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Opioid deaths require a complex response

How do we minimise the risk of deaths from opioid use and ensure that people with chronic pain get the best possible treatment? More restrictions on the availability of opioids is not the answer, according to Lesley Brydon, Chief Executive Office of Painaustralia. She argues that instead we need to give chronic pain the high profile it deserves within the health system and to develop a complex, multi-disciplinary response to this debilitating condition.

The recent National Drug and Alcohol Research Centre (NDARC) report raising alarm about growing numbers of deaths from prescription opioids, reflects a much bigger issue: the millions of Australians whose lives are severely affected by chronic pain.

At least one in five Australians, including children and teenagers, live with chronic pain; among people aged over 65, it’s one in three. Whilst the report’s revelation of more than 500 opioid related deaths in a year ( the majority from prescription drugs such as oxycodone)  is indeed tragic, the number of young people whose lives are ruined because of chronic pain,  is devastating on an even bigger scale. 

Opioid drugs such as oxycodone play a valuable role in treating acute pain, including after surgery or trauma.  However they may not be suitable for the treatment of long term chronic pain, which may be caused by a known disease or injury,  but quite frequently, may have no clear diagnosis. 

Pain medicine specialists advise that long term prescription opioids for chronic pain should be considered only under guidelines which emphasise the role of multi-disciplinary approaches to pain management and the need for a thorough assessment and careful ongoing supervision.  

Among the vast majority of people with chronic pain, other measures such as an integrated, multidisciplinary pain program which may include cognitive behavioural therapy along with exercise, physio or  occupational therapy and meditation, can actually be more effective in managing, if not eliminating the pain. 

However such programs are not covered by medical insurance so are available to relatively few people who could benefit from them, and the waiting times at pain clinics may range from 6 month to two years. 

The Royal Australian College of General Practitioners and the federal government are pushing for a nationwide electronic system that would allow pharmacists, doctors and state health authorities to monitor the prescribing and dispensing of addictive drugs. 

But it is not helpful to call for further restrictions on prescribing opioids.  A more rational and strategic approach, which helps doctors to manage pain in a holistic and enlightened manner, is by far the best way to tackle this problem.   

We need to transform the way doctors, and their patients, think about pain,  with the understanding that the experience of pain is subjective, and is influenced by physical, psychological and  environmental factors.  

Pain is the most common symptom reported by people visiting a GP. Pain-relieving medications are the most frequently requested over-the-counter medication in pharmacies. Some 20 per cent of suicides are linked to physical problems, often associated with chronic pain.  And the most common reasons for people of working age to drop out of the workforce are back problems and arthritis- both associated with severe, debilitating, chronic pain.  

The National Pain Strategy recommends that chronic pain should be recognised as priority health issue, based on evidence that it has its own distinctive pathology which constitutes a disease in its own right, associated with neuroplastic changes in the nervous system and the brain.  

Developed by over 150 leading health care professional’s consumers and other stakeholders, and agreed at the 2010 National Summit,  the strategy states that the issue of chronic pain is every bit as big as cancer, AIDS and coronary heart disease (CHD). Yet it remains one of the most neglected areas of health care.

Whilst committing the  resources needed for a strategic national campaign, similar to those for CHD and Cancer may be a bridge too far for government  in the current fiscal climate, one option that could be considered would be a “ Better Outcomes in Pain Management” program, similar to that for mental health, which could be introduced nationally through Medicare Locals. This would entail: 

  • Education and training for health professionals in multidisciplinary pain management, with guidance on prescribing and managing opioids, including a timeframe for ceasing the drugs.
  • Better access to alternative approaches to pain management , appropriately supported by Medicare ( as for mental health)
  • Primary care and community networks for management and support of people living with pain.
  • A nation-wide integrated system of pain management services linking tertiary, primary and community care as recommended in the National Pain Strategy, and now being implemented through state-wide plans in NSW and Queensland.
  • Effective use of telehealth to ensure better access to pain management services in regional areas, and indigenous communities. .

 The current alarm about opioid deaths needs to be considered as part of a much bigger problem requiring a strategic, humane approach to addressing chronic pain.

 With the high incidence of chronic pain among Australians especially those over 65, it is clear that an effective long term solution is needed to reduce health costs, restore the working lives and productivity of people with chronic pain and address the economic realities of an ageing population.

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    Alex Wodak
    Posted November 6, 2012 at 11:23 am | Permalink

    According to a recent NDARC report, opioid overdose deaths have increased rapidly from 360 in 2007 to 705 in 2010. While the precise proportions attributed to heroin and sustained release oral opioids is not known yet, the report claimed that most of these deaths are due to prescription opioids. The rapid increase in annual incidence in Tasmania and Western Australia, states where heroin is relatively less available, supports the view that most of these deaths are from prescription opioids. Australia is following trends in prescription opioid consumption and overdose deaths which started earlier in the US (and Canada). These deaths should be a matter of concern to all Australians.
    Opioids are very effective in relieving pain from cancer pain, and acute severe pain (such as following surgery) and managing heroin dependence. But the evidence that opioids are effective in relieving chronic non cancer pain is much less impressive. There is also evidence that cannot be discounted of significant unintended negative consequences. Opioids prescribing for chronic non-cancer pain should be more discriminating, try using lower doses for shorter periods and be started on a trial basis with an understanding that prescribing will not be continued beyond the trial if the treatment proves ineffective and is accompanied by significant side effects. Treatment for chronic non cancer pain should increasingly involve non-pharmaceutical modalities.
    Supply controls should be tried but supply measures are often not as effective as hoped. Demand should also be reduced. The availability and uptake of methadone and buprenorphine treatment for heroin dependence should be increased. Pain is a serious issue and not well managed. But opioids are no panacea for chronic non cancer pain.
    Dr Alex Wodak AM

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