Lessons from the US opioid epidemic – Expert reaction

An article in the New Zealand Medical Journal has reflected on the lessons New Zealand can learn from the opioid epidemic in the United States.

Auckland City Hospital’s Dr Paul Morrow says that opioid drug misuse is increasing worldwide which puts New Zealand at risk of a similar drug death epidemic. He suggests an ‘early warning’ system combining information from coroners, pathologists and emergency departments.

The SMC asked experts to comment on the article.

Dr Jeremy McMinn, Consultant Psychiatrist and Addiction Specialist, comments:

“An early warning system designed to trigger a rapid public health response sounds good in principle. It could be conceived as a feedback loop in a system waiting in readiness to respond quickly and flexibly to a new threat.

“If this is a priority, it suggests we are already sufficiently good at responding to the more substantial known threats. This is not the case.

“Despite our efforts, the evidence suggests we have not stemmed New Zealand’s steadily increasing prescription of potent opioids. We are slow to learn the lessons from abroad, unthinkingly accepting Oxycodone into our prescribing despite over a decade of warning signs from the US. We are behind the Australians in making steps to restrict our rising codeine use, when this has been an obvious step for the last 5 years.

“We can have no confidence we have made headway with the 1000 deaths per year directly attributable to alcohol. We allow our suicide rates to rise, knowing the crucial part alcohol plays in so many.

“There are obvious ways crying out already to reduce drug harms, but left undone. Let’s pay attention to what we already know needs to be done.”

Dr Paul Quigley, emergency medicine specialist, Wellington Hospital, comments:

“This is very interesting work, though already very well-known information. 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.

“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 over-dose 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.

“Then, particularly in the USA, knee-jerk prohibitive legislation after some high profile celebrity deaths aimed at preventing and penalising prescribers was done without also providing treatment services. For those users now cut-off from prescription opiates, it saw a huge swing from controlled use to street use. The rise was so great that the dealers struggled to provide enough heroin, morphine etc. and started substituting with Fentanyl. A very small dose goes a long way, but in naïve users leads to death.

“Currently, we have a very stable opiate-using community that has traditionally stuck with morphine or diverted methadone. There are, of course, oxycodone and other users but these remain small due to diligent prescribing practices and a strong position from the specialist colleges on the harms of opiates.

“As long as in New Zealand we continue to recognise that doctors are the biggest opiate drug dealers we will avoid many of these problems.

“Key elements are:

  • A united change to the language of pain relief. We cannot make you ‘pain-free’ (only an anaesthetic can do that) but we can make your pain manageable.
  • DHB- and MOH-led campaigns on safe prescribing both in hospital and on discharge. Limiting the accessibility of oxycodone and other synthetic opiates
  • College-based programs of a similar nature especially the support of the College of GPs.
  • Diligent management of restricted prescribing and dangerous drugs scripts through Medsafe and pharmacies.
  • Providing robust and easily-accessible opiate treatment clinics such as methadone or suboxone for those who are already addicted.
  • Providing Naloxone to high-risk users and to the needle exchange clinics and first responders significantly reduces the risk of death related to opiates.

“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.

“The Coroners of New Zealand have been a very pro-active 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.

“There are a number of elements that need to be considered in making an early warning network, including how the information is actually shared and released:

  • What ‘harm index’ do we use? Illegal opiates crossing the border are all dangerous and would be ‘high’ on an alert index. But how about MDMA? Some would say that alerting to the presence of something like MDMA actually encourages drug use.
  • How is it notified? On a public website, on a secure website? What is the onus on public notification versus security?
  • What is done with the information? The recent synthetic cannabis issue highlighted the ‘conflict’ between the need for public good (health alert a bit like an infectious disease outbreak) and enforcement (it is already illegal, but a heavy Police presence drove the problem underground with patients unwilling to present).”