Opioid therapy challenges in rural Australia

For more than a decade, healthcare workers in rural and remote areas have been aware of the rising incidence of non-prescribed opioid medicines use. But access to treatment there remains challenging.

Australians living in these areas are significantly more likely than their city cousins drink alcohol to excess.¹ They also consume more cannabis and methylamphetamine.^1,2 The non-medical use of opioids, from heroin to fentanyl, one of the strongest opioids available in Australia, adds to the caseload.

Deaths associated with the non-prescription use of substances in rural Australia are up 41% since 2008, compared with a 16% increase in major cities over the same period.¹ And while opioids play a role in the provision of strong pain relief for many people, there are still three opioid-related deaths and 150 hospitalisations from opioid harm in Australia each day.³ In 2016, deaths from opioids exceeded the national road toll.^4,5

While concern has increased, the number of patients in opioid substitution therapy (OST) per population in Australia has remained static for more than 15 years.⁶ And despite the effectiveness of both methadone and buprenorphine in pharmaceutical opioid use disorders treatment, fewer than 10% of GPs prescribe methadone or buprenorphine/naloxone, even though training and credentialing requirements in most states and territories have been eased recently.⁶

COVID-19 has presented new challenges in supporting people on OST. Queensland Health, for instance, has warned that OST should be considered an essential treatment during the COVID-19 pandemic, ‘as significant risks exist to the community if the stable provision of opioid treatment is interrupted’. Methadone and buprenorphine are on the 2019 WHO list of essential medicines, it points out.

Barriers to treatment

An estimated 3.24 million Australians suffer chronic pain, many of them in rural areas.⁷ A person in a remote area with back pain awaiting surgery might use opioid medicines for years before accessing a pain physician. Adverse event outcomes from opioids – including toxicity – are also higher in rural and remote areas.¹

Most small towns don’t have the population to justify health infrastructure or public transport. People who live there who require alcohol and other drug services often face a long, frequently expensive journey to the nearest town where help is available. There are usually no harm-reduction schemes, such as needle and syringe programs, or residential or outpatient rehabilitation programs.

If a town does provide a program, staff may find it difficult accessing more specialised services and retaining experienced personnel. Healthcare professionals in rural areas, particularly pharmacists, face growing separate but related issues, not least of which is dependence on opioids after 3 months use, or longer, whether prescribed or not.

Before the opioid crisis was recognised over 10 years ago, pharmacists in rural and remote areas had monitored consumers with substance-use dependencies. By 2015, almost 15 million opioid prescriptions had been dispensed in Australia.⁶

The latest report of the National Wastewater Drug Monitoring Program² assessed 52 wastewater treatment plants during one week in April 2019 to identify drug use trends across the country by comparing it to historical data included in previous reports. It found that after alcohol, nicotine and methylamphetamine, oxycodone and fentanyl had noticeably elevated consumption levels across Tasmania and regional Victoria.²

‘A striking feature of oxycodone consumption across the nation was the very high levels in regional areas, the average being almost double that of the capital cities,’ the report stated. It noted that use of both oxycodone and fentanyl was higher in regional centres compared to capital cities.²

Community pharmacies in rural areas contribute to the treatment and services provided to people who have an opioid substance-use disorder, whether that person’s exposure to opioids developed from a prescribed source, a non-prescribed source, or a combination of both.

Pharmacists in rural areas are also involved in identifying and reducing the incidence of opioid diversion due to prescription forgery, Medicare fraud or identity theft.

A growing crime

In the past 5 years, police in NSW and Victoria recorded more than 35,000 offences involving manufactured medicines, according to an investigation into Australia’s opioid crisis by Farrah Tomazin published in The Age newspaper.⁸

‘Victoria had the most significant increase in pharmaceutical-related crimes, with offences involving prescription drugs up by more than 400% in 10 years, from 826 offences in 2010 to 4,234 in September 2019.’⁹

Pharmacist and Lecturer in Professionalism in Pharmacy at the University of Sydney Associate Professor Betty Chaar says forged prescriptions are on the rise, as is the expertise of the criminals behind them.

‘A pharmacist, who suspected a fake script, called the number listed. The person on the other end affirmed the script was genuine. The suspicious pharmacist called a second time using a different name and was again told the prescription was genuine. The person on the phone was reading from a prepared script.

‘Young pharmacists in rural areas can find themselves in trouble if they don’t have the confidence to answer back or ask more questions,’ A/Prof Chaar said.

Back of Bourke

Lack of awareness and knowledge, stigma and fear and a professional’s perceived moral responsibilities have all been identified as barriers to pharmacists providing treatment in the community pharmacy setting.

The 2019 PSA Pharmacist of the Year Peter Crothers FPS has conducted an opioid therapy program for years at his Bourke pharmacy. ‘When I first took over the pharmacy, I became aware there were people being prescribed opioids inappropriately. I got together with the local doctors, and, between us, we were able to bring it to a halt.

‘Things are substantially better now than they were 8 or 10 years ago.

‘Mine is the only pharmacy in a 100-kilometre radius, but I’m fully aware there are a lot of opioids in town that completely bypass me.

‘I’ve had local police come to me with opioids they’ve recovered. In one case the product was Oxycontin 80, the highest strength oxy on the market. My drug register showed I hadn’t dispensed that product in 11 years.’

Mr Crothers has found himself a vital cog in attempts to address the issue. ‘Many of the people on my substitution program are not people I’ve ever dispensed a prescription to. They are getting their drugs from elsewhere.

‘I’m told in my town of 2,500, there are at least 50 people who should be on the program, but fewer than 20 are. There is no local opioid treatment prescriber, no doctors want to do it and no local caseworkers. The nearest treatment centre is in Dubbo, 375 kilometres away,’ Mr Crothers points out.

‘It’s difficult for a local who wants to join the program. Someone must do a risk assessment on them, because they might not be suitable for pharmacy dosing. The client has to be lined up with a prescriber and a local dosing point to get them trusted with take-home doses.

‘It’s a considered, deliberate, risk-prone medical intervention, which has to be approached with due care. Where I am, those resources do not exist.’

Monash Addiction Research Centre Deputy Director Associate Professor Suzanne Nielsen sympathises.

‘In NSW some people travel 3 hours to make a doctor’s appointment. In Victoria we know, because of the distances, some people don’t continue treatment or bother to go. It has an impact on the health outcomes. People not in an evidence-based treatment program have four times the mortality rate of those in a program. Many states and territories have been working on trying to increase pharmacy participation. It used to be that only one-third of them offered programs. Now, that figure is closer to half. But most of those pharmacies are in the bigger population centres. There are not so many in between. ‘In rural areas, the problem can be a lack of confidence or experience by the pharmacist – or the cost.’

A/Prof Nielsen says pharmacists often do it without reimbursement, with lack of communication also part of the problem. ‘Pharmacists often face barriers with their local doctors. They can get criticised or ignored by prescribers. For many, it’s not worth the money or the risk. For others, there’s a bias in how they deal with harm minimisation. They don’t want to attract certain people to their pharmacy or they fear being taken advantage of.’

It is unfair to make pharmacists verify each prescription,’ A/Prof Nielsen believes. ‘It is also an ethical issue for pharmacists,’ she says. ‘Perhaps if the government made therapy programs compulsory, the load would be shared more evenly.’

What next?

Community pharmacies have delivered OST since 1985. But there are jurisdictional differences, and many variables for every OST service. The differences can cause confusion and errors, particularly for pharmacists who move interstate, or practise in multiple states.

The federal government plans to expand My Health Record, but there is concern among consumers that centralised information could be accessed via the criminal justice system, which may cause another barrier to treatment.

New treatments and initiatives are emerging, including weekly or monthly injectable formulations of buprenorphine, and real-time prescription monitoring, which assists clinicians to make decisions about the risks associated with prescribing or dispensing a medicine. The TGA recently announced changes to opioid prescribing, including smaller pack sizes, improved package warnings, recommendations for prescribers about inappropriate use of opioids for pain management and tightened regulations around fentanyl.²

Most healthcare providers agree that a multidisciplinary approach, incorporating medicines, psychological and physical therapy, is needed. Of 57 pain management services in Australia, only four offer a combined pain and addiction service.

A/Prof Chaar suggests that provision of opioid therapy could be a licensing requirement for pharmacists, to get around an already inefficient and voluntary system and improve ethical responsibilities and training in the pitfalls of opioids.

A/Prof Nielsen is optimistic but says double the current number of people should be able to access treatment – with more government funding to reduce costs.

Peter Crothers knows what the problem is in Bourke. ‘You don’t get the same support here that others take for granted. Everything is that bit more difficult in the bush – but also much more rewarding when you do make a positive difference to people’s lives.’

References

1. Australian Institute of Health and Welfare. Alcohol and other drug use in regional and remote Australia: consumption, harms and access to treatment 2016–17. Canberra. AIHW. At: www.aihw.gov.au/getmedia/78ea0b3d-4478-4a1f-a02a-3e3b5175e5d8/aihw-hse-212.pdf.aspx
2. Australian Criminal Intelligence Commission. National Wastewater Drug Monitoring Program – Report 8, August 2019. At: www.acic.gov.au/sites/default/files/national_wastewater_drug_monitoring_program_report_8_2019_pdf.pdf?v=1571983781
3. Australian Government Department of Health. Therapeutic Goods Administration. Prescription opioids hub. 2020. At: tga.gov.au/alert/prescription-opioids-hub
4. Australian Government Department of Infrastructure and Regional Development. Road Safety in Australia. At: www.bitre.gov.au/sites/default/files/Road_Safety_Australia_1117 INFOGRAPHIC 2 March 2018.pdf
5. Tomazin F. Australia’s opioid crisis: deaths rise as companies encourage doctors to prescribe. The Age. 2020. At: www.theage.com.au/national/australia-s-opioid-crisis-deaths-rise-as-companies-encourage-doctors-to-prescribe-20200203-p53x72.html
6. Campbell G, Lintzeris N, Gisev N, et al. Regulatory and other responses to the pharmaceutical opioid problem. Med J Aust 2019;210(1):6–8.e1. At: www.ncbi.nlm.nih.gov/pubmed/30636303
7. Deloitte Access Economics The cost of pain in Australia. March 2019. At: www2.deloitte.com/content/dam/Deloitte/au/Documents/Economics/deloitte-au-economics-cost-pain-australia-040419.pdf
8. Tomazin F. Australia’s opioid crisis: how pain management got out of control. The Age. 2020. At: http://www.theage.com.au/national/australia-s-opioid-crisis-how-pain-management-got-out-of-control-20200204-p53xrn.html
9. Tomazin F. Crimes involving prescription medication explode as opioids flood market. The Age. 2020. At: www.theage.com.au/national/crimes-involving-prescription-medication-explode-as-opioids-flood-market-20200214-p540u2.html