The problem with painkillers

July 28, 2014

With chronic pain such a big problem as our population ages, Australia’s seen a big rise in the prescribing of strong painkillers, commonly known as Endone and OxyContin. These provide relief from severe pain to tens of thousands of Australians. But because the active ingredient of both drugs is oxycodone, an opioid (or painkiller) that’s related to morphine, Australia’s high consumption has been ringing alarm bells. Australians rank as the third highest consumers of oxycodone per head in the world. The evidence has grown that these prescription painkillers are contributing to addiction, over-doses and deaths.

The Australian actor Heath Ledger died in 2008 from the acute effects of oxycodone in combination with sleeping pills and anti-anxiety drugs. And the American actor Philip Seymour Hoffman, who died earlier this year from an accidental drug overdose, was known to have fought a long battle with addiction to prescription painkillers. So it’s little wonder some doctors here are urging their colleagues to think twice before prescribing Endone or OxyContin, or at least to limit the number of pills their patients get at any one time. “It’s an enormous problem in Australia,” Sydney anaesthetist and pain specialist, Dr Jennifer Stevens, told me. “There’s an increasing number of deaths in Australia where Endone or OxyContin was one of the drugs found in people’s bloodstreams.”

A concern is that young people are getting access to left-over painkillers that have been prescribed to their parents or grandparents. Young people can crush, snort or inject them to get what’s been described to me as a “lovely warm high.” These prescription painkillers can be addictive, lead to ever-bigger doses, and be mixed with other drugs with sometimes fatal consequences. Allegations that pensioners have been selling their Endone and OxyContin to young drug users to supplement their income have been discredited by a recent study. But more drug users are getting their hands on the prescription painkillers one way or another. A survey of Australians who regularly inject drugs found almost one-third were injecting oxycodone in 2013 compared to just 17 per cent in 2005.

Dr Stevens urges older Australians to clean out their medicine cabinets and return their unused Endone or OxyContin to the chemist. The more that’s in the community the greater likelihood of problems. Older people are at risk of addiction and even death if they hoard their painkillers and use too many when the pain gets on top of them. Between 2001-9 there were 465 oxycodone related deaths, and in half the cases the deceased person had had a history of pain or a chronic medical condition. A 2011 Victorian coroner’s report showed deaths where oxycodone was present increased from four in 2000 to 97 in 2009.

Last month Dr Stevens circulated a letter to all junior doctors at St Vincent’s Hospital warning against inappropriate prescribing of oxycodone to patients being discharged. “While no patient should be discharged without adequate analgesia we should all be aware of the potential for hoarding and diversion of these drugs,” she wrote. Prescriptions for Endone for patients being discharged from St Vincent’s had trebled in the seven years to 2012, Dr Stevens wrote. But an audit had shown as much as 30 per cent of the prescribing was inappropriate. Endone and OxyContin were useful drugs to alleviate post-operative pain, cancer pain and in palliative care. But the evidence they lessened chronic pain, such as back pain, was much less clear. Instead they were associated with unintentional overdose and addiction, Dr Stevens said in her letter.

Last year Dr Stevens co-authored a paper with Dr Ngaroma Steele titled Where oh where has your Endone script gone? The oxycodone epidemic. Published in the journal Australasia Anaesthesia, the paper questioned whether some of the Endone and OxyContin was “ending up in the nightclub district of Kings Cross” – up the road from the hospital – “or handed out and swallowed at a party?”

“Prescriptions are done out of the best intentions,” Dr Stevens told me. “Junior doctors who do the paperwork when patients are discharged don’t want patients to have a lot of pain when they go home. To make sure, they give patients a box of 20 when what they need is two or three tablets.”

Some of the growth in Australia’s oxycodone consumption from 92kg in 1998 to 2058kg in 2011 is undoubtedly related to the dawning acknowledgement that being pain-free is a human-right. So how to strike the balance between two legitimate problems – too many people suffering pain, and risks of addiction, over-doses, and death? Professor Louisa Degenhardt, of the National Drug and Alcohol Research Centre, at UNSW, is undertaking a study of 1500 people, average age 58, who are taking prescribed oxycodone. Despite the medication, many people’s lives are bleak. Half suffer moderate or severe depression, one-quarter an anxiety disorder, and half have thought of killing themselves. On average they’ve suffered pain for 10 years. Their lives could be worse off drugs. But drugs alone don’t seem the answer. “With chronic pain, it’s about managing it, accepting the reality they may have to live with it for the rest of their lives, and working out strategies that help people regain quality of life,” Professor Degenhardt said.

As I’ve written previously this is where people need teams of experts to help, including perhaps physiotherapists, meditation teachers, and exercise physiologists. Pills alone, it seems, just aren’t enough, and in some cases, can be dangerous, not only to individuals but the wider community.

What’s your experience/view on prescription pain killers? Please leave a comment.

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