Issue 47 / 7 December 2015

MORE timely data on prescription opioid-related deaths could help to emphasise the urgency of dealing with the problem, which has been displaced on the national agenda by illicit methamphetamine use, says a leading addiction specialist.
Professor Nicholas Lintzeris, clinical professor and addiction medicine specialist at the University of Sydney, acknowledged the devastation that methamphetamines could cause to families, but said these illicit drugs did not result in as many deaths as prescription opioid drugs.
“[Prescription opioid misuse has] been displaced as a priority by the emphasis on methamphetamines, which don’t kill anywhere near as many people as prescription opioid drugs”, he told MJA InSight.
Doctors were currently prescribing opioids without basic systems in place to prevent these deaths from happening, Professor Lintzeris said.
His comments come as Canadian researchers reported on the use of algorithms to streamline access to timely estimates of prescription opioid-related deaths from vital statistics data. (1)
The study authors wrote that the ability to use vital statistics datasets could facilitate national surveillance and monitoring strategies to reduce deaths from prescription opioids that, until now, had been impossible because of incomplete and inaccessible coroners’ data. 
The research, published in the Canadian Medical Association Journal, evaluated five algorithms for sensitivity and specificity in identifying prescription opioid-related deaths in vital statistics data, and found that four had positive predictive values of more than 80% for identifying deaths.
Professor Lintzeris said while Australia’s standardised national coronial system was superior to the Canadian system there were still barriers to accessing data here.
He said identifying prescription opioid-related deaths in coronial records was a cumbersome process that was costly and required ethics approval.
The Canadian algorithm approach, while lacking the sensitivity and specificity of coronial research, was a “ballpark way” of quickly assessing the impact of changes in practice or drug formulation, and would enable regular monitoring, Professor Lintzeris said.
Professor Michael Farrell, director of the National Drug and Alcohol Research Centre (NDARC), said Australia was way ahead of Canada in terms of the level of detail included in coronial reports.
“The Australian [coronial] system is very impressive and the data that we get is very good”, he said. However, there were issues with the timeliness of data drawn from coronial records.
“We are always well behind the curve with coronial data, because we have to wait a year for the data to come in and we’d rather be more up to date.”
Professor Farrell said NDARC was currently tracking about 1500 people taking opioids for chronic, non-malignant pain to get a clearer picture of the issues of concern. He said initial results from the NHMRC-funded study indicated that the majority of people were using opiates appropriately.
“But we separately reported on excess [opioid] deaths in the Australian general population and we are concerned about them”, Professor Farrell said. “We need to be doing everything humanly possible to see that we prevent every death we can.” 
He said prescription opioid-related deaths were a complex issue, particularly due to significantly increased prescription opioid use among older Australians. 
“We have to find the fine balance between seeing that people with pain get appropriate treatment and not badly treating people with pain with drugs that make life more complicated for them. It’s a tightrope-walking exercise.”
Professor Farrell said education initiatives — such as improving doctors’ understanding of chronic pain management — were captured in the National Pharmaceutical Drug Misuse Framework for Action. The framework was introduced in 2012. (2)
However, Professor Lintzeris said the impact of the framework had been underwhelming. 
“We have a national framework, which largely doesn’t seem to be getting implemented by governments across Australia”, he said, citing a lack of resources and government focus on illicit drug use as reasons for the sluggish implementation.
Earlier this year, the Victorian coroner reported that there were more prescription drug deaths in the state than road fatalities and renewed calls for a real-time monitoring system for prescription drugs. (3)
A real-time drug monitoring system (Electronic Recording and Reporting of Controlled Drugs) is in place in Tasmania, and earlier this year the RACGP and AMA joined forces with other peak medicine, pharmacy and consumer bodies to call on federal, state and territory governments to work towards implementing such a scheme as a matter of urgency. (4)
(Photo: Adam Gault/Science Photo Library)
In this week’s Comment section of MJA InSight, Dr Walid Jammal reports on his visit to Tasmania to see how its real-time drug monitoring system is working. 

4 thoughts on “Opioid problem “displaced”

  1. Alex Wood says:

    Judging from my own experience before retirement and my late wife’s experience as a patient, some doctors do not fully comprehend pain with its many facets. To me some seem to believe analgesics and opiates are the mainstay, whereas empathy & understanding, which both take more time & brainpower are possibly more important.

    More education seems required. 

  2. SA Health Library Network says:

    Opiates are not the only drugs for which we should have real time reporting and an online ability to view what is prescribed and also what is dispensed. We especially need to be able to track efficacy, safety and value, particularly of high cost medications to help with the management of complex chronic disease.We doctors are (very reasonably) being asked to help provide high value care and to use drugs wisely, yet we get extremely limited information or feedback from the PBS. In many instances individual patient privacy concerns seem to be valued over safety and certainly over the ultimate funder’s (the taxpayer) reasonable right to know whether we get value for what we spend…..Given that our healthcare is almost completely subsidised by the taxpayer, isn’t it time that systems are developed for the community to get proper reporting around value in care? This would also help stop doctor shopping and many other problems which waste time and resources.

  3. Neil Cullen says:

    Trying to make the medical practitionerthe policeman and prevent chronic pain patients from doctor shopping until they obtain the medication they believe they require is not going to work. There has to be an incentive to rely on a more appropriate non-narcotic analgesic. If my assumption is incorrect please correct me but I suspect that individuals taking recommended dosages of narcotic analgesic probably have impaired response times equivalent to 0.1% alcohol levels. These people should not be driving. The licence should be automatically suspended when the prescription is issued and reinstated when they accept that the medication is no longer required. Taking prescription narcotics should not be an acceptable excuse for avoiding the penalties for driving under the influence of narcotic drugs. This simple legislative change would be a great motivator assisting those medical practitioners who wish to prescribe analgesic responsibly. And if they drive a car without a licence? Apply wheel locks to the car parking it on the front lawn for three months.

  4. Roderick Ryan says:

    As it has been reaffirmed in the latest Government document – “Current evidence does not support the long-term efficacy and safety of opioid therapy for chronic non-cancer pain” – Australian Atlas of Healthcare Variation, chapter 5 –

    Therefore the main part of the solution is for doctors to stop this inappropriate prescribing of deadly medications for which there is no evidence of efficacy.

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