Doctors as dealers and the battle over opioids

Leading health advocates are calling for tighter regulations of opioid prescribing, but the challenge is to keep painkilling medication available to those who need it, writes Ann Arnold.

“Sometimes if I’ve missed it by an hour or two I am on the floor in pain. I can’t walk, I can’t move, I’m in tears.”

“It” is Oxycontin, the well-known opioid painkiller. On the floor is Professor Merrilyn Walton. She has been a professional consumer health advocate for decades, first as commissioner of the NSW Health Care Complaints Commission, and now as Professor of Medical Education and Patient Safety at Sydney University.

But in recent years, Professor Walton has been privately battling excrutiating back problems. Her L5 vertebrae shattered into eleven pieces, which meant surgery to remove them. Several years later, she had a spinal fusion. She now has titanium scaffolding up her spine: “It’s about $30,000 worth, and it’ll stay in my body till I die.”

Eleven months after that operation, Professor Walton is still on Oxycontin and occasional Endone, both highly addictive painkillers.

“Look, I’ve worried endlessly about addiction,” she says, adding that her doctors are sick of her asking about it. But she doesn’t feel addicted in the sense of any drug-induced euphoria or wellbeing.

And that pain when she misses her regular medication intake is purely the back-related pain resurfacing, she says. “It’s not a withdrawal. It’s in my back. It’s not headaches, it’s not vomiting or sweating. The symptoms are my symptoms.”

At the same time, “I know I must be addicted.”

To address that, Professor Walton is getting her dosage down, ahead of her doctors’ instructions.

Prescriptions of oxycodone – the active ingredient in Oxycontin – have trebled in the past decade, according to Medicare records. It is not known how many of those prescriptions result in addictions: most, it is believed, do not. NDARC, the National Drug and Alcohol Research Centre, has begun a large study of opioid patients that should shed further light.

But with prescription rates rising, there is growing concern that a cultural attachment to opioids is inevitably leading to increased addiction and other forms of abuse, such as overdose, and black market trading. And that Australia, if it doesn’t act quickly, could emulate the US epidemic of opioid abuse.

Real-time prescription monitoring, where prescribing and dispensing of Schedule 8, or controlled, drugs is shared electronically, is held up as an important antidote. It was a focus of the National Pharmaceutical Drug Misuse Framework for Action, released late last year.

But Dr Steve Hambleton, immediate past president of the Australian Medical Association, says we can’t wait for that. Although Tasmania has real-time monitoring up and running, the rollout is stuck at various points in other states and territories, with the Federal Government having paid for the licensing, and the other jurisdictions now having to pay for the build.

Dr Hambleton is chair of the National e-health Transition Authority, which is overseeing a different scheme – the patient opt-in system of keeping health records electronically. That technology should be used, he told Radio National this week, for compulsory registration of all opioid prescribing. And it should start now.

“If it looks like you’re going to need ongoing prescriptions (of opioids), that should be the trigger for … setting up an electronic health record.”

It should be a contract between patient and doctor(s), he says, that that information will be shared, if there’s prescribing beyond, say, a short-term dose issued after surgery.

Transparency, rather than inhibiting availability to those who need strong painkillers, should make both doctors and patients feel more confident about getting the most appropriate medication, Dr Hambleton said.

“It decreases the suspicion on everybody.’

Professor Walton, conscious that the individual experience of opioids varies greatly, believes not all doctors should be able to prescribe them.

“Not all GPs know about opioids, and the consequences, or even how to manage pain.”

Background Briefing was told of people with histories of addiction being issued opioids as they left hospital; of first-time addicts finding it impossible to get off their medication; of under-confident doctors not knowing how to manage that; and of numerous schemes to extract prescriptions from doctors, to sell on the black market.

Professor Walton argues that doctors should be specially qualified to prescribe opioids.

“So in the future, I can see that for a GP to do it, they would be credentialed by their college or there will be a protocol about referring to a pain clinic, if (patients) are on it for more than about three months or something.”

She is critical of doctors who issue repeat scripts because they’re time-pressed.

“Well I’ve never agreed with time poor. It’s the most unsafe excuse from any doctor, even in hospitals, where they say we don’t have time. I ask them ‘do you always disinfect a site where you’re going to give an injection with a needle?’ They say ‘of course we do, it’s clinical practice’. Well you do it because you make the time. So prescribing, you need to make the time.”

Make another appointment, she says, and “take a proper history … and ring the previous doctor”.

Professor Walton invokes the prescribing mantra of “the right medication for the right patient for the right amount of time”.

“I work in Vietnam and Sulawesi and Bougainville and there is no pain relief whatsoever. I see patients go home with broken necks, broken backs to die. And I am absolutely amazed.”

“So I think pain relief in our country is a precious, precious commodity and to see it abused is very upsetting. But to put it in a straitjacket as well, with doctors feeling scared at prescribing, is not desirable either.”

Ann Arnold investigates Australia’s new drug war in a Background Briefing report.

Ann Arnold is a Sydney-based journalist with Radio National’s Background Briefing. View her full profile here.