#9 If codeine is passe and opioids are ineffective for long-term pain, what next?
6 June, 2018
Since beginning my role as CEO of Painaustralia, I have become aware of the thin divide between an individual who has become dependent on drugs and someone with chronic pain who is reliant on opioids. Both depend on drugs for their perceived survival. The drug dependent person is more likely to prioritise drug seeking behaviour over every other aspect of their lives, but will be all too aware of what they are doing and why. Many who use opioids prescribed by their doctor for pain, do not realise how dependent they have become.
According to the Australian Bureau of Statistics, the person most likely to die from a drug-induced death in Australia today is a middle-aged male living outside of a capital city who has misused prescription drugs, such as oxycodone, usually by accident because they used other drugs at the same time that multiplied the effect of the opioid.
In research associated with our recent ‘Real Relief’ consumer education campaign – part of our information campaign around codeine upscheduling – we found most people were unaware that codeine is a potentially harmful opioid. When people understood the serious potential harms associated with codeine – addiction, poisoning and death – they became more supportive of the decision to make it a prescription-only product.
Opioids are very effective in relieving acute pain and cancer pain, and in palliative care, however, numerous studies have shown use of opioids for long-term chronic pain is fraught with risk and danger, with minimal or no benefit. Despite this growing body of research, chronic pain is the main reason cited for increasing rates of opioid prescribing.
The 2015 AustralianAtlas of Healthcare Variationfound the number of opioid prescriptions dispensed in Australia is more than 10 times greater in the areas with the highest rate of chronic non-cancer pain. The variation was also associated with socioeconomic disadvantage as well as poor access to effective pain management services including non-pharmacological approaches.
Chronic ongoing or recurrent non-cancer pain affects one in five Australian adults and children and one in three aged over 65. It costs Australia at least $34 billion per year – our third most costly health burden and the leading cause of early retirement and absenteeism.
The opioid issue is not just an addiction problem or a prescribing problem in need of some consumer education and accredited doctor training. We have a pain epidemic that needs strategic, focused, nationwide action. Not the kind being touted in the US, where the administration has called for the death penalty for drug traffickers dealing in prescription drugs and believes punitive action is an effective solution. If the opioid crisis is largely a result of our inability to appropriately manage pain, a strategy to better manage pain is the most sensible place to create a momentum for change.
As a nation we have no more excuses for inaction on pain. While restriction of codeine and other opioids is in keeping with our evolving understanding of best-practice pain management, if codeine up-scheduling showed us anything, it is that too many Australians are relying on potentially harmful pain medication because there are too few alternatives.
In most cases chronic pain can be successfully managed with a multidisciplinary approach. This addresses the bio-psycho-social nature of the pain experience, with input from doctors and a range of allied health professionals – most commonly psychologists and physiotherapists with specialised training – who help develop individualised management plans.
The problem is that patients face long wait times to access multidisciplinary pain clinics – frequently more than a year – resulting in deterioration of their pain condition. In some cases significant travel is required and in the case of specialised paediatric care, the clinic may be interstate. There is insufficient assistance through Medicare for allied health services for people with chronic conditions, and poor rebate structures for those who have private health insurance.
These issues highlight the urgent need for a national and holistic strategy to better prevent, treat and manage pain as an emerging national health emergency. It requires a cross-portfolio and multi-level response by the Federal and State Governments.
We already have a national strategy for pain. Our goal is for the Australian Government to endorse and coordinate implementation of this strategy to ensure a consistent approach to pain health services Australia-wide. This is likely to be the safest and most effective path to address the opioid issue in Australia. We can and must do better at managing pain.
This article appears in the June/July 2018 edition of Vicdoc magazine. References available from the Editor on request.