With independent public policy thinktank Australia21 publishing a landmark report Monday calling for a complete overhaul in the nation’s approach to illicit drugs, Professor Dan Lubman and Christian Smyth argue that the current system is broken.
In this piece for Croakey coinciding with the Australia21 release, Lubman and Smyth from Turning Point and Monash University warn that fatal overdoses in Victoria now exceed the number of road deaths and this is just the tip of the iceberg.
Professor Dan Lubman and Christian Smyth write:
Australia’s record on drug-related overdose deaths makes for uncomfortable reading – 88.1 per million of population, compared to 44.6 per million in the UK, 10.2 per million in the Netherlands and 3 per million in Portugal. There has also been a 61% increase in the number of accidental overdose deaths from 2004 to 2014.
Australians aged 40-49 are the most likely to die, with prescription medication being responsible for more overdoses (69%) than illicit drugs. Indeed, over the period 2008-2014, there has been an 87% increase in prescription opioid deaths.
So when we think of drug overdoses, we have to move away from the stereotype of the inner-city, alleyway heroin user, maybe destitute and probably young, and we have to wake up to the fact that in Victoria, overdose deaths now exceed the number of road deaths.
Victoria has a looming crisis in pharmacotherapy policy. Governance is unchecked and there is a disproportionate balance of opioid management in the hands of a diminishing number of GPs.
All patients on opioid maintenance therapy for addiction have to have a permit before the doctor starts prescribing and there are about 13,500 active permits, with limited review once approved. There are no limits on dosages prescribed or the number of patients allowed in a single prescriber’s caseload, meaning that there are a small number of prescribers who hold hundreds of permits, and others that prescribe well above current clinical guidelines.
This is a system that would not be tolerated in other areas of health.
Victoria has rested on a tired assumption that its system is superior by pointing out that states like NSW have long waiting lists for opioid maintenance treatment and that Victoria’s system is cost effective and normalises treatment of opioid addiction.
The reality is that after decades of underfunding addiction training and specialist support for doctors, the majority of GPs feel unskilled in this area of medicine, and hence are reluctant to get involved, meaning that Victoria has few GPs and pharmacists who are able to manage the number of Victorians needing opiate pharmacotherapy.
Last year there were 172 heroin-related overdose deaths in Victoria, many of which occurred in the City of Yarra, concentrated around North Richmond and Collingwood. This has led to a high degree of community concern, with a growing coalition of residents, health professionals, business associations and local government calling for the introduction of a supervised injecting facility to reduce deaths.
Similarly, community concern about public injecting and overdose in the Footscray area has been growing in recent years, whilst both local media and community health organisations continue to raise concerns about a paucity of drug services throughout the western suburbs more broadly.
In 2001, the Sydney Medically Supervised Injecting Centre (MSIC) commenced operation on a trial basis. Operating within a clinical model, the Centre’s primary objective was to reduce the morbidity and mortality associated with drug overdose. Staff included nurses who were authorised to administer naloxone.
In 2010, the New South Wales Government announced it would continue funding the MSIC on an ongoing basis after three comprehensive evaluations which were positive and broadly comparable with evaluation results of other similar supervised injecting drug facilities, mostly located in European cities. Among other things, the MSIC had treated a substantial number of overdoses that would otherwise have occurred in public places and without medical support, thereby increasing the risks to drug users and others.
The challenge for the major political parties is to reverse fifty years of ‘tough on drugs’ policy and to implement strategies that work.
The reality is that people are dying and families and the wider community, especially in North Richmond, are calling for solutions. And things could soon get much worse.
Tip of the iceberg
In New York State, where real time prescribing has been operating since they introduced the Internet System for Tracking Over-Prescribing (I-STOP) in 2012, heroin overdoses have increased by 25%.
Last week, New York’s Mayor Bill de Blasio announced that all 23,000 city patrol officers would be given naloxone to use on overdose victims, and that it would be available through pharmacies without prescription. He vowed to spend $38 million a year on a broad array of services, including expanding methadone and buprenorphine treatment for addicts, focusing on city hospitals on dealing with addiction and overdoses, and a more aggressive prosecution of illicit opioid distributors and heroin dealers.
Victoria will implement its own real time prescribing system within the next 2 years, and the experts are saying that New York’s experience is likely to be followed here in Melbourne. So what we are seeing now is just the tip of the iceberg.
The number of trainees and qualified addiction specialists in Victoria is low, due to a longstanding lack of investment in training and specialist positions. New South Wales, by way of contrast, has almost 10 times the numbers of addiction doctors in training, as well as a number of funded specialist positions within each health service.
The lack of a career pathway for doctors interested in pursuing a career in addiction means that Victoria is facing a future without such expertise, with an exodus of specialists to funded positions interstate in recent years, and many of the remaining cohort of addiction specialists nearing retirement.
Victoria needs to wake up to this crisis before the opioid bubble bursts.