Killer Pain Meds In A Patch
By Joel TozerNovember 11, 2012
Pain medication fentanyl is liberally prescribed by Australian doctors, with increasingly fatal consequences.
Bernadette Williams, 27, had been preparing herself for a phone call like this for years.
“Mum’s gone,” said her auntie, crying into the telephone.
“What? Your mum, or mine?” Bernadette replied.
Bernadette’s mother and her nan, both addicted to painkillers, had been living together for more than seven years, all the while sharing any type of drug they could get their hands on. In the drawers of their home, in the regional New South Wales town of Albury, were dozens of prescriptions for pain medication, such as valium and fentanyl. In the pockets of her mother’s handbag there were always empty tablet packets.
“Straightaway, I knew it was drugs,” Bernadette says.
Bernadette’s mother died of a drug overdose and heart complications on June 29, 2011. She was 45 years old. Her nan found her mother passed out on the edge of a mattress with three fentanyl patches stuck to her body. Each patch contained a powerful dose of this pain medication that is 100 times stronger than morphine.
Fentanyl was what her nan’s local doctor prescribed to treat her stomach pain which was caused by pancreatitis; she would often share the patches with her daughter.
“Eventually it got to the point where they accused each other of taking one another’s medication to cover up the fact they both had a problem,” Bernadette says.
Just months after her mum’s death, Bernadette’s nan also died, of heart complications.
Fentanyl patches, which come in a range of doses, are widely used to treat pain in patients with terminal illnesses, or after operations. But the numbers of prescriptions being issued for the drug have sky rocketed, with some medical professionals suggesting it is now being used to treat aches and pains that it was never intended to remedy.
“Patients who complain for the first time of a significant headache or maybe a recurrent migraine are possibly going to get a fentanyl patch these days, which is absolutely unnecessary, inappropriate and carries with it the risk of dependence,” says Dr Bob Batey, a former clinical advisor to the NSW health department.
Fentanyl prescriptions are being given out 60 times more frequently than they were just over a decade ago. More than 450,000 fentanyl prescriptions were issued in 2009 under the Pharmaceutical Benefits Scheme (PBS), compared with fewer than 8,000 scripts in 1998.
The PBS determines which medicines will be subsidised by Australia’s federal government and to what extent they’ll be subsidised for different categories of patients. In 2006, a change to the scheme’s listing for fentanyl made it available not only to patients with terminal illnesses such as cancer, but also to some people with chronic pain.
Patients who are prescribed the drug are directed to stick the patch onto their skin, through which the drug is gradually absorbed into the body, providing pain relief for about three days. Doctors say fentanyl is extremely effective because it is fast-acting and has minimal immediate side effects, such as the nausea and vomiting, which are common when using other painkillers such as oxycodone.
Highly potent, fentanyl, is also highly addictive.
Fuelling a black market
Drug workers at syringe exchange programs in regional New South Wales and Queensland told The Global Mail of a lucrative black market for fentanyl patches, known on the street as “stickers”. Addicts extract the drug from the patch and boil it down in order to inject it directly into their bloodstream — this delivers a three-day dose in one potentially deadly hit.
“Going back a year, year-and-a-half, it was really something we hadn’t heard of,” a drug worker from Queensland told The Global Mail on the condition of anonymity. “And then it came onto the scene with fatal overdoses happening on the Gold Coast, Sunshine Coast and Cairns.
“We had a client the week before [who] came in with a box of it, which is five patches, which he got from the doctor. He knew about the dangers, but he came to get his needles and he was just psyched up, ready to go and use it.”
Fentanyl users describe the “high” as a warm feeling throughout the body, which is accompanied by loss of pain and a pleasant dulling of anxiety. Bernadette says that fentanyl gave her mother “the calming effect that slowed her down and helped her to just pass out or not feel anything”.
Drug workers say addicts usually buy their fentanyl on the street. It’s a profitable business for sellers — a box of five patches can be purchased with a script for as little as $5.80 and is then sold on the street for anywhere between $25 to $100 a patch.
“I’ve heard that people are going through the trashcans at hospitals or at nursing homes, dumpster diving and getting it that way,” the Queensland drug worker says. “Older people are getting them prescribed and people are offering them a lot of money for these patches.”
Other people go straight to their doctor for a script. Health experts say getting a script for powerful drugs such as fentanyl has become all too easy, with many local doctors being targeted by addicts who don’t actually suffer chronic or severe pain.
“Drug-seeking people are very good at telling stories of terrible migraines, crippling back pain, et cetera, and they can convince practitioners to write pain scripts,” says Dr Batey.
“Many patients will — and I talk about this after 30 years of it — come in and say ‘I can’t take buprenorphine, I can’t take morphine I’m allergic to that. The only drug that works is…’. They set it up so the poor doctor doesn’t have a choice to do anything other than write a script for fentanyl.”
Doctor-shopping for prescriptions — that is, cultivating more than one source of supply — is common among addicts. The practice is possible partly because there is no official register or means of checking whether another doctor has prescribed a patient the same medication.
Bernadette says her mother was a master at doctor-shopping, targeting doctors who were new to the region. “She might be having two doctors going at one time, so she could sort of cross over with what she was getting, and then go back and get more of the next drug,” she says.
This could be your last hit
Dr Batey says many doctors aren’t aware of how the drug can be misused.
“I think there is a significant lack of awareness [among doctors] of the ability to extract this product [from] patches,” he says. “There is a very big responsibility for doctors [who prescribe it] to be aware of all of the issues surrounding its use.”
Dr Batey says he is concerned that fentanyl abuse is following the same trajectory as that of the opioid, oxycodone, which provides a chilling example of how the use of prescribed drugs can get out of control.
Oxycodone is now one of the most widely prescribed opioids in Australia, with almost 2.5 million scripts for the drug written in 2009. Fatalities linked to oxycodone use have been widely publicised, with 465 oxycodone-related deaths recorded between 2001 and 2009.
Fentanyl is relatively new to the streets, and it has become popular with addicts whose tolerance for drugs such as oxycodone has grown. Drug workers say that many addicts are “cocktailing” fentanyl, using it simultaneously with other opioids, and thereby increasing the risk of overdose.
“I think for a lot of injectors the attraction [of fentanyl] is the adrenaline rush, that this could be your last hit. It’s like anything I suppose, if you are taking it for the first time it’s good and then over time you get immune to it, so you take more,” a NSW drug worker told The Global Mail on the condition of anonymity.
“There’s a lack of knowledge about how powerful the drug is. I think over time, the more people that overdose on it, I think it will become a lot less popular. People will learn, unfortunately, from other people’s mistakes.”
New figures released by the National Coroners Information System show the number of deaths related to fentanyl misuse is rising each year. The figures don’t offer a complete picture of the issue, but are indicative of a worrying trend; the NCIS report shows that at least 26 deaths in 2011 were associated with fentanyl, compared with 10 in 2008, and at least 32 deaths related to fentanyl are still under investigation with the coroner.
The majority of these deaths were registered as unintentional, and most occurred after the drug in the fentanyl patch was extracted and injected
“The numbers are still small, I guess that is the key issue,” Dr Batey says. “Now that people are more aware [doctors will] start asking more questions about whether [patients have] been using agents other than the standard opioids and we may get a more systematic collection of accurate data coming in.”
Australia’s growing opioid death toll
In the meantime, prescription-related deaths are becoming more prevalent in rural and regional towns, according to drug workers who spoke with The Global Mail. Anecdotal evidence suggests that the misuse of prescription drugs is more frequent in these areas because access to illicit drugs such as heroin and cocaine is limited.
Towns such as Albury and Wodonga, which sit opposite one another on the New South Wales-Victorian border, have become regional hotspots for the misuse of these prescription drugs.
“There has been a lot of new doctors coming into the Albury area, a lot of new clinics. So it is easy for people to go around and doctor shop at the moment,” Bernadette says.
“There are a lot of people in the Albury area who just sell off their medication. People are getting away with it too easily here. They are just going to keep pushing to see how much they can get away with.”
In Victoria, fentanyl recently made headlines when it was revealed that hundreds of vials of the painkiller had been stolen and replaced with tap water. The Age newspaper reported that three paramedics from Ambulance Victoria have been fired for stealing the drug, while at least two others have stood down pending an investigation by Ambulance Victoria.
Figures from the Victorian coroner’s court indicate that at least 15 people in the state have died of fentanyl overdoses since December, 2011.
National statistics support state findings that deaths from opioid misuse are on the rise all over the country. At least 500 Australians died from of an opioid overdose in 2008, compared with 360 in 2007, according to the latest available figures released by the National Drug and Alcohol Research Centre. Estimates put the 2010 death toll at more than 700 people.
While the death rates from overdose are significantly lower than a decade ago, when heroin was more readily available, the latest deaths are largely the result of opioids other than heroin — such as oxycodone or morphine. And preliminary estimates for 2009-10 show that deaths among 35 to 44 year olds have, for the first time, overtaken deaths among younger age groups.
“The age of the deaths is probably likely to get older as time goes on because the injecting drug users that we’re talking to for our programs, they’re getting older and they’ve stayed in the market [for opioids],” says Amanda Roxburgh, lead researcher of the NDARC study.
The only positive news to come out of the study, Ms Roxburgh says, is that the death rate is not increasing among those aged 15 to 24 years — it has stabilised at around 50 deaths a year, compared to 250 in 1999.
“We’re not seeing the same trend among younger Australians and we think most of them left the market after the [heroin] shortage,” she says.
A doctor’s prescription
To try to arrest the illegal trade in prescription drugs, the federal Department of Health and Ageing is currently developing a national, electronic database that will record the prescriptions of opioids. This would allow the department to identify people who are doctor-shopping, and to block the issue of repeat scripts in such cases.
Dr Batey says there are a number of barriers to getting the database up and running, and cites cost and state-to-state rivalries as the greatest among them. He adds that while the register would provide accurate prescription data for most patients, there would remain holes in the system.
“Obviously the way around [it] is to change your name from one doctor to the next and appear as somebody else. But if it is linked to a Medicare card, that will be harder to pull off,” he says.
The most effective method of addressing the misuse of prescription drugs, Dr Batey says, would be to create awareness that opioids are not the best answer to chronic, non-malignant pain.
“The answer to the problem is using less opiates to start with, setting a limit and letting the patient know that once we get to that limit we’re going to have to look at other methods for relieving pain,” he says.
Bernadette Williams’s message to doctors is simple: fewer prescriptions will mean fewer deaths.
“They should be more careful because they are playing with not only one person’s life, but most people have families and kids,” Bernadette says. “They are messing with lives and they are messing with the community.”