JOHN DWYER.The Opioid crisis should focus attention on the inadequacy of Primary Care in Australia.

John Menadue’s insightful essay on urgently needed reforms to health care in Australia ( P&I Feb 7) correctly emphasised that a “priority area for implementation and funding should be primary care with the rollout of multi-disciplinary primary health care clinics across Australia.

General practice is failing, particularly with the rapid commercialisation of private practices by large corporations. ‘Turnstile’ consulting based on fee for service must be changed”.This imperative is highlighted by the problems we face tackling the current epidemic of opioid dependence and it consequences.

Some three millions of us live with daily severe pain. Arthritis, back injuries, headaches, nerve damage and even psychologically induced pain are some examples and in far too many cases relief associated with opioid consumption is leading to addiction and opioid related deaths. One often sees opioid addiction discussed excluding cancer related pain. While it is, of course, important to relieve pain in terminal cancer patients where long term addiction concerns are irrelevant, increasingly many cancers are being managed as chronic diseases with very much improved longevity from modern treatment albeit without the likelihood of a cure. In such patients strategies to avoid opioid addiction are also important and I fear neglected.
Perhaps the most distressing reality in all this is that so much of this suffering could be avoided if our health system was resourced adequately to focus on prevention.

Our opioid epidemic is as real and entrenched, if of a lesser magnitude than the one described for the US. Approximately 15 million opioid prescriptions are dispensed in Australia each year. It is estimated that 750,000 Australians may be addicted. Addiction to OxyContin kills many more of us than does Heroin. Of the 1,740 registered drug-induced deaths in Australia in 2018, opioids were responsible in close to two-thirds of cases (1,123 deaths) with accidental overdose being a very common cause. This represents a marked increase in deaths related to opioid use which were in the 400 a year range a decade ago.

As I discussed herein (P&I Jan 20) too many Australian doctors have allowed financial and other inducements from drug companies to influence their prescribing habits. The international arm of the American company Purdue, regarded as the main offender in the causation of the US epidemic, Mundipharma, has been much criticised for its marketing tactics in promoting its OxyContin in Australia. Spending on inducements to use its OxyContin have included a $66,000 conference in Italy for the International Association for the Study of Pain where Australian and New Zealand delegates were wined and dined in Milan; an $8200 “product launch meeting” for pharmacists over drinks and canapés in NSW; and an all expenses paid “pain master class” weekend for GPs at Brisbane’s Stamford Plaza, costing $128,000.

While I am surprised that a number of our GPs were mislead by misinformation re the safety of long term opioid use I am not surprised by the number of prescriptions supplied.

Imagine an average GP consulting with a patient with real and severe pain.
Both the GP and patient know that opioids will bring a blessed relief from that pain. The patient insists that he needs the prescription, the doctor cannot cure the pain causing condition. He has not been trained in alternative pain management techniques, has a waiting room full of patients to be seen, and, as he “bulk bills” like 80% of his colleagues he is only rewarded with $37 for his consult. Volume not time spent provides his needed income. He may wish to refer his patient to a specialist pain clinic but there are far too few of them to meet demand and if his patient is addicted he knows very few off the pain clinics have experts in addiction management available. Our GP writes the prescription.

I noted in the SMH the following comment from Tom Ballantyne, the principal lawyer in the medical negligence department at plaintiff law firm Maurice Blackburn, “Many of Australia’s opioid deaths could be prevented if the medical system didn’t “incentivise” quick consultations “where decisions aren’t properly reviewed and patients aren’t properly assessed.”

The situation in rural Australia is even worse. We need an additional 1800 GPs in rural Australia, those who are available have long waiting lists and a very high percentage of rural GPs are foreign trained doctors who, though currently essential, often have cultural backgrounds and poor English skills that make it particularly difficult for them to handle issues such as opioid dependence. In many of our more isolated rural communities we rely on “fly in, fly out” visiting medical officers who are paid more than $2000 a day and cannot supply long term management.

In our current system it is easy to visit multiple GP practices, tell the same story and walk out with an opioid prescription. Hoarding of tablets is very common. One Victorian man, court records reveal, was given 58 prescriptions for 1500 OxyContin tablets and a further 29 scripts for diazepam, a dangerous benzodiazepine used for anxiety, in the months before his death from an overdose.

What can we do to blunt this epidemic which the NSW Coroner recently opined would kill thousands of Australians over the next few years without the implementation of needed reforms. Prescription tracking is one of the needed reforms. Doctor shopping has seen addicts visit multiple doctors obtaining multiple prescriptions. Plenty of overdose deaths have been related to the ready availability of large amounts of OxyContin.

The Federal government promised a national tracking system for opioid prescriptions by the end of 2018 to help identify patients attempting to have multiple prescriptions dispensed but to date nothing has materialised. Health Minister Greg Hunt insists the Morrison government is “deeply committed to directly addressing the needless loss of life from the misuse of prescription medicines such as opioids.” However three years after pledging $16 million to roll out national prescription monitoring, the government still cannot say when the project will be delivered. Apparently the delay is caused by a lack of State and Federal cooperation, such a familiar frustration on the Australian landscape. However even after the introduction of such a system refusing further prescriptions without adequate supportive care will see many availing themselves of the ready availability of the drugs “on the street” for even committing suicide.

There is an enormous amount of information on line re managing pain without the use of long term opioids and strategies to help those addicted, (see my article in P&I Nov 27) but in the real world of today’s Primary Care system the implementation of such advice is unlikely to be satisfactory. How different would be our success in managing this problem if, as John Menadue emphasises, we had, as is now increasingly common in other countries, multidisciplinary primary care teams working in a “Medical Home” where enrolled patients have available a range of health professionals who can provide the expertise and time they need to manage, in house, complex problems such as those we are discussing. Such a facility would be funded by Medicare through contractural arrangements rather than the current fee for service model. Such reforms can readily be demonstrated to be economic winners reducing the burden of disease and hospital admissions but we seem to be in a period of policy paralysis in Australia that is hampering needed initiatives in so many areas.

Professor John Dwyer, Emeritus Professor of Medicine UNSW and founder of theAustralian Healthcare Reform Alliance.

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2 Responses to JOHN DWYER.The Opioid crisis should focus attention on the inadequacy of Primary Care in Australia.

  1. Jeremy Coleman says:

    The recent $572 million fine imposed on Johnson and Johnson in Oklahoma, for promoting the opioid epidemic, with aggressive push marketing the opioid Oxycontin and denying its addictive qualities, is history repeating itself.

    In 2013, the U.S. Justice Department announced that Johnson & Johnson would pay $2.3 billion to the federal government and most states to settle a civil False Claims Act investigation into its off-label marketing of its drug Risperdal. It was no better than its then off-patent predecessor haloperidol for acute psychosis. So off label uses for Risperidol were encouraged by J@J, including to children.

    Johnson & Johnson has already settled thousands of cases involving illicit promotion of Risperdol.
    According to J@J there had been money taken from earnings and put into a column vaguely called “accrued liabilities,” in order to account for the expected billions that might still have to be paid out in verdicts or settlements.It pales in comparison to their earnings.
    “It’s their cost of doing business,” according to a J@J lawyer.

    Eight of the other nine largest pharmaceutical companies in the world have settled federal claims over the last decade related to allegations similar to what Johnson & Johnson was accused of in selling Risperdol, although their conduct was arguably less egregious. They, too, seem to have settled the charges without torpedoing their profit and loss accounts.

    This unconscionable behaviour is the result of’ corporatising’ sickness. It’s never in the financial interest of the drug seller to promote health or a cure from their patients addiction. The drug product ideally should be taken for as long as possible, by as many people as possible for as many conditions as possible to satisfy the corporate bottom line.

    We went to war because 3500 lives were lost in Twin Towers. Where is our moral outrage when we know the 4th highest cause of death in USA, well over 100,000pa, is a result of recognised side effects of prescription medications.. Compare this to 11,000 deaths pa in the USA from illicit drug use. Are we focusing on the harm minimisation when it comes to prescription medication? For example how many car accidents/suicides/ homicides /accidental deaths are associated with prescription medications. Is this data available Currently in Australia 1000 people pa die from opioid overdose alone, about three times the number of Australians who died in the Vietnam War.

    The other rhetorical question I would ask is who is educating the doctors to prescribe pharmaceutical products? It is of course the pharmaceutical industry.
    Which drugs should we have a war on? CBD oils or opiates?

  2. Ian Webster says:

    Dear John,

    You are absolutely correct that a key issue in opioid use and misuse is the fact that this issue and the pain problems that generate much of this use has to managed in primary health care; primary health care poorly supported by specialist mental health and addiction services. Yet, the load of these problems falls on the GPs; specialists divest themselves of the long-term management of these patients. If it is thought that specialist pain clinics are the answer, we need to think again. The waiting list times to be seen in the pain clinic at the hospital I attend is months to a year, and, in any case, more often the problematic patient is referred on to the grossly underfunded and unsupported addiction medicine clinic. From the community clinic, it also takes months to a year to have a patient seen in the pain service at the regional public hospital. (See ‘Waiting in pain…” by Malcolm Hogg, in MJA April 2012 – not much has changed since then.)

    And as you say, time and patience is required to manage the increasing burden of pain and related medical/mental health problems now more frequently manifest in primary care – from survival of illnesses, cancers and injury and an ageing population – but, time, for a GP, is a scarce resource. Certainly the claimed alternative methods of pain management require far more resources and time than can be offered by most primary care providers to the ubiquitous problem of unremitting pain. And, suggesting that these alternatives are available in underprivileged and rural areas is a fantasy. I am not suggesting that you are saying this, as you are not. But the implications of much of the public rhetoric and policy are that all that now needs to be done is to stop the opioids pain patients are using. To do that abruptly without careful management of the withdrawal process is unprofessional practice now being recognised in the US and will be in Australia.

    We have to accept that managing chronic pain is very difficult and for many doctors the intractability of the management of chronic pain leads them to describe these patients as “heart sink” patients. There are no clear solutions, except that a range of modalities can help to some degree, none are perfect, some downright harmful (I don’t mean here judicious pharmacotherapy). But I do know that empathy and trying to understand the meaning that a patient attaches to their pain and being prepared to remain engaged with their suffering contributes to a patient’s sense of agency and control over their predicament.

    I return to your theme. Yes, it has to be primary care where these difficult and intractable problems are managed. Yes, far more support and commitment to primary health care is needed and problems of pain, addiction and mental health must be accepted as mainstream issues throughout the health care system.

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