Pharmaceutical drugs: The delicate balance between reducing pain and reducing harm

A public health based vision for the management and regulation of opioids

Prohibition of the possession of opioids for non-medical purposes and medical/pharmaceutical commercialization of opioids are important contributors to the current opioid overdose epidemic. A new model of regulation is urgently required. Within the context of a public health framework, we explore supply control, demand reduction, health promotion, and harm reduction and describe an alternative regulatory model that includes access for medical and non-medical purposes. Oversight of this proposed new system would include a control structure with an explicit public health mandate to minimize harms and maximize benefits of opioids. Medical access would be achieved through multi-disciplinary teams who would prescribe a range of opioids for 1) pain, 2) treatment for patients who develop opioid use disorder, and 3) other medical indications. Non-medical access could be achieved through models that would allow adults to purchase and use opioids for either supervised or take-home use. We describe three possible models to support jurisdiction specific discussions around the world. The first includes education and training that could result in certification with a basic or advanced license or a purchase authorization card. The second includes mandatory training that allows general access to opioids, but excludes people with problematic opioid use. The third model has optional training and excludes people with problematic opioid use. Allowing for inclusion of people dependent on the current illegal market during transition is highlighted. With any of these models, this approach, while attending to illegal market drivers, would result in a greatly reduced illegal opioid market and its attendant toxic products, reduced violence and corruption, and at the same time, provide a sharper focus for medical use with more appropriate prescribing and indications.

A comparison of opioids and benzodiazepines dispensing in Australia

Background

Inappropriate utilization of prescription opioids and benzodiazepines is a public health problem. This study examined and compared user-types and trends in dispensing of these medicines, and identified associated factors related to the duration of dispensing in Australia.

Methods

A random 10% sample of unit-record data of opioids and benzodiazepines dispensed nationally during 2013–2016 was analyzed. Users were categorized into four types: single-quarter (i.e., three months), medium-episodic (dispensed 2–6 quarters), long-episodic (dispensed 7–11 quarters), chronic (dispensed 12–16 quarters). Dispensing quantity was computed in defined daily dose (DDD). Generalized multilevel ordinal models were developed to examine the factors associated with the duration of dispensing.

Results

There were similarities in terms of trends of dispensing of opioids and benzodiazepines in Australia. Overall, more people were dispensed opioids than benzodiazepines. Around 52% of opioids users and 46% of benzodiazepines users were dispensed these medicines for a single quarter. However, chronic users were dispensed 60% of opioids and 50% of benzodiazepines in DDD/1000 people/day, respectively. On average, 16.6 DDD/1000 people/day of opioids and 14.2 DDD/1000 people/day of benzodiazepines were dispensed in Australia during the study period. Tasmania was dispensed the highest quantity (in DDD/1000 people/day) of these medicines, followed by South Australia and Queensland. Women compared to men, and clients of age-group 20–44, 45–64 and 65+ compared to age-group 0–19, were significantly more likely to have dispensed opioids/benzodiazepine for a relatively long duration. Clients with a history of dispensing of one of these two medicines were significantly more likely to have dispensed the other for a relatively long period.

Conclusions

There were similarities in patterns of dispensing of opioids and benzodiazepines in terms of user characteristics and structural variables. Consistent use of real-time drug monitoring program and tailored intervention are recommended.

An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions

Background

In an effort to control non-medical use and/or medical abuse of prescription drugs, particularly prescription opioids, electronic prescription drug monitoring programs (PDMP) have been introduced in North-American countries, Australia and some parts of Europe. Paradoxically, there are simultaneous pressures to increase opioid prescribing for the benefit of individual patients and to reduce it for the sake of public health, and this pressure warrants a delicate balance of appropriate therapeutic uses of these drugs with the risk of developing dependence. This article discusses pros and cons of PDMP in reducing diversion of prescription opioids, without hampering access to those medications for those with genuine needs, and highlights tensions around PDMP implementation.

Discussion

PDMPs may help alleviate diversion, over-prescription and fraudulent prescribing/dispensing; prompt drug treatment referrals; avoid awkward drug urine test; and inform spatial changes in prescribing practices and help designing tailored interventions. Fear of legal retribution, privacy and data security, potential confusion about addiction and pseudo-addiction, and potential undue pressure of detecting misuse/diversion - are the major problems. There are tensions about unintended consequence of excessive regulatory enforcements, corresponding collateral damages particularly about inadequate prescribing for patients with genuine needs, and mandatory consultation requirements of PDMP.

Summary

In this era of information technology PDMP is likely to flourish and remain with us for a long time. A clear standard of practice against which physicians’ care will be judged may expedite the utilisation of PDMP. In addition, adequate training on addiction and pain management along with public awareness, point-of-supply data entry from pharmacy, point-of-care real-time access to data, increasing access to addiction treatment and appropriate regulatory enforcement preferably through healthcare administration, together, may help remove barriers to PDMP use.

Triage in opioid replacement therapy: what's the wait?

In Australia, a wait for Opioid Replacement Therapy (ORT) has been reported although the magnitude is unknown. This study examined data recorded by one urban publicly funded ORT clinic (from 2009 to 2011) to identify if people (n = 803) were waiting for ORT assessment appointments and to explore how triage influences access to ORT. Data analysis incorporated descriptive methods and the use of Kaplan-Meier estimator of the cumulative incidence function. The implications and limitations of this study are included with further research suggestions.