Addiction to prescribed opioid drugs is on the rise in first-world countries and New Zealand is no exception.
Auckland pathologist Dr Paul Morrow, in an article published in today’s New Zealand Medical Journal examines the epidemic of deaths due to opioids in the United States, and compares it to the situation in New Zealand, warning that a similar pattern is entirely possible.
The American opioid death epidemic—lessons for New Zealand? outlines Morrow’s concerns that “the current epidemic of opioid deaths in the US may be a warning to New Zealand” and his suggestion that reporting systems are transformed to help track hospital data.
In the United States, where 80% of all opioids manufactured in the world are consumed each year, deaths from these drugs have reached epidemic levels.
By 2015 the number of fatal overdoses in that country had quadrupled from the 1999 rates, with 63.1% of drug deaths involving opioids.
The New York Times estimates the 2016 data, when available, will show an increase of 19%.
Morrow describes how in recent years the pattern has moved from usage of prescription drugs such as commonly prescribed natural and semisynthetic opioids and methadone to illicit fentanyl.
Closer to home, there has been concern about increased prescription opioid use, but we have not seen the same rise in associated deaths.
During the period 2008–2012 in New Zealand, 179 deaths resulted from unintentional opioid overdoses.
However, because drug overdose deaths currently fall under the jurisdiction of the coroner, there is a lag, sometimes of several years, before statistics of such deaths are publicly available.
This in turn could hinder a timely public health response to the problem.
“Individual coroners and pathologists and their consulting toxicology laboratory (ESR) may become aware of an emerging problem, but there is no formal mechanism other than the coronial inquest channel to report their suspicions,” he states.
“The creation of a rapid reporting system, including data from coroners and pathologists, emergency departments and St John’s, on suspected drug overdose deaths in New Zealand might serve as an “early warning” system in order to coordinate a response plan to a developing opioid death epidemic.”
In 2016, four of the leading six causes of disability were chronic pain conditions, and opioids are increasingly being prescribed for chronic non-cancer pain, despite limited data on efficacy.
Besides the risk of overdose (unintentional or intentional), chronic opioid use can result in tolerance, physical dependence, and addiction, which highlights the need for education of both prescribers and the general public.
Morrow recommends multidisciplinary pain management education sessions for primary and secondary care practitioners, and a more comprehensive strategy to reduce reliance on prescribed painkillers such as prescription drug monitoring programmes.
Along with the use of opioid assessment screening tools, random urine testing, opioid treatment agreements and use of universal precautions, Morrow calls for more specialist pain medicine physicians because they use multimodal therapy (biopsychosocial rehabilitative approach) and can educate their patients about the risks of opioids and monitor them.
Wellington hospital emergency medicine specialist Dr Paul Quigley says Morrow’s article covers an issue that is well known.
“The ‘opioid crisis’ has dominated international conferences for the last 2 – 3 years and is regarded amongst the drug and alcohol community as the leading prescribing-based problem of the 2000s,” he says.
“Opiate-related presentation is very variable throughout New Zealand and is proportional to the prevalence of users in the community and the level of access to opiate treatment programs. In Wellington, for example, it is very rare for us to have opiate overdose presentations, Auckland has more.
“However, it is very important not to confuse the issue with casual recreational drug use and the rise of the new psychoactive substances.
“The opiate crisis overseas was almost completely created from prescription-based opiate addiction from doctors. The rapid rise of the prescribing of synthetic opiates like oxycodone for simple injuries without taking into account the potential for addiction led to the mass of prescription-based addiction.”
Dr Quigley agrees that warning systems are important.
“As for early warning networks, they are invaluable for detecting changes in the drug market and for the dissemination of emergency information to first responders and enforcement agencies.
“New Zealand is actually quite a long way along this pathway and there has been a multi-sectorial working group on this topic for the last 18 months. The most significant delay we have had is actually just the timing of the election/change of government and the summer holidays.
“Coroners of New Zealand have been a very proactive group within this, seeking to accelerate the public health and warning component of drug-related deaths without compromising the legal and potential prosecution component of these cases. It must be noted that in some cases if the death has been due to the provision of an illegal substance, it may be referred back to the police,” he says.