It’s the kind of drug addiction that starts out in the open, right in the face of the people you love most. You can justify it at first, it’s legal after all. You purchase it at the pharmacy and it’s been prescribed to you by a doctor. You’re not meeting dealers in dark alleys.
But, before too long, you require a higher dosage to achieve the same effect and you realise (or keep denying) that you’ve become addicted to the medication that was originally prescribed to help you.
This is happening across the globe with opioids – a class of drugs that span the legal and the illegal. Pain killers are a derivative of opioids, so is heroin. Both forms of the drug act on opioid receptors in the brain and can result in the same feeling of euphoric anaesthesia. Both drugs are highly, highly addictive.
For doctors, opioids are an easy fix. Perfect for alleviating acute pain in patients after an operation or an accident. And especially useful in treating those with chronic pain, a more difficult condition to pin down and cure.
But over-prescription of opioids has lead to an ‘epidemic’ of addiction in the U.S. An epidemic that saw 52,404 deaths from overdoses in 2015, according to the Centres for Disease Control and Prevention (CDC). And the number of deaths involving any form of opioid quadruple since 1999.
In Australia, the same thing is happening. The National Drug and Alcohol Research Centre (NDARC) released a report last week showing how the rate of accidental deaths due to opioids has more than doubled among Australians aged 35-44 in the last 10 years. More than two thirds of these accidental deaths are due to prescription opioids.
Read that again: More than two-thirds of accidental opioid deaths in Australia are from drugs prescribed by a doctor and purchased at a pharmacy.
“Opioid dependency can happen to anyone and they don’t necessarily have to be injecting the medication to have a problem. It could be your brother, sister, mother, father, lawyer, gardener or your best friend, no one is immune,” Pene Wood, who is acommunity pharmacist, Lecturer in Clinical Pharmacy at LaTrobe University and an Opioid Management Clinical Advisor for the Western Victoria Primary Health Network told Mamamia.
“With ongoing use, especially at high doses, tolerance can develop and people may need to take more of the medication to have the same effects. Trying to stop can lead to distressing withdrawal symptoms so these patients keep taking the medication.”
And taking the medication. And taking the medication.
In the U.S. there were enough opioids prescribed by doctors in 2015 to medicate every American around the clock for three weeks, according to research out of the CDC, as reported by Vox.
Australia is not there yet, but steadily on the way. Approximately 20,000 doses of opioids are prescribed for every one million people in Australia (compared to 50,000 per one million people in the U.S.), as listed in a recent paper published in the medical journal Lancet. And, in 2014, “more than 13 million prescriptions for opioids were written across the country”, Wood told Mamamia.
With increased prescription comes increased misuse.
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Before his accident, Robby McMahon was an “outdoor person”. He loved sky diving and playing sport, his mother Anna McMahon told Mamamia. He was 21 when the forklift he was driving at work tipped over. The lower half of his leg was crushed and there were further complications when he contracted osteomyelitis – an infection of the bone.
Robby was in and out of hospital for 18 months because, as long as the bone was infected, the breaks couldn’t fuse. It was a year and a half of pain medication, anti-bioitics and, eventually, anti-depressants. Finally, things were looking up. The latest surgery had worked Robby could “see a way forward”, Anna said.
By that time, however, it was too late. Robby was hooked on pain medication and, behind his mother’s back, he began ‘doctor shopping’ for morphine – a form of opioid. Over the space of four weeks he was given higher and higher doses of the medication. His mother found his body one morning, slumped over in his friend’s car. He had died from overdose leading to asphyxiation at age 23.
"People can become obsessed with acquiring the drug," Dr Stephen Bright from the National Drug Research Institute at Curtin University told Mamamia. "The severity of the Substance Use Disorder can range between mild and severe. While some people are able to easily cease the use of these medications, others find that they relieve psychological trauma and reduce stress. [These people are more likely to] try doctor shopping or even move to the illicit market.'
The Australian Alcohol and Drug Foundation (ADF) tells a similar story: that the number of Australians misusing pharmaceuticals increased from 7.4 per cent to 11.4 per cent in the 12 months between 2012 and 2013. And that substance abuse often starts with people using the medication to alleviate stress, anxiety, pain or insomnia without consulting a doctor.
"Epidemic is an emotive word but we do have a big problem with the over use of opioids; codeine, oxycodone, morphine, methadone and fentanyl," National Policy Manager at the ADF Geoff Munro told Mamamia.
"Opioids are powerful pain killers but the problem is they kill people when we take too much of them -- or when we mix them with alcohol or other drugs. Of all the accidental opioid deaths in Australia, seven out of ten are now caused by opioids prescribed by a doctor. Some don’t understand how to use them safely, and are taking too many, and for too long."
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Still, there remains a false sense of security, even complacency, when it comes to opioid misuse. These drugs don't lead to the crazed or psychotic episodes associated with methamphetamine usage. And, when purchased from the pharmacy, they're not laced with who-knows-what-might-harm-you as seen in the MDMA or ecstasy horror stories.
"Perhaps because the drugs are authorised by doctors and pharmacists we overlook the dangers, or are unaware of them," Munro said. "Pharmaceutical companies have promoted opioids to doctors as the most powerful and effective painkillers. As patients, we often demand a prescription and we want the most powerful medication."
But this oversight and 'quick-fix' mentality means people are dying and we are turning away.
In the U.S, overdoses are now the leading cause of death of people under 50, according to an analysis from The New York Times. And, in Australia, overdoses from prescription medications took more lives than road accidents in Victoria last year.
"With a high enough dose, the automated part of the brain stem (telling you to breathe in and out) can be stopped completely," medical practitioner and an expert in opioids and benzodiazepines, Dr Hester Wilson, told Mamamia.
"When it stops, there is no oxygen flowing to the heart and the person dies. This can happen when the dose is too high, or when opioids are mixed with other sedatives such as alcohol, relaxants, anti-histamines (allergy medication) and anti-depressants. Most of the coroner's cases I see are combination cases."
Cameron Daddo talks to Mia Freedman about addiction. Post continues below.
If those addicted to opioids aren't dying, they're at extreme risk of turning to stronger drugs such as heroin and fentanyl.
A 2014 study, which was published in JAMA Psychiatry, found 75 per cent of heroin users in treatment started their addiction with painkillers, Vox reports. As well as this, a 2015 analysis by the CDC found people who are dependent on painkillers are 40 times more likely to become addicted to heroin than those who are not.
This shows us: the 'opioid epidemic' is just the first phase.
Next, we will see the number of opioid painkiller deaths plateau and the number of heroin and fentanyl deaths increase, as people move from pain killers onto something stronger. This is what's happened in the U.S., according to data from the National Institute on Drug Abuse, and Dr Bright says a similar trend is beginning to occur in Australia: "The rate of heroin dropped in 2013 and, though 2016 data from the NDSHS has not yet been published, anecdotal evidence indicates that there has been an upward trend in heroin availability and use."
This increased demand means the illegal market becomes stronger, leading to the introduction of more potent, more dangerous, opioids.
"One of the key problems overseas has been the emergence of novel potent opioids such as carfentinal which are increasingly being found in batches of heroin and counterfeit opioid medications," Dr Bright told Mamamia. A form of carfentinal was what killed pop legend Prince last year.
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You can't just 'come off' opioids. Some people will never overcome dependency and will rely on medication to manage their addiction for the rest of the life.
For others, withdrawal is a process. "Symptoms include anxiety, stress, trembling, abdominal pains, sweating, diarrhoea, vomiting," Munro said. "Some people experience a craving where they feel compelled to keep taking the drug to avoid feeling nervous."
It has to be done in stages. Pulling someone off of pain medication entirely both increases the chances they'll seek out other, illegal forms of the drug, and also sky-rockets the risk of overdose. Why? Because lowering the dose reduces tolerance, while also increasing the chance of relapse, putting users at a "very real and very dangerous risk of overdose", the ADF warns.
At the moment, the darkness is pressing in from the outside. We are reading about it in headlines but we are constantly underestimating the extent and danger of opioid addiction: 'It won't happen to me', we tell ourselves. 'Addiction is the realm of junkies'; 'I am in control'.
None of these assumptions are true. These misconceptions are what lead to Robby McMahon slumped over in a car at 23. These throw-away lines are what lead to more than 52,000 deaths in the U.S. last year.
"Often people don’t realise they have a dependence problem until they try to stop taking the medication or they start suffering health or social complications because of their use," Wood told Mamamia.
Recognition is the first step in reducing harm and preventing the problem growing to 'epidemic' proportions within Australia.
Patients need to be aware of the dangers, and educated about the alternatives. Families of patients need to monitor dosages and look for signs of dependency. Doctors must consider other methods for treating patients in pain and start dealing with those already dependent on prescription medication.
There is a role in policy-making, too.
"Our medical system should reward doctors who treat people with minor pains and ailments by teaching them to deal with their conditions by non-medication means," Munro said. "We also need tighter controls on the advertising methods of pharmaceutical companies."
Real time prescription monitoring, as is seen in Tasmania, might help prevent doctor shopping; the mandatory prescription of Naloxone (an antidote that can reverse opioid overdose) might help reduce deaths; testing of illicit drugs is also an option to stop people dying.
But awareness is where the 'epidemic' begins and ends.
"There needs to be money spent on awareness raising and treatment before any prescription restrictions are implemented," Dr Bright said. "In the US a number of people who were accessing prescription opioids moved to the illicit market once restriction where placed on them. We don't want to see the same thing happen here in Australia."
The time to make the change is now. If we don't start talking about it, acknowledging it and realising the damage it can potentially cause, we won't stare the problem of opioid addiction in the face until it's way, way too late.