Australia’s Response to The Pharmaceutical Opioid Problem
With the rapid proliferation of opioid overdoses amidst our ever-growing society, Australia is one of the many countries facing skyrocketing rates of opioid prescriptions and related deaths. Over a single year, opioid use—whether through misused pharmaceutical opioids or illegally obtained opioids—has caused more than 2,200 deaths, 32,000 hospital admissions, and the loss of over 70,000 years of life in Australia (1). According to the Australian Institute of Health and Welfare, an overwhelming majority of these deaths were related to the drastic increase of prescribed opioids for chronic non-cancer pain (CNCP) rather than illicit opioids such as heroin (2,3). Indeed, more than 3 million Australians receive at least one opioid prescription a year (3).
Several strategies to minimize unnecessary opioid exposure and adverse effects have been outlined by the National Pharmaceutical Drug Misuse Framework for Action (2012-2015). These strategies include coordinated medication management systems, increased access to pain and addiction services, development of resources, and workforce advancement (4).
In 2016, one of the most common analgesics for non-medical purposes were over the counter (OTC) codeine products (4,5). Codeine is an opioid medication used to treat mild to moderately severe pain. However, its rapid breakdown in the liver may lead to dangerously high levels in the body, slowing breathing and possibly even resulting in death (6). In May 2010, the Australian government’s attempt to restrict codeine accessibility by up-scheduling products from schedule 2 (pharmacy medicine) to Schedule 3 (Pharmacist Only Medicine) had no significant impact on codeine poisonings. It was later further up-scheduled to Schedule 4 (Prescription-only medicine) in 2018 (4). In addition to tighter restrictions on codeine, programs designated to track prescribing and dispensing of prescription drugs of potential extra-medical use (PDMPs) are being implemented in Australia. However, little is known about its characteristics and there are likely to be jurisdictional differences with potentially different outcomes (4). Australia has also continued to increase access to Opioid Substitution Therapy (OST) for those with Opioid Use Disorder (OUD). Although higher doses of buprenorphine or methadone and have proven to be effective in the treatment of patients with chronic pain or OUD, no more than 10% of Australian general practitioners prescribe buprenorphine or methadone (7). This results in an unmet need for OST services. Studies have reported many barriers to general practitioner involvement, including overbearing workloads, inaccessible specialist support, and insufficient training for behavioral challenges (4,7). A greater availability of multidisciplinary pain treatment options and an expansion of specialist addiction services must be implemented to impact overall levels of opioid related deaths.
Throughout the past few years, the ‘take home naloxone’ (THN) initiative has garnered growing support and popularity from the World Health Organization. THN programs have been incorporated in a wide range of services in Australia, particularly targeting those with a history of drug or alcohol use (6,8). In February 2016, naloxone was re-scheduled to Schedule 3, and is now available OTC as an injection or intra-nasal spray (6,8). As of December 2019, the Australian government is investing $10 million in a new Take Home Naloxone Pilot which is freely accessible to those who may experience or witness an opioid overdose (9). While THN is beneficial in reducing opioid related overdoses, it does not impact the overall levels of opioid utilization. Ultimately, the breadth and extensiveness of the opioid epidemic reveals the inherent need to revisit the implementation of national policies in order to enhance patient outcomes and safety for all.
References
1) Conversation T, Manning S, Report AP, Robie D. Evening Report. EveningReportnz 2020. https://eveningreport.nz/2020/05/14/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712/ (accessed March 28, 2021).
2) Kolodny A;Courtwright DT;Hwang CS;Kreiner P;Eadie JL;Clark TW;Alexander GC; The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annual Review of Public Health. https://pubmed.ncbi.nlm.nih.gov/25581144/ (accessed March 28, 2021).
3) Gelineau K. Opioid crisis goes global as deaths surge in Australia. AP NEWS 2019. https://apnews.com/article/cfc86f47e03843849a89ab3fce44c73c (accessed March 28, 2021).
4) Campbell G, Lintzeris N, Gisev N, Larance B, Pearson S, Degenhardt L. Regulatory and other responses to the pharmaceutical opioid problem. The Medical Journal of Australia 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698322/ (accessed March 28, 2021).
5) Non-medical use of pharmaceuticals: trends, harms and treatment 2006–07 to 2015–16, Table of contents. Australian Institute of Health and Welfare. https://www.aihw.gov.au/reports/illicit-use-of-drugs/non-medical-use-pharmaceuticals/contents/table-of-contents (accessed March 28, 2021).
6) codeine. Codeine | Michigan Medicine. https://www.uofmhealth.org/health-library/d00012a1 (accessed March 28, 2021).
7) A; SJEJB-M. Opioid substitution therapy--a study of GP participation in prescribing. Australian Family Physician. https://pubmed.ncbi.nlm.nih.gov/21597537/ (accessed March 28, 2021).
8) Dwyer R;Olsen A;Fowlie C;Gough C;van Beek I;Jauncey M;Lintzeris N;Oh G;Dicka J;Fry CL;Hayllar J;Lenton S; An overview of take-home naloxone programs in Australia. Drug and Alcohol Review. https://pubmed.ncbi.nlm.nih.gov/29744980/ (accessed March 28, 2021).
9) Australian Government Department of Health. Take home naloxone pilot. Australian Government Department of Health 2021. https://www.health.gov.au/initiatives-and-programs/take-home-naloxone-pilot (accessed March 28, 2021).