Pharmaceutical drug misuse problems in Australia: Complex issues, balanced responses Roger Nicholas Nicole Lee Ann Roche Pharmaceutical drug misuse problems in Australia: Complex issues, balanced responses Roger Nicholas Nicole Lee Ann Roche Suggested citation: Nicholas, R., Lee, N., & Roche, A. (2011). Pharmaceutical Drug Misuse in Australia: Complex Problems, Balanced Responses. National Centre for Education and Training on Addiction (NCETA), Flinders University, Adelaide. ISBN: 978 1 876897 39 0 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the National Centre for Education and Training on Addiction, available from Level 3B Mark Oliphant Building, Science Park, Bedford Park, South Australia, 5042, Australia. Any enquiries about or comments on this publication should be directed to: Professor Ann Roche National Centre for Education and Training on Addiction (NCETA) Flinders University GPO Box 2100 Adelaide 5001 South Australia Australia. Published by the National Centre for Education and Training on Addiction (NCETA). www.nceta.flinders.edu.au Design and layout by Inprint Design www.inprint.com.au Foreword Over recent years, there has been growing awareness of potential harms that can result from the misuse of pharmaceutical drugs. This concern culminated in the decision by the Ministerial Council on Drugs (MCDS) through the Inter-Governmental Committee on Drugs (IGCD) to take decisive action to develop a comprehensive set of strategic responses. This task was overseen by Victorian Department of Health who in 2010 called for tenders to undertake the development of Australia’s first national strategy to address pharmaceutical drug misuse. The National Centre for Education & Training on Addiction (NCETA) headed a consortium that was awarded this tender. As part of the process of developing the strategy, a comprehensive examination was undertaken of relevant contextual factors. This document provides a summary overview of these contextual factors. It is hoped that this document will contribute to understanding the complex nature of pharmaceutical misuse and will help inform appropriate preventive responses. NCETA The National Centre for Education and Training on Addiction is an internationally recognised research centre that works as a catalyst for change in the alcohol and other drugs (AOD) field. Our mission is to advance the capacity of organisations and workers to respond to alcohol-and drug-related problems. Our core business is the promotion of workforce development (WFD) principles, research and evaluation of effective practices; investigating the prevalence and effect of alcohol and other drug use in society; and the development and evaluation of prevention and intervention programs, policy and resources for workplaces and organisations. NCETA is based at Flinders University and is a collaboration between the University, the Australian Government Department of Health and Ageing and the SA Department of Health. Pharmaceutical drug misuse in Australia: Complex problems, balanced responses. i ii Pharmaceutical drug misuse in Australia: Complex problems, balanced responses. Acknowledgements The authors are particularly indebted to Dr Malcolm Dobbin from the Victorian Department of Health for sharing information and data and for his support throughout the development of this review. A range of groups and individuals also provided input into this review as follows and their efforts are gratefully acknowledged. The Project Management Committee for the National Pharmaceutical Drug Misuse Strategy (NPDMS) from the Victoria Department of Health: Mr Pier DeCarlo Dr Malcolm Dobbin Ms Jenny Holmes Ms Irene Tomaszewski Members of the NCETA NPDMS Project Consortium Group: Associate Professor Robert Ali (University of Adelaide) Ms Carol Bennett (Consumer Health Forum of Australia) Dr Penny Briscoe (Royal Adelaide Hospital) Mr Colin Brown (SA Health) Professor James Dunbar (Flinders University) Professor Michael Kidd (Flinders University) Ms Anne Lawrance (NSW Health) – Technical adviser Ms Tania Steenson (NCETA, Flinders University) Professor Jason White (University of SA) Members of the NPDMS Project Steering Committee: Ms Pat Ward (NSW Police) Mr Michael Gorman (Victoria Police) Mr Michael Pitt (Australian Government Department of Health and Ageing) Mr Michael Bolt (Australian Government Department of Health and Ageing) Mr Bruce Battye (NSW Health) Ms Fiona Wynn (NSW Mental Health and Drugs and Alcohol Office) Superintendent Patrick Paroz (NSW Police) Ms Sarah Gobbert (NT Health) Dr Sue Ballantyne (Queensland Health) Det Sergeant Mick Ackery (Queensland Police) Sergeant Adam Frost (Queensland Police) Ms Simone Cormack (SA Health) Mr Steve Morris (SA Health) Ms Maryann Elias (SA Health) Ms Sylvia Engels (Tasmania Health) Dr Adrian Reynolds (Tasmania Health) Ms Anna Gelavis (WA Health) Superintendent James Migro (Western Australia Police Service) Ms Jacqueline Durand (Australian and New Zealand Policing Advisory Agency) Mr Kim Bessell (Australian Health Ministers Advisory Council) Dr Allan Quigley (Australian Health Ministers Advisory Council) Members of the NPDMS Project Expert Reference Group: Associate Professor Yvonne Bonomo (RACP Australasian Chapter of Addiction Medicine) Professor Jon Currie (RACP Australasian Chapter of Addiction Medicine) Dr Penny Briscoe (Faculty of Pain Medicine, ANZ College of Anaesthetists) Dr Michael Nolan (Australian General Practice Network) Professor Dan Lubman (Royal ANZ College of Psychiatrists) Pharmaceutical drug misuse in Australia: Complex problems, balanced responses. iii Dr Lynn Weekes (National Prescribing Service) Mr Irvine Newton (Pharmaceutical Society of Australia) Ms Kate Mackie (Society of Hospital Pharmacists of Australia) Mr Stephen Marty (Pharmacy Board of Australia) Professor Jason White (University of SA) Detective Superintendent Nick Bingham (NSW Police) Superintendent Charlie Carver (WA Police Service) Ms Christine Vincent (Victoria Police) Dr Suzi Nielsen (Alcohol and other Drugs Council of Australia Pharmaceutical Drug Working Group) Ms Ros Burnett (Drug and Alcohol Nurses Association) Professor Margaret Hamilton (Australian National Council on Drugs) Ms Mary Sharpe (Tas Department of Health and Human Services) Mr Matthew McCrone (Department of Health, Victoria) Mr Kim Bessell (Australian Government Department of Health and Ageing) Mr Sam Liebelt (Australian Injecting and Illicit Drug Users League) Ms Coralie Wales (Chronic Pain Australia) Associate Professor Nicholas Lintzeris (Drug and Alcohol Services, South Eastern Sydney and Illawarrah Area Health Service) iv Pharmaceutical drug misuse in Australia: Complex problems, balanced responses. Table of Contents Executive Summary viii PART A: WHAT’S THE PROBLEM? 1 Extent and nature of pharmaceutical drug misuse problems in Australia 2 1 Which groups misuse pharmaceutical drugs? 3 2 Levels and patterns of misuse 5 2.1 Use among the general population 5 2.2 Pharmaceutical drug misuse among illicit drug users 5 2.3 Drug treatment data 7 2.4 Pharmaceutical drug misuse and offending 8 3 Drug supply patterns 10 3.1 Opioids 10 3.2 Benzodiazepines 12 4 Knowledge gaps 13 4.1 Monitoring, research and data sharing limitations 13 4.2 Indigenous Australians 14 4.3 Limitations of Pharmaceutical Benefits Scheme data 14 5 Evidence of harms 16 5.1 Fatal and non-fatal overdoses 16 5.2 Problematic routes of administration 17 5.3 Demand for treatment 18 5.4 Harms associated with over the counter medicines 18 5.5 Illicit sale of pharmaceutical drugs 18 5.6 Problems among individuals without a history of illicit drug use 18 6 Police data 19 6.1 Police trend data 19 6.2 Police data from 2009 20 7 How drugs are obtained 21 8 Systemic factors 23 8.1 Multiple formulations of opioids, especially slow (or controlled, or modified) release forms 23 Pharmaceutical drug misuse in Australia: Complex problems, balanced responses. v 8.2 Hospital discharge planning arrangements 23 8.3 Access to comprehensive pain management 24 8.4 National registration of health practitioners 24 8.5 Access to drug treatment, opioid substitution therapy options, access and dispensing fees 25 8.6 Availability of adjuvant drugs on the PBS 26 8.7 Returning Unwanted Medications (RUM) Project 27 8.8 Intimidation of prescribers by patients 27 9 Demographic factors 28 9.1 Ageing of Australia’s population 28 9.2 Ageing opioid substitution clients 30 10 International developments 32 10.1 Global issues 32 10.2 North America 35 10.3 Global promotion of pharmaceuticals 39 11 Good practice in opioid prescribing and pain management 40 11.1 Introduction 40 11.2 The role of opioids in the treatment of chronic non-malignant pain 40 11.3 Universal precautions 43 11.4 Hyperalgesia 44 11.5 Cost effectiveness of general practice care for lower back pain 44 11.6 Summary 44 12 Good practice in benzodiazepine prescribing 46 12.1 Sleep disorders and use of benzodiazepines 46 12.2 Anxiety and use of benzodiazepines 47 12.3 Prescribing for withdrawal 47 12.4 Use of benzodiazepines in opiate dependent patients 47 13 Medication shopping 48 13.1 A note on terminology 48 13.2 Evidence of medication shopping 48 13.3 Reasons for and methods of medication shopping 49 13.4 The Medicare Australia Prescription Shopping Program 49 13.5 Medication shopping online 50 PART B: THE BROADER POLICY CONTEXT 52 14 Key stakeholders, paradigms, policies and activities 53 14.1 Introduction 53 14.2 Key stakeholders 53 vi Pharmaceutical