opioid addiction problem.

In Australia, opioid deaths are increasing and experts say countless pain patients are unable to access proper treatment for ‘opioid use disorder’ – a physiological and a psychological dependence on prescription opioids – let alone their chronic pain, which could be managed in other ways, if non-pharmacological pain treatments were affordable.

The rise of opioids in Australia

Even though Australia has, for a variety of reasons, so far avoided the worst of the opioid epidemic seen elsewhere, official data paints a bleak picture.

Deaths involving opioids have nearly doubled in the decade to 2016 in Australia, with fatal overdoses from strong prescription pain medicines, such as codeine and oxycodone, outstripping those from illicit opioids, such as heroin.

And according to research published in 2021 and commissioned by the Therapeutic Good Administration (Australia’s drug regulator), only half of surveyed opioid users felt they were using opioids safely. One third reported they were dependent on their opioid medication.

In response to the problem, the TGA introduced a suite of policy changes to restrict what pharmaceutical opioids can be supplied for, starting with codeine – which since 2018 has been a prescription-only medicine.

Smaller pack sizes also now limit the amount of prescription opioids supplied at any one time, while fentanyl, one of the strongest opioids available, is recommended only for the treatment of severe pain and in palliative care.

Real-time prescription drug monitoring programs have also been implemented across most states of Australia. These electronic systems capture a patient’s prescription history, so doctors can make safer, informed clinical decisions about appropriate care.   

Monash Addiction Research Centre pharmacist Professor Suzanne Nielsen says while it’s still too early to see the impact of those programs, policy makers need to be vigilant in monitoring the downstream effects, to make sure programs are reducing harms as intended and without mistreating people who need pain relief.

“We’re actually at a fairly sensitive point in time in terms of actually seeing what impact those changes have, but also making sure that we don’t overshoot the mark,” says Nielsen.

In the US, restricting opioid prescriptions has pushed some people to seek out illicit drugs, most recently illegally manufactured fentanyl, when they were abruptly cut-off from their usual supply of prescription pain killers.

Algorithms developed to trawl state-based prescription monitoring databases and alert doctors to risky or improper opioid use are also allegedly causing unnecessary harm to patients who legitimately need pain relief.

It’s feared the same might happen in Australia. Nielsen says ‘supply shocks’ resulting from more cautious prescribing practices could precipitate the emergence of illicit fentanyl in the Australian drug market.

“We don’t really know why we haven’t seen fentanyl emerge in Australia – and we don’t know that it won’t,” says Nielsen, which makes it difficult to know which harm reduction strategies policy makers should invest in and roll out. Nielsen’s own research shows expanding the distribution of naloxone, a drug that rapidly reverses opioid overdoses, is one cost-effective option.

Dr Hester Wilson, an addiction medicine specialist and GP, says her peers have welcomed the recent regulatory changes including prescription drug monitoring programs.

But she too urges caution.

“I am concerned that what we’ll see is a pendulum swing which goes too far, so that people who do need opioids are unable to access them,” Wilson says. “We really want a middle course that uses opioids appropriately for acute, severe conditions and tends not to use them for chronic pain.”

Accessing pain relief, and support

Even before the first mandatory, real-time prescription drug monitoring program was introduced in Victoria in 2020, people with chronic pain were finding it challenging to access opioid pain relief. One Australian study found that in 2018, one-third of chronic pain patients had difficulties obtaining opioid prescriptions or had their opioid medicines cut back.

Wilson says people with opioid addictions are also having to wait up to two years to access opioid replacement therapies such as methadone that reduce opioid use and deaths, in part because of a dire shortage of accredited prescribers that only gets worse in rural and regional areas.

“There are places where people who want it can’t access care because the care just isn’t there,” she says.

The issue, at its core, is about funding: for specialist addiction services that are stretched thin and to enable GPs to upskill to become accredited prescribers, Wilson says.

Some experts estimate that the capacity of drug treatment services needs to double to meet current needs. But finding willing practitioners is a hard ask when so many doctors are on the brink of burnout, Wilson says.

The stigma around opioid use disorders also complicates matters, as it can take a long time, years even, for chronic pain patients to accept they need treatment to manage their opioid use, Wilson says.

Fear their pain will relapse is one factor behind why so many people put treatment off. Attending a clinic for daily dosing is another barrier to treatment on top of the cost, especially for chronic pain patients who often have limited mobility and may struggle to maintain work.

“Overnight, they’ve seemingly stopped being a genuine pain patient with significant health issues who can access medicines through the PBS [Pharmaceutical Benefits Scheme] just like anyone else, to being part of this stigmatised group who are drug-seekers, who have to go to a drug and alcohol service to access treatment,” Wilson says.

Treating addiction saves lives

Many younger doctors are also reluctant to prescribe opioid replacement therapies, fearing that those treatments are risky to supply, Wilson adds. Yet she finds the work incredibly rewarding, and plenty of evidence shows treating opioid addiction saves lives.

“What we see is that people do incredibly well in this treatment; [they] get their lives back on track, get back to work, and reconnect with their families.”

However, the true scope of Australia’s opioid problem remains unclear, Wilson says, because the prevalence of opioid use disorder is still a big unknown.  Not only does the stigma around misuse of prescription opioids deter people from seeking care, but also consequently, from reporting they have a problem.

Wilson says modelling suggests there could be between 100,000 to 250,000 people addicted to opioids in Australia, “but we just don’t know.” Around 50,000 people are accessing treatment around the country, she adds, which means “at least half of people who need treatment are not accessing it.”

As it is, Australia’s health system is struggling to respond to the increasing number of patients who shoulder complex chronic pain together with mental health and addiction conditions. Mental illness and mood disorders such as depression are terribly common amongst people with opioid use disorder, creating a vortex of overlapping health problems for people with chronic pain.

Nielsen and Wilson both say doctors are cognisant of the addictive potential of prescription opioids, given the gobsmacking scale of the opioid crisis in North America, but that few patients can afford to access other types of pain treatment.

Counselling and physical therapy are prohibitively expensive compared to government-subsidised pain medications. And while a combination of strategies including better access to multidisciplinary pain clinics is sorely needed, the lack of affordable treatment options leaves doctors hamstrung in what support they can offer patients.

“What we don’t necessarily have is a system that allows people to access effective alternatives,” Nielsen says. “We need to go a lot further to make it realistic for people to access other kinds of pain treatment.”