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Response to “Recommendations and guidance for opioid prescription“

Norman Swan – The health report podcast on ABC – interviewing Dr Chris Hayes, Pain Medicine Specialist

“Last week the Australian Commission on Safety and Quality in Health Care released standards on what should be expected with opioid use. Pain medicine specialist Dr Chris Hayes chaired the group that developed the standards. Welcome to the Health Report, Chris.”

The podcast is compares the ‘opioid epidemic’ or ‘opioid crisis’ in the US to Australia.  While the podcast admits that Australia has a smaller problem than the United States, it would be far more accurate to say that Australia does NOT have an opioid problem at all. 

Our doctors have not over prescribed, and we do not have the ‘pill mills’ that the US has.  Opioid prescribing in Australia has always been well-monitored and well-regulated, and therefore addiction and overdose related to prescription opioids is very rare.

We also don’t have the illicit fentanyl coming over the border from Mexico that the US has, which is the true cause of the ‘opioid epidemic’ in the US.

Nevertheless, Dr Chris Hayes insists that we have an opioid crisis here and is using a false narrative to make his point.  Dr Chris Hayes very purposefully implies that the opioid-related deaths in Australia are similar to the road toll stating:

It is, as you say, a smaller problem than it is in the States, but nevertheless a substantial rate of opioid-related deaths in Australia has been very similar to the rate of deaths from car crashes in recent years, that being up over 1,000 deaths per year…”

Very clever, he has put the idea into listeners heads that there are around 1,000 opioid related deaths per year and neglected to mention the actual numbers. And he has named no sources.  So let’s check his facts, as all journalists should.

The Penington Institute is a very reputable non-profit organisation in Australia which puts out an Annual Overdose report using ABS data.   The most recent one was released in 2021 and relates to the 2019 calendar year.

So what are the actual figures?

In 2019 there were 882 opioid related deaths. This includes HEROIN deaths, so clearly not prescription opioids.  Heroin can be very difficult to detect post-mortem, so the heroin statistics are almost certainly under reported and some heroin deaths have instead been attributed to prescription opioids. Therefore, the prescription opioid figure is inflated. The report acknowledges this in a footnote, as do all statistical sources of heroin and prescription opioid deaths. 

From the report: “Heroin and morphine: Drug-induced deaths involving heroin may be under-counted, or misattributed to morphine, due to challenges in interpreting toxicity data and the rapid conversion of heroin to morphine in the body after administration.”

In 2019, there were 422 unintentional drug-induced deaths involving heroin (representing 47.8% of unintentional drug-induced deaths involving opioids)

So that means there were 460 deaths attributed to prescription opioids. That’s 882 opioid related deaths, minus 422 heroin related deaths.   And remember, as noted above, the deaths related to prescription opioids will be inflated due to the difficulties in detecting heroin post-mortem.

So, to be clear, in 2019 there were 460 deaths related to prescription opioids.

The 2019 road tool was 1,195.

Source: https://www.roadsafety.gov.au/performance/road-deaths-road-user

Therefore this means that the road toll was more than 2.5 times the number of opioid-related deaths.   Not ‘very similar’ by any means.

Additionally, most of these opioid-related deaths are related to polypharmacy.  A death where an opioid is the only medication detected is vanishingly rare.

Clearly,  the problem so small that Dr Chris Hayes has to twist the facts and purposefully choose his words to imply the deaths from opioids are much higher than they truly are.  If the problem were real, he would not have to obfuscate the facts.

This idea that opioid deaths are comparable to the road toll is persistently reported in the media and it’s disappointing that someone of your stature, Dr Swan, and the ABC in general, would not fact check and instead keep reporting false information.

While the regulations that the podcast refers to are a positive thing, it’s something that all doctors should have been doing anyway, simply taking five minutes more on discharge to prescribe an appropriate dose and duration script for opioids.  These changes should be made without resorting to myth-building and hyperbole.  It’s time we stopped demonizing opioids and reported the facts, the science. Especially on the Health Report. 

I expect better from a doctor, the medical community, and far better from the ABC and its journalists.   The credibility of this podcast is destroyed when it’s based on lies.

Dr Swan, rather than quoting incorrect statistics please take a look at these studies on opioids.

This is a recent, very large study done in Ontario, Canada.  It found

“Among the 2,021,371 individuals meeting our inclusion criteria, 1121 (or 0.055%) experienced an opioid overdose within 1 year and 64,013 (3.17%) continued treatment for at least 1 year. “

https://pubmed.ncbi.nlm.nih.gov/33300138/

So opioid overdose is very, very rare. And people remaining on opioids long-term is also rare.

And another recent study comparing oxycodone to hydrocodone:

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0266561

Which found an overdose rate of 0.3% and ongoing use at 2.6%.  Again, very rare.  Hardly a crisis.

So the science does not support the narrative that the opioid crisis was caused by prescription opioids, or that we need to cut down on opioid prescribing at all.  You cannot say opioids are ‘highly addictive’ based on these very large and recent studies.

We are basing all our policies on US data, even while now the US is admitting they got it wrong.  The CDC is currently rewriting their infamous 2016 Opioid Prescribing Guidelines that did so much harm to chronic pain patients, and admitting that the opioid epidemic in the US is being driven by illicit fentanyl, NOT prescription opioids.  Yet Australia is not learning from the flawed US policy, is making the same mistakes the US made, and denying patients effective pain relief.

Another very important aspect to consider is the development of chronic pain after an episode of acute pain. It is well-established that untreated or undertreated acute pain often leads to chronic pain. So not treating post-operative pain effectively and trying to manage on less effective pain medications such as paracetamol and nsaids, can actually cause chronic pain.  Not the desired outcome.

Close to 15.5 million scripts for opioids were written in Australia in 2016-2017.   15.5 million. Resulting in 460 deaths.  This says to me that opioids are a very safe medication, with a tiny mortality rate compared to the number of scripts written.  Clearly, there are far larger problems in this country and far more dangerous medications on the market than opioids. 

It’s time we stopped demonizing opioids and allowed the people who need them for severe pain, acute or chronic to have access to them.  And stop pressuring doctors to use less effective methods of pain relief, and to deprescribe patients who rely on long-term opioid therapy.

The real ‘opioid crisis’ in Australia is that chronic pain patients are being force-tapered and their lives are being destroyed by a lack of access to opioid pain-relieving medications.

Since the introduction of the new opioid prescribing regulations in June 2020 chronic pain patients have been force-tapered off their medications.  While the regulations are admirable as written, they have been widely misinterpreted and misapplied in practice with many doctors deciding it’s all too hard, and force tapering ALL their patients off their opioid pain-relieving medications. Some are refusing to provide healthcare to people on long-term opioid therapy, so voracious is the demonization and stigmatising of opioids, and chronic pain patients.

Some of these patients had been on stable doses for years, or even decades and were functioning well.  Taken off their opioids, people are forced to live with severe, daily pain.  They lose their careers, their close relationships, their social lives, and become housebound.  Depression is very common, understandably, as living with severe, daily pain is devastating.  Even more so when you are aware that there is a safe, effective treatment that is being withheld based on cherry-picked science and rhetoric.  

Due to the same rhetoric and bad science that Dr Chris Hayes is displaying in this podcast.  That’s the REAL scoop.  I wonder if you, Dr Swan, would consider talking to chronic pain patients and raising some awareness of what is happening in the chronic pain community?   I have plenty more evidence that shows opioids are both safe and effective in well-screened and well-monitored patients, with the risk of overdose and addiction being tiny in this population.  But instead, the media continues to push a narrative that opioids are inherently dangerous, addiction is unavoidable and they are not effective for pain.

All of which is demonstrably untrue.

I look forward to hearing from you.

Thank you for your time.

Pain Patient Advocate

www.painpatientadvocacy.org.

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