Pills prove a prescription for addiction

''Worked like magic'' … Narelle Caldwell says the drugs she was prescribed were very effective at first but she soon fell into addiction.
''Worked like magic'' … Narelle Caldwell says the drugs she was prescribed were very effective at first but she soon fell into addiction.

When Narelle Caldwell suffered an agonising back injury two years ago, she was grateful to receive one of the strongest painkillers on the market.

At first, the opioid known as oxycodone worked like magic, dissolving the pain from a slipped disc between her shoulder blades almost instantly. But, over the course of a few weeks, its power started to wear off. Fearful her pain would return, Caldwell started to watch the clock. She was counting down the minutes until she could take another pill.

''It completely took over my thinking,'' she says. ''I couldn't function without them. I was completely consumed by the fear of the pain and what it was going to do to me.''

The oxycodone gave her a pleasant feeling, too. Not a euphoric high but a sense of relief and relaxation. Caldwell tried to stick to the recommended times to take her pills but, as her tolerance grew, she couldn't resist taking them more often. After two months of chasing her pain with various opioid formulas and other medications to offset their side effects, her boss suggested she do a three-week pain management course.

She agreed and, when she got in, a doctor told her she had to come off the drugs so she could find other ways to manage her pain. It was going to be an uncomfortable ride because, whether she liked it or not, she was already dependent and had to withdraw.

''It was amazing. When I stopped taking them, I went through the whole thing. I had night sweats, I couldn't sleep, I was agitated and fidgety and I was having mood swings,'' Caldwell says. ''It took about two weeks for the drug haze to lift.''

Since the course, Caldwell, 49, has stayed off opioids and now manages her pain with meditation and exercise, among other things. She says her short time on oxycodone introduced her to the intense pull of addiction. She can see how some get lost forever.

''I'm so glad I got into that program because if I didn't, I would still be taking those drugs and wouldn't have a life,'' she says.

Caldwell, a well-educated woman who has never smoked, let alone taken illicit drugs regularly, is one of a growing number of Australians to have been hooked on opioid painkillers.

Prescription of the drugs, which were once reserved for acute pain such as broken bones or post-surgical wounds, have soared over the past two decades as doctors started thinking they were useful for chronic pain and degenerative conditions such as arthritis. But the shift has had unintended consequences. Many patients are being given them for too long, causing them to spiral into addiction or, worse, overdose.

Wider availability of the drugs has also created a thriving black market. As drug companies started making them in every conceivable form - pills, patches, syrups, suppositories and nasal sprays - illicit drug users increasingly realised their value.

In the US, where opioids have been prescribed most liberally, more people are using the drugs for pleasure than heroin, cocaine, hallucinogens, ecstasy and inhalants combined.

Australia is heading in the same direction. The last national drug survey found non-medical use of prescription drugs was 21 times more common than heroin use. While many are happy to pop pills, the injecting drug-using community has learnt how to crush tablets and modify skin patches so the drugs can be injected for a more intense high. The trend is so strong that doctors at Sydney's medically supervised injecting centre recently reported two-thirds of their 225 daily clients were now injecting prescription opiates.

Growing demand has meant doctors are being asked for the drugs more often. While many can spot drug-seeking behaviour and report it to health authorities (more than 100,000 suspected ''doctor shoppers'' were reported to Medicare last year), some are still being tricked by scams.

Several Australian health departments have warned doctors about new methods, including fake prescriptions being generated from images on the internet and people successfully posing as doctors to convince others the prescriptions they are asking for are legitimate.

According to the Victorian Department of Health, one person recently used a fraudulent letter from a hospital specialist to obtain 820 OxyContin tablets in two months from 22 doctors. Others have stolen sheets from prescription pads while their doctors were not watching.

Some doctors now believe elderly people - the group most commonly prescribed opioids - are selling their drugs or passing them on to demanding friends and relatives who are misusing them. The phenomenon, known as ''fossil pharming'', is worrying Adelaide pain specialist Dr Penny Briscoe, who says all Australian patients on opioids should be routinely drug tested to make sure they are actually taking their drugs.

''People are saying they are getting them out of their grandmothers' cupboards and we've had one palliative care patient admit to selling them to supplement his income, so diversion is occurring, we just don't know how common it is,'' she says.

Briscoe says urine testing would also allow doctors to check patients are taking their medication safely because people on opioids are at high risk of overdose if they mix them with alcohol or other drugs.

She says that in the US, where monitoring of all patients on opioids is recommended, up to 20 per cent of patients have urine and drug screens that do not match the medication they are reportedly taking.

''If you do the test and you get an unusual result, it gives you the chance to sit down with the patient and say 'OK, I'm really confused - this isn't showing up as it should so perhaps you and I need to have a chat about this'. Colleagues in Perth have said it's quite useful in that it lets someone say 'well, actually, I haven't told you something, doc'.''

In most cases of accidental and intentional overdose deaths, patients have mixed their drugs with alcohol or medications, causing respiratory failure or aspiration - the inhalation of saliva, food or drink into their lungs.

Research by the National Drug and Alcohol Research Centre at the University of NSW recently found 500 Australians aged 15 to 54 died of an opiate overdose in 2008, up from 360 in 2007. Only one-third involved heroin. Preliminary figures suggest there were 612 such deaths in 2009, a 22 per cent increase from 2008, and 705 in 2010, a 15 per cent increase.

Dr Mike McDonough, the head of addiction medicine at Melbourne's Western Hospital, says while concern about prescription opioids has been growing in Australia for years, there is now a universal feeling among doctors it is getting out of control.

While some people can function well on opioids for a long time, he says the painkillers are turning some ordinary people with no history of substance abuse into addicts. In some specialist pain clinics, he says, these people are sharing tips in waiting rooms about how to crush their tablets and inject them because their doctors are not giving them enough to satisfy their need.

McDonough says doctors and governments are debating ways of limiting supply of the drugs to reduce harm in a way that does not deny doctors reasonable access to them to treat pain. While opioids have their place, he says GPs need to know there is no evidence supporting their long-term use for chronic pain, which affects about one in five Australians.

However, many GPs are already in a difficult place with patients dependent on the drugs. Long waiting lists of up to a year for specialist pain and addiction medicine mean many GPs are continuing to prescribe them for patients who should be ending their use of such medication.

The head of clinical services at Turning Point Alcohol and Drug Centre, Dr Matthew Frei, says this shortage of services is exacerbating the problem for people because the longer they stay on the drugs, the more risks there are to their health.

GP and addiction medicine specialist Dr Philip Crowley says a lack of government support means there is also a shortage of GPs willing to provide proven pharmacotherapy treatments such as methadone and buprenorphine to people.

''As a GP, I can earn more money treating someone for a cold than treating someone for an opiate addiction, so the economics are against it,'' he says. ''These people are complicated patients as well. They take time and they are high risk. If something goes wrong, they can die.''

Crowley says people wanting to go on these treatments have to pay between $25 and $50 a week for them when they could be spending less money on the drugs they actually want.

''The argument has always been 'oh well, it's cheaper than heroin' but, these days, you can get 20 tablets of morphine for $6 if it's subsidised through the government, so the government is actually subsidising the problem without helping with treatment,'' he says.

The federal government announced in February that it would spend $5 million on a real-time prescription monitoring system to help doctors see a patient's prescription history so they can curb ''doctor shopping''.

The national system was to be made available to the states and territories by July this year but, so far, only South Australia, Western Australia and the ACT have signed licences to access the system.

Last month, the Victorian government said there was ''significant detail to be worked through'' to see if the scheme would work and warned it was no ''magic bullet''. Funding issues are believed to be at play between the states and the federal government.

A federal government spokeswoman refused to say when the system would be running but said it had the backing of all states and territories and would be implemented as soon as possible.

Associate Professor Milton Cohen, a pain specialist at St Vincent's Hospital, says the delay is frustrating because misuse and abuse of opioids is exacerbating stigma for people with chronic pain.

''People with chronic pain are already called bludgers or accused of putting it on and now, if they're being prescribed these drugs, they are presumed to be addicts,'' he says. ''Opioids are not the be all and end all but, if they're used properly, they can improve people's quality of life. We're interested in the quality use of opioids, using them for the right person at the right dose and for the right time so, if this is getting out of hand, we need to be able to track it.''

Caldwell backs the call for action. She says the government should boost specialist pain management services so people can learn to cope with pain without drugs sooner rather than later.

''You really have to learn to control the pain yourself without the drugs and through other natural therapies but that takes a long time,'' she says. ''People need strong support from professionals to get to that point.''

Habits put in the spotlight

Fairfax Media is partnering with the Global Drug Survey, created by Adam Winstock, a psychiatrist and researcher in London, to help create the largest and most up to date snapshot of drug and alcohol use in Australia and how we compare with the rest of the world.

Mr Winstock says last year's survey - filled out by 15,000 people globally, including 500 from Australia - showed that, for many, drug use was characterised by confusion and dishonesty.

''People are appalling at knowing how their drug use compares to other people,'' he said.

Nearly 40 per cent of people asked about their drug use by their GP either lied and said they never used drugs, or downplayed their use. About 22 per cent of alcohol drinkers did the same.

Dr Winstock said he created the project to capture a broader snapshot of drug use than is usually available.

''Most governments are interested in drug use patterns among the sickest and most disadvantaged,'' he said. ''But that represents a fraction of the people who use drugs''.

Results of the survey have been published in BMJThe Lancet and Addiction and have helped produce a project called the drugs meter, where people can find out how their drug use compares with others.

You can take part of the global drugs survey over the next month at globaldrugsurvey.com/mixmag2013.

The Australian results will be published exclusively by Fairfax Media early in 2013.

The survey will ask questions about your use of specific drugs, what happens if you are caught with them, new drug trends and the consequences of your drug use.

It will also ask about the short and long-term benefits and harms of different drugs.

This story Pills prove a prescription for addiction first appeared on The Sydney Morning Herald.