Opioids: What clinicians have to say 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 opioidrelated 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.
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/Opioidsbenzodiazepines-and-other-S8medicines along with lots of other useful information) explains the prescribing rules for WA. MF: What are your views on a prescription monitoring service?
MF: When is it appropriate to prescribe opioids? When is it not?
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 those 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.
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
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?
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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 (Prenoxad®), and a single-use pump for intranasal administration (Nyxoid®). 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.
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. Although WA has some patients on high-dose opioids, it seems there maybe 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: Alternative pharmacological and multidisciplinary approaches? RG: I think it’s cultural both for
MEDICAL FORUM | PAIN MANAGEMENT ISSUE
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