Two ABC documentaries – ‘Opioid America’, Foreign Correspondent, 19th March and on TV Tonight, Louis Theroux, April 2nd portrayed the cycle of addiction in damaged US communities with no hope or future. Both were in West Virginia where opioid deaths are 2 to 3 times higher than other US states. The people and their environments are forever written off. Alarm bells ring.
The narratives centred on the company manufacturing and promoting opioid analgesics (OxyContin) and making huge profits. Unscrupulous doctors and pharmacists, the agents of distribution, were condemned as well. This is the supply side of the US opioid epidemic. Less evident in the narratives was the idea that – opioid addiction, alcohol and other addictions and suicides – are responses to despair and hopelessness. The demand side of the equation.
Opioid-related deaths in United States are of an order twice that of Australia with the synthetic opioid, fentanyl, the highest. Life expectancy is declining as white males die increasingly from overdoses. And as the US celebrates current low unemployment rates, little regard is given to the non-participation rate, the work drop outs. Opioid addiction makes a significant contribution to the low participation in the workforce. US emergency departments and outpatient clinics report high levels of pain medications with an increasing proportion of opioids and the potent opioid – fentanyl.
In an environment in which harm minimization has such little traction and treatment options are rudimentary, and access to effective treatment, compared with Australia, Canada, UK and Europe, is poor, the US flounders in its attempts to tackle these problems.
These are warning signs for Australia. But there are differences which can moderate the impact here.
Problems in health and social systems
Primary health care (general practice) is the gatekeeper for health care in Australia. It is underpinned by universal health insurance and strong public health services and hospitals. Whereas access to health care in the US is poor. And health outcomes are at the bottom end of middle-to-high income countries whereas Australia’s outcomes are at the top end.
The gatekeeper, primary health care, is poorly linked to specialist services in the US. It is possible to directly access specialists and by-pass the usual referral pathways seen in other countries. In Florida, for example, a state hard-hit by the opioid epidemic, patients are able to attend “pain specialists”. These ‘pill-mills’ are lucrative businesses for doctors, clinics and pharmacies commonly pre-prescribing or dispensing opiates outside legitimate medical purposes.
A recent New York Times article by David Hart comparing US health care to other countries, said,
“….all of them ….coverage is universal, where life spans are longer, where working people are not made destitute by serious illnesses, where a choice between food or pharmaceuticals need never be made, where the poor cannot be denied treatments by insurance adjusters, where pre-existing health conditions could never be denied coverage, where most people have far more savings and much lower levels of debt than is the case here, where very few families live only a pay check away from total poverty, where wages generally keep pace with inflation, where every worker has decent vacation time each year, where suicide and opioid addiction are not the default lifestyle of the working poor, where homeless is exceedingly rare, where retirement care is humane and comprehensive and where the schools are immeasurably better than ours are.”
The relationship between prescribed opioids and the opioid epidemic is a conundrum. Few people prescribed opioid analgesics ever progress to heroin or unsanctioned drug use. Progression to addiction in patients prescribed opioids for pain is of the order of 6 to 8%. Whereas, the majority of heroin and other illicit drug (e.g. fentanyl) users in the US, started their addiction with medical opioids – prescribed, off the street, from the ‘dark web’ or through the black market.
Another conundrum is that opioid deaths were increasing at the same time as drug prescriptions were falling in the US; a sign the epidemic is more than a problem of reckless prescribing.
US drug companies can advertise and promote drugs directly to the general population. Purdue Pharma and other companies have strongly promoted opioid analgesics to the general population and to physicians. This behaviour has led to many different class actions.
The main treatment approach in the US is coercive abstinence, but this is commonly associated with relapse. Opioid substitution treatment, more widely available in Australia and Europe, UK and Canada, struggles to gain a foothold in the US, despite the pioneering of methadone substitution for heroin in New York in 1965. Naloxone used to reverse opioid overdoses is less available in the US compared with Australia.
Twenty percent of US prison inmates are there because of opioid problems and yet there is poor access to treatment within the prison system. Indeed, community physicians face ethical dilemmas making transitional arrangements when their patients, legitimately on opioids, are abruptly sentenced to prison. And then, when opioid naïve inmates, following “cold turkey” in prison, are discharged, deaths from overdose are increased 10 times
Improving control of prescribed opioids
It must be recognised that many people benefit from opioid analgesics especially for intractable and terminal conditions. A knee-jerk response to the current concerns about opioid abuse must not jeopardise the legitimate and humane treatment of patients. The New England Journal of Medicine, and other US medical publications, report the dilemmas faced by ED physicians in managing patients in pain in an environment of institutional restriction on opioid prescribing; and there are reports of suicides when opioids have been abruptly withheld or patients denied access to them.
Measure which would help in Australia are: –
· A national accessible drug database to ensure safer prescribing and prevent much abuse. Tasmania and Victoria have introduced such systems; other states need to do so as well.
· The pharmaceutical industry invests heavily in educating and detailing doctors. It would be a small step for government to pro-actively communicate with doctors and other health professionals about controlled drugs, their regulation and the legislation governing their prescription, especially when legislative changes are made.
· Front-line practitioners are time-poor with competing demands for their attention. They should be better supported by government agencies and specialist services in managing pain, addiction, suicide risk and mental health.
· At present there is virtually no communication between the different management perspectives and roles of general practitioners and the formal opioid treatment programs. That needs to be fixed.
· A system of patient registration with general practitioners as in UK, NZ and Europe would obviate many of the problems with unsanctioned opioid use.
Emeritus Professor Ian Webster AO, UNSW, has been active in government and non-government organisations dealing with alcohol and drug problems – in treatment, advocacy and policy development.