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Opioid use in Australia: have government restrictions avoided the crisis faced in the USA?

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Last year, former Purdue Pharma director David Sackler testified in a US House Oversight committee hearing on the prescription opioid crisis that had overtaken America.
“OxyContin is a medicine that Purdue intended to help people, and it has helped and continues to help millions of Americans. Far too many lives have been destroyed by addiction and abuse of opioids, including OxyContin.”
The problems with synthetic opioid use in the US have been largely traced to medicinal prescribing practices – a finding that has caused some concern in Australia.
Between 1990 and 2014, there was a fourfold increase here in the prescription of opioids, and also a rise in accidental drug-related deaths from those medications that has outpaced the national road toll.
GP Danielle McMullen is the Vice President of the Australian Medical Association.
“We in Australia – like many parts of the world – were seeing an increase in challenging use of prescription opioids. And whether that’s overuse or misuse, and certainly just expanding use of prescription opioids.”
Tighter restrictions on prescription and supply were introduced in 2020 by the Therapeutic Goods Administration, or T-G-A, in a bid to address the potential harm of opioids. 
That meant new limits on pack sizes and dosage amounts covered under the Pharmaceutical Benefits Scheme, with the government sending letters to thousands of GPs, telling them their opioid prescriptions were being monitored.
States and territories also made their own moves, introducing real time checking of prescriptions.
Dr Hester Wilson, from the Royal Australian College of General Practitioners, says that this means GPs and health care workers are able to see exactly what medications a patient has been prescribed.
“If I had a patient that comes in to me and I look on SafeScript I can see the high risk medicines. So that will include benzodiazepines, it will include opioids. Depending on the state and territory that you are in there are also some other potential high risk medicines that are on there as well… And it’s both private and PBS scripts, because it comes from both prescribing and dispensing data.”
But how effective have these changes been?
A spokesperson for the federal Department of Health issued this statement to SBS which argues the T-G-A restrictions have started to have the desired effect.
“The TGA is working with the Health Economics & Research Division of the Department of Health and Aged Care to evaluate the overall impact of the 2020 opioid reforms and other policies as new data sets become available. Interim data from the Australian Institute of Health and Welfare shows that in 2020/2021 opioid-related hospitalisation had decreased to 6,690, down from 9,194 in 2015. In 2017 there were 1,370 deaths caused b opioids and this fell to 946 in 2021.”
Dr Ben Daniels from the University of New South Wales has just completed a study about the impact of the T-G-A restrictions.
He says there ARE now fewer opioids being prescribed under the Pharmaceutical Benefits Scheme – but some people have opted to still access these medications by paying full price.
“All of these medicines can also be accessed outside of the PBS ((Pharmaceutical Benefits Scheme)) through private prescriptions, and it looks like some people did move to the private market to avoid PBS restrictions – because PBS restrictions only apply to the PBS.”
Dr Wilson says there’s been a positive shift in the medical community on their willingness to prescribe opioid pain relief – BUT there is still some concern the pendulum has swung from practitioners being generally too permissive, to too cautious.
“In the background there has been this – a lot of teaching and education and kind of a cultural shift around the use of opioids. And what you want to try and get out of that is this kind of middle road that goes, we make a good assessment. We are the ones that are making that assessment with our patients and we’re best placed to do that. So we don’t want to have it so massively crushed and controlled so that people who need it can’t get it, but we’re also looking at the benefits and the risks of this medication… So that was the other thing… the shift from very permissive opiofilic prescribing to being quite opio-phobic. Do people miss out on treatment that they need and should get?”
 John Ryan is the CEO of the Penington Institute which produced a report on overdose deaths in 2023.
He says we don’t yet have the balance right on our approach to prescription opioids – and that government policies have simply encouraged some doctors to close their books.
“The doctors are obviously worried about well (a) about being misinformed by their patients because there was a lot of that going in the last 10 or 15 years, and doctors really rely on a trusting relationship with the patients… But I think the bigger problem is that we’ve got a tendency in Australia to take a big stick approach to drug issues… and in the prescription space we’ve also implemented a lot of changes to supply without actually carefully improving the demand management.”
The demand for opioids appears to be largely driven by the numbers of people with chronic long-term pain, which affects around 3.4 million Australians – more than half of whom are women.
SBS has previously reported that gender bias has often stopped these women from getting effective, timely treatment, the government’s own End Gender Bias survey, which more than 2,500 women responded to, finding that two thirds of women experience this in health systems.
For women with a disability or from the LGBTQIA+ community the figure jumped to a staggering 80 per cent.
Kate Sear is a Professor at the Australian Research Centre in Sex, Health and Society at La Trobe University and Deputy Chair of the Victorian Pain Inquiry.
She says it’s hoped the inquiry can find solutions to a complex problem.
“Two in five women live with chronic pain that adversely affects their wellbeing. We know that there are also often differences for women who might be Aboriginal and Torres Strait Islander, women from LBTQIA+ populations, trans women etc. So essentially one of the things we need to look at through this pain inquiry is not just the experiences of women but look at them through that what we call the intersectional lens… how experiences might be different from people of different ages, racial and ethnic backgrounds, sexualities and so on – and then try and generate a set of recommendations for how we might address all of those women’s needs.”
But it’s not just discrimination that can be an issue.
Dr McMullen says GPs can provide access to alternative therapies through chronic disease management plans – with rebates available for mental health consultations, exercise physiologists, and physiotherapists who can support the recovery process.
Susi Tegen from the National Rural Health Alliance says many patients are physically or financially unable to reach these services.

“When patients want to access a clinician, it is very difficult to access that service because for a clinician it’s very difficult to cover the running costs of a practice if you’re just receiving Medicare funding or grant funding… We are hoping that in the Budget there will be some changes. Because we cannot sustain running practices – or multidisciplinary clinics in rural and remote Australia – if the funding models that works in the city purely because of scale and there are others you can refer to that are available. Well, we don’t have that in the country.”

 

Publicly available data suggests that overdose deaths are consistently higher in regional areas than in metropolitan centres, and in socio-economically disadvantaged postcodes.
Ms Tegen says a massive injection of funding is required for regional and rural health services to enable patients to build relationships with trusted health professionals.
She estimates rural health is under-funded to the tune of $6.55 billion every year.
“There is a massive underspend of health care in rural, remote and regional Australia. And that is partly because of the maldistribution of the health workforce, and that significantly contributes to the low mortality rate. We don’t have enough doctors, nurses, allied health professionals, dentists, pharmacists, in rural and remote Australia. And that is why the burden of disease is 1.4 times greater in rural, remote and regional Australia compared to the cities.”
The Penington Institute’s 2023 overdose report also indicates that most people who died from overdoses had more than one drug in their system – mostly commonly benzodiazepines.
Researchers say most of these deaths are unintentional, and that more study is needed to determine how and why these drugs are being mixed – and what role prescribing practices or a patient’s history and risk profile might play in these outcomes.
Meanwhile, Guilia Jones, from advocacy organisation Pain Australia, says she believes that it doesn’t have to be an either/or situation when it comes to prescription opioids, with doctors and patients choosing between those medications and other therapies.
She says the crisis of misuse versus the importance of appropriate use are two distinct issues and need to be dealt with separately.

“Even after GPs were basically held over a barrel by the government to make these changes, GPs are still having to prescribe quite a bit of opioids because there isn’t a simple solution to chronic pain, and it’s part of the mix of people’s treatment.”

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