Medical Forum asked pain and addiction medicine specialists for their view on a range of issues around the use of opioids in WA.
Dr Wendy Lawrance, addiction medicine specialist, Next Step Drug and Alcohol Services, Fresh Start Recovery Programme
MF: In your experience, does WA have an opioid ‘crisis’?
WL: In 2018 there were 172 opioid-induced deaths in WA, being a rate of 6.63/100,000 population, which is higher than the rate of 5.61/100,000 at the peak of the ‘heroin crisis’ in 1999. Of the 2018 deaths, 91 were exclusively attributed to pharmaceutical opioids, 24 also had illicit opioids involved, leaving only 57 exclusively attributed to illicit opioids such as heroin, which is commonly thought of as the main culprit in opioid overdose deaths. More than two thirds (66) of the exclusive pharmaceutical opioid-related deaths were accidental. All of these rates have been steadily increasing since 2007, and all but the illicit plus pharmaceutical rates are higher than the national rates. Interestingly, at a national level, there has been a noticeable increase in the accidental death rates exclusively due to pharmaceutical opioids since 2007 in the age brackets above 35 years-old.
Reference: Man, N., Chrzanowska, A., Dobbins, T., Degenhardt, L. & Peacock, A. (2019). Trends in drug-induced deaths in Australia, 1997-2018. Drug Trends Bulletin Series. Sydney: National Drug and Alcohol Research Centre, UNSW Sydney.
MF: When is it appropriate to prescribe opioids? When is it not?
WL: Opioids are effective, evidence-based treatments for acute pain, and pain in a palliative care context. As opioid substitution therapy for opioid dependence, they reduce accidental overdose risk, improve physical and mental health, reduce blood-borne virus transmission and criminal involvement. There is little evidence of marked efficacy or functional gains for opioids in chronic non-cancer pain beyond a few months. The Schedule 8 Medicines Prescribing Code (available at https://ww2.health.wa.gov.au/Articles/N_R/Opioids-benzodiazepines-and-other-S8-medicines along with lots of other useful information) explains the prescribing rules for WA.
MF: What are your views on a prescription monitoring service?
WL: Comprehensive S8 prescription monitoring already exists in WA, and very useful, though limited information is available to prescribers on patients they are consulting by calling the Schedule 8 Prescriber Information Service on (08) 9222 4424 in office hours. A National Real Time Prescription Monitoring System is under development and eagerly awaited by addiction doctors and others. It will identify people who would benefit from addiction and pain services, and from skilled GPs, and we may face workforce capacity challenges. Abrupt cessation of opioids can lead to increased overdose rates, and to changing to illicit opioids including strong synthetic opioids, which are a very worrying problem in North America. It won’t be a panacea as illicit, including internet, supply of pharmaceuticals will not be captured.
MF: Much time and energy has been put into developing alternative pharmacological and multidisciplinary approaches to deal with chronic pain. In your experience, what is working? What is showing potential?
WL: Effective and well-tapered treatment of acute pain, along with caution and universal precautions in opioid prescribing for chronic pain will go a long way to preventing medication related problems that I see in an addiction service. There is lots of useful information on the Department of Health website above.
Naloxone, for opioid overdose reversal, is available both as a prefilled syringe for intra-muscular injection (PrenoxadÒ), and a single-use pump for intranasal administration (NyxoidÒ). Both are available S3 and S4 (PBS). Under a Commonwealth program, many pharmacies, health, homeless and addiction services in WA are able to supply these efficacious treatments free to people who are at risk of experiencing or witnessing opioid overdose, full list of sites see https://www.mhc.wa.gov.au/getting-help/preventing-opioid-overdose/
Dr John Salmon, pain specialist, Cottesloe
MF: Is there an opiate crisis in WA?
JS: I don’t think there is an opiate crisis in WA, certainly not compared to the US where rampant, unscrupulous, income-driven opiate prescription has wreaked havoc. A concerted effort from the Health Department and pain specialists in WA has, fairly, successfully disendorsed the prescription of higher dose, strong opioids for non-cancer pain. The pendulum may even have swung too far the other way with the patients who were parked too frequently by the medical profession on high-dose opiates over the past 20 years, abruptly disconnected from their medication without appropriate alternative treatment options causing considerable, avoidable distress.
MF: Appropriate opiate prescribing
JS: There is a consensus now that routine strong analgesic medication should be confined, as far as possible, to tapentatol (Palexia), slow and quick release, and buprenorphine (Norspan) patches and possibly sublingual (Temgesic).
Tapentadol has a predominant noradrenergic mechanism with the opiate component less potent than codeine. Many years use in the US and Europe with monitoring has not identified any significant addiction or abuse behaviours. It also has low toxicity and no tendency to provoke hyperalgesia and immune system dysfunction. Its risk-benefit profile should therefore be viewed quite differently from the other strong opiates and it’s unfortunate that it has been bracketed with them as a Schedule 8 based purely on its potency being equivalent to up to 80mg of oxycodone a day. It is apparent that many GPs view tapentatol the same as oxycodone, morphine or fentanyl on this basis which is not appropriate. The Health Department does not require a permit to prescribe tapentadol up to a dose of 500mg a day.
Buprenorphine is also distinguished by much reduced dependency, abuse and toxicity issues and also does not provoke hyperalgesia and immune dysfunction.
There is at least a tenfold genetic variation in individual patients’ response to medications including analgesics and therefore a requirement for dose flexibility. Some patients, particularly those previously on high-dose opiates, require a combination of tapentadol and buprenorphine to achieve reasonable analgesic effects. It is quite safe to combine these medications.
Complex chronic pain patients with long-standing high-dose opiate dependency are frequently a management challenge. Transition to tapentadol needs to be done gradually with slow tapering of their usual opiate because tapentadol being mostly non-opiate does not counter withdrawal issues. It is most important to fully identify and treat neuropathic and nociplastic pain mechanisms utilising anti neuropathic pain medication such as tricyclics (NNT 2-3), duloxitine and Lyrica (NNT 12+) rather than strong analgesics alone.
Regarding when to prescribe strong analgesics the principle should always be to implement adequate evidence-based nonpharmacological pain management as far as possible before or at least in parallel to prescription of stronger analgesics. Always use the lowest dose that achieves reasonable symptom control and maintains function and quality of life without side-effects such as daytime sedation.
Patients with a history of medication, substance and particularly opiate addiction and abuse need to be identified and managed appropriately, which does not mean exclusion from adequate pain management. Confine prescriptions to tapentadol, buprenorphine and methadone in selected patients.
MF: Prescription monitoring
This would clearly be a very helpful facility to pick up abuse-prone patients early.
Provision of nonpharmacological pain management treatment
If there is a crisis in pain management it is the ongoing failure of health (including medical) professionals in general to assimilate and implement the current knowledge regarding mechanisms of chronic pain disability. Undergraduate and postgraduate training remains woefully inadequate regarding pain medicine, which is a paradox considering that pain is the most frequent presenting symptom in medicine. While chronic pain disability, interactive with anxiety and depression, are the dominant causes of loss of quality of life and function and health-related economic cost in the Western World.
The health system as a whole remains biomedically focused and there are huge commercial drivers rewarding physical interventions and surgical procedures, in turn fuelled by ever more detailed imaging of pathologies which are most frequently asymptomatic, degenerative change.
The toxicity of rampant biomedical-based management is exemplified by the appalling outcomes for work injured patients becoming permanently disabled chronic pain patients after relatively minor soft tissue injuries (about 4000 a year in WA). The adversarial environment inherent in the workers compensation and motor vehicle accident insurance schemes virtually ensures that psychologically vulnerable injured patients (about 25% of those injured) develop disabling chronic pain.
Early identification of vulnerable patients and early proactive CBT pain management treatment, with adequate GP and allied health support, has been shown to largely prevent the evolution of chronic pain disability in recent controlled studies. The coming availability of high-quality Internet pain management CBT should markedly improve provision in the wider community.
Patients with intractable neuropathic or nociplastic pain mechanisms, the most prevalent mechanism in the more severely disabled and distressed patients, who have failed to respond to non-interventional management can be very successfully managed with implanted neuromodulation therapies, which now have a strong evidence level I base for efficacy and safety.
Externally powered, smartphone-controlled, minimally invasive implanted systems are becoming available, which should also be considerably cheaper than the fully implanted devices making the therapy more accessible.
Dr Michael Christmass, Consultant in Addiction Medicine at Next Step Community Alcohol and Drug Service
MF: In your experience, does WA have an opioid ‘crisis’?
MC: 1. Based on my experience (clinical practice, information from discipline-specific resources) WA does not have an opioid crisis. However, there has been a clear increase in opioid overdose deaths in Australia (i.e. doubling between 2007-2016) and the majority of these deaths involve prescription opioids. In my experience in WA, the prescription of drugs that contribute to opioid overdose, in particular, gabapentinoids and benzodiazepines, is concerning.
MF: When is it appropriate to prescribe opioids? When is it not?
MC: The RACGP Guidelines Prescribing drugs of dependence in general practice, Part C provide a comprehensive description of the factors to consider here. In brief, opioids are indicated for treatment of some acute pain states based on a multi-model approach that includes non-pharmacological techniques. Several acute pain presentations should not be treated with opioids (e.g. uncomplicated headache, primary dysmenorrhoea), especially exacerbations of chronic non-cancer pain. Limited use of opioids in treatment of chronic non-cancer pain is a complex issue and requires a careful biopsychosocial assessment with a sound diagnosis; long-term and durable therapeutic alliance; discussion of risks/benefits; agreed plan (+/- contract) for continuation/discontinuation based on functional goals; regular close monitoring and review. Assessment should consider: examination for signs of injecting drug use; urine drug screen; information from previous prescribers/service providers; inquiry to Department of Health Medicines and Poisons regarding patient registration as drug dependent; inquiry with Medicare Prescription Shopping Information Service, naloxone prescription and opioid overdose education.
MF: Prescription monitoring
MC: Currently in WA the only accessible monitoring service is Medicare Prescription Shopping Information Service. This service is helpful but does not provide ‘real time’ data. Services that provide real time prescribing data to frontline clinicians (e.g. SafeScript in Victoria) will be implemented in WA in the foreseeable future. Such a system will provide doctors with up-to-date patient information, including alerts, on prescribing of high-risk medications. This will greatly assist doctors in decision-making before reaching for the prescription pad. At present, however, it is unclear whether these systems actually reduce opioid overdose deaths. Unintended consequences could include diversion of patients with substance use disorders to illicit drug markets. Access to evidence-based addiction medicine treatment services is inequitable (e.g. rural and remote regions) and must be considered during implementation of a system that may identify, and isolate, patients with substance use disorders.
ED: Re Alternatives, Michael replied his experience was limited in relation to treatment of chronic pain states.
Dr Roger Goucke, pain specialist, Nedlands
MF: In your experience, does WA have an opioid ‘crisis’?
RG: I suppose it depends on with whom we are comparing. In general, WA has some patients on high-dose opioids. It seems there may be some diversion but I get the feeling this is less of an issue than it was several years ago. The Department of Health WA has clamped down on some high prescribers. It would be interesting to get an opinion from the Police.
MF: When is it appropriate to prescribe opioids? When is it not?
RG: Acute trauma, post op pain, cancer pain. There is little indication now to start opioids in chronic non-cancer pain. However, there will continue to be existing patients already on opioids.
MF: What are your views on a prescription monitoring service?
RG: It’s generally useful. It would be better if it was real time.
MF: Much time and energy has been put into developing alternative pharmacological and multidisciplinary approaches to deal with chronic pain. In your experience, what is working? What is showing potential?
RG: I think it’s cultural both for patients and practitioners. It’s easier to give a tablet and the patient wants a fix to the pain. The psychological techniques are well described on how to help manage pain that persists. Access to either one-on-one or (better) group-based therapies are limited through both state government and Medicare funding, although it’s improving. Engaging patients in therapy is also an issue and complex barriers exist. Preventing chronic pain in the first place now has good evidence for efficacy; aggressive treatment and follow-up of post-op pain, especially high-risk patients. Early intervention (in first 10 days) for workers comp pain cases.