New Zealand’s emergent opioid trends - the influences and impacts: Consumer and clinician understanding of New Zealand’s changing patterns of opioid use, availability and impacts Klare Braye A thesis submitted in partial fulfilment of the requirements for the degree of Master of Health Sciences Department of Psychological Medicine University of Otago, Christchurch New Zealand 2014 “Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium”. (Sir Thomas Sydenham, 1680) ~ iii ~ Abstract This thesis explores opioid users and addiction service providers’ understandings of the changing patterns, availability and impacts of opioids and opioid use in New Zealand with a particular focus on the last two decades. Throughout history, the availability of substances of abuse have waxed and waned. Their emergence and availability is influenced by social, legislative and political circumstances. Extensive literature exists related to the use of opioids such as morphine and methadone in New Zealand, and heroin overseas. However, few studies have examined the emerging trends of opioids that are often used as adjunctively to these substances; examples of which in recent years include poppy seed tea (PST), over-the- counter codeine-containing analgesics and most recently some prescribed pain medications. Information regarding the use, availability and impacts of these adjunct opioids from the consumers who use them, and the clinicians who work with these consumers could usefully inform service provision and public policy. This qualitative study, adopting a Husserlian phenomenological philosophy was used, to gain an understanding of the use, access to and implications of these emergent opioid trends. Nine opioid users and five service providers were recruited through purposeful sampling as key informant participants. Their stories were elicited through in-depth interviews and analysis allowed for descriptive interpretation of participants’ experiences to emerge. The experiences described by participants were varied, although a general pattern indicated the ebb and flow of the adjunctive use of a range of opioids in New Zealand. The diverse and at times, localised sources of supply of these opioids are described. The roles of legislative processes and policy, government agencies, pharmaceutical companies, prescribers, pharmacists, and the users themselves as creative and flexible people are discussed. The findings of this study offer insights into the ways in which opioid availability is inextricably interwoven with the impacts that availability can have on the user. Reference is made to mortality and morbidity, as well as the impacts of ~ v ~ displacement; the unintended consequences of stigma, discrimination, and criminalisation; and the accessibility of some opioid formulations, notably metered doses and abuse deterrent formulations (ADF). Overarching these descriptions is the sense that opioid users are in the main resourceful and adaptable, and that opioids hold a persistent place in the lives of dependent users. Recommendations from this study fit within a harm minimisation perspective that considers the needs of the dependent user, alongside the general population and a context of ‘public good’. These findings and recommendations support the need to appreciate the challenges facing opioid users who access treatment or support for their substance use; to consider the availability and access to a range of opioids from the perspective of minimising harm; to carefully consider the responsibilities of a number of stakeholders; to inform treatment delivery, workforce development and in the consideration of policy development and implementation. ~ vi ~ Acknowledgements My greatest appreciation goes to the participants in this study, without whom this work would not have been possible. The openness, honesty and willingness to share their stories with me was humbling. Many thanks also to the staff at both the needle exchange (Drugs and Health Development Project) and opioid treatment service who affirmed my interest in this study and aided me in the quest for service user participants. Secondly, I am indebted to my children, Hayleigh and Olliver, who tolerated their mum’s grumpiness, maintained sanity in the house and reminded me of what was important in life. And to my partner, Phil, who did not know what he was getting himself in to, but journeyed alongside me the whole way. Thank you. Special thanks goes to Dr. Ria Schroder, my primary supervisor and Dr. Daryle Deering for their encouragement, support and often all too honest feedback that guided me in my blindness to a better place of understanding in both the formulation of this thesis and in my own journey as a research student. I am looking forward to resuming conversations with them above and beyond the world of thesis writing. I must also thank all those who have assisted in the proof reading, transcribing, editing and formatting of this work, especially Helen, who ensured anonymity by being 12,000 miles away. And to Sarah - for your motivation and encouragement to keep on going. You never got to see me through the finish line, but I know that you will always be there with me. Miss you. ~ vii ~ Table of contents Abstract ..................................................................................................... v Acknowledgements ................................................................................ vii Table of contents ..................................................................................... ix List of figures ........................................................................................... xv List of abbreviations ..............................................................................xvii Chapter 1 - Introduction ........................................................................... 1 1.1 Context ........................................................................................................ 1 1.2 Thesis overview .......................................................................................... 3 1.3 Terminology ................................................................................................ 4 1.3.1 Introduction ................................................................................................4 1.3.2 Drugs and medications ................................................................................5 1.3.3 Opioids .......................................................................................................5 1.3.4 Substance use ..............................................................................................6 Chapter 2 - Literature Review .................................................................. 9 2.1 Introduction ................................................................................................. 9 2.2 Literature searches .................................................................................... 10 2.3 Common substances reported in this study ............................................... 10 2.3.1 Introduction .............................................................................................. 10 2.3.2 The opioids ................................................................................................ 11 2.3.2.1 The opium poppy - Papaver somniferum .............................................. 11 2.3.2.2 Poppy seed and poppy seed tea ............................................................ 11 2.3.2.3 Morphine ............................................................................................. 12 2.3.2.4 Codeine ............................................................................................... 12 2.3.2.5 Methadone........................................................................................... 13 2.3.2.6 Oxycodone .......................................................................................... 13 2.3.2.7 Buprenorphine (Suboxone) .................................................................. 14 2.3.2.8 Fentanyl .............................................................................................. 14 2.3.2.9 Over-the-counter (OTC) opioid analgesics ........................................... 15 2.3.3 Precursors................................................................................................. 15 2.4 Patterns of opioid use ................................................................................ 16 2.4.1 Introduction .............................................................................................. 16 ~ ix ~ 2.4.2 Historical context of opioid use ................................................................. 16 2.4.3 Challenges of identifying drug use, patterns and prevalence ...................... 20 2.4.4 International prevalence ............................................................................ 21 2.4.5 New Zealand prevalence ........................................................................... 23 2.4.6 Summary ................................................................................................... 24 2.5 Opioid availability ..................................................................................... 25 2.5.1 Introduction .............................................................................................. 25 2.5.2 Treaties, legislation and policy influencing availability ............................