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Fentanyl
<p>Courtesy Bernadette Williams</p>

Courtesy Bernadette Williams

Bernadette Williams with her mother, who was found passed out with three fentanyl patches stuck to her body.

Killer Pain Meds In A Patch

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.

<p>The Global Mail</p>

The Global Mail

A fentanyl patch containing a three-day dose of the painkiller.

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.

<p>The Global Mail</p>

The Global Mail

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.

“We had a client the week before that 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.”

“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.

<p>The Global Mail</p>

The Global Mail

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.

<p>The Global Mail</p>

The Global Mail

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.

Bernadette Williams’s message to doctors is simple: fewer prescriptions, mean fewer deaths.

“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.”

16 comments on this story
by Dean

Abuse of prescribed opioids is a tragedy in two ways; death and harm to the abusers and it makes life far more difficult for legitimate users. I believe the UN made pain relief a human right recently so what should a doctor do if people with addiction issues act the same as people with physical pain. One of the initial selling points of the patches is that they are less likely to lead to addiction (slow release rather than high peaks) and harder to abuse than tablets (crush, inject) and this is part of the reason for their increased use.

The only thing standing in the way of more effective management are privacy laws, the data on usage already exists. As a pharmacist I send a report on dispensing of all controlled opioids to the health department every month. All that is needed is for this data to be utilised in an alert system, similar to Project Stop for cold and flu, or allow doctors access to a patient's history before prescribing, even though this partly deprives patients of their right to lie to their doctor.

November 12, 2012 @ 6:44pm
by Gweneth

As a person who uses fentanyl patches for chronic cancer pain these stories are worrying. You really do need help to record and monitor usage even if you have no intention of abusing the drugs. It is relatively easy to lose track of what you are having. They are good in that side effects are reduced though. More controls would not bother me if it meant protecting people from abuse, intentional or not.

November 13, 2012 @ 2:29pm
by George Kara

Patient smart cards containing individual medical histories would help eliminate 'doctor shopping' and greatly assist medical practitioners, pharmacists and patients in all aspects of healthcare management. The utility, efficiency and confidentiality of patient held smart card based medical history systems has been proven extensively in other nations such as France. We could get effect vast improvements in our national healthcare system by studying their example.

November 13, 2012 @ 4:06pm
by Ben

The slippery slope analogy seems appropriate. Ten years ago, when my late wife was in the last stages of incurable cancer she was prescribed Fentanyl patches for pain relief and at that time everyone seemed to know how valuable they might be in the drug market. She was unable to tolerate them because of the hallucinations that they caused, and they were logged back by the pharmacist to ensure that they did not move into the illicit market. If that is not done now it seems inevitable that the patches will find their way into the wrong hands.

Recently I had knee reconstruction and was given what I believe was oxycodone when panadol was sufficient to handle the pain. It made me exceedingly sick and I could not stop it fast enough because of the side effects. Perhaps the pain relief profession is trying to be too kind to us.

November 14, 2012 @ 10:07pm
by Walter P. Komarnicki

why not try pain relief without drugs, get the endorphins going through exercise or fasting and meditation?

"Intense pain is not prolonged, and prolonged pain is not intense." (Epicurus)

November 16, 2012 @ 1:37pm
by Bob Kelso

Seems the drug abuser is the one playing with peoples lives including their own, nice try attempting to shift the blame to others.

November 17, 2012 @ 10:04pm
by Kirren

Walter your comment borders so close to the hilarious that it's hard to believe it's not a joke. This medication was initially used on people with terminal illnesses and now should still only be prescribed to a patient with chronic pain. For many of these people physical activity is definitely not an option, meditation only increases pain tolerance and doesn't ameliorate the pain and fasting for someone seriously sick is potentially deadly.

Any pain specialist will recognise that opioids and other strong pain medications are problematic but they are prescribed because the benefits outweigh the risks. In the case of muscle/joint pain any doctor or specialist worth their salt will construct a plan with their patient to increase strength and mobility and thereby reduce dependence on painkillers.

November 19, 2012 @ 7:07pm
by Dee Scarland

I would draw your attention to the recent ABC Health Report which discussed this very topic and mentioned the program now operating in WA under the auspices of the North Metro Medicare Locals and Sir Charles Gairdner Hospital. This is the way to manage this problem. The patients get appropriate pain management and are taught non medicinal ways of coping and managing chronic pain, both psychologically and with physiotherapy. They are not denied strong painklllers, when appropriate, but these are phased out as quickly as possible.

November 19, 2012 @ 9:07pm
by harleymc

It's a mongrel trying to get good pain relief via legitimate sources.
Sadly the black market is often the only way to go.

November 19, 2012 @ 9:55pm
by Annie

Pain is personal. Pain is private. Pain is relative and no one else should have a right to say 'how it should be tolerated'.
Other peoples pain is easy to bear.
People like Walter have no idea.
Put in place checks and balances but always remember don't put those with chronic pain on the back burner just because 'some people' abuse the system.
Pain management should be individualised. Pain is personal.

November 21, 2012 @ 5:22pm
by Lee

Many commenters here make very valid points. About 1:5 Australians suffer from chronic pain. harleymc, have you considered that in order to access the 'black market' in pain killers (fetanyl patches, oxycodone etc) someone would have to have obtained a prescription from a Doctor and then be selling their drugs on the street. So while the black market is a means for some people to obtain much needed pain relief, it is also an avenue for recreational drug users to obtain the drugs they seek. Inappropriate prescribing of opiates is therefore an important issue that needs addressing.

November 28, 2012 @ 8:40pm
by Jim Paterson

Annie's post hits home with me and I have also sourced the streets and other pensioners for help as Harleymc mentions.
I rarely take any form of pill. i hate them. For a few years I accessed Tramil , 9 can't take codone) so I gave myself an occasional rest from chronic and permanent back pain. One 100mg dose approx every 6 weeks and for spine and when I went through the public dental service for my teeth. 20 years of falling off the systems boards, poisoned blood , chronic raw nerves and teeth aches, broken teeth, half my teeth gone , and a heart attack and still having appts put off.

I'm afraid I cannot comment that doctors hand these things out like lollies. I 'm instantly treated like a drug addict , a village idiot or child. I have sourced the neighbourhood instead. My spine used up 10 or twelve a year and a chronic emergency toothache could take two to 4 a day for the sometimes 2 weeks it takes to get into the public dentist and have it out without the anesthetic working. 4 times I've had to do that.
The system seems highly corrupted, full of hypocrisy and cunning in relation to market ,insurance and liability, and public health service. And we seem to have no journalists in mainstream.

December 25, 2012 @ 10:36pm
by Dr Thilini Mahaliyana

The problem that we face as doctors is definitely the not knowing. Not knowing if someone is genuinely out of their scripts or not. And having a centralised system which keeps track of opiates would definitely help us:

1) Avoid represcribing to someone who is doctor-shopping for extra meds
2) Help the people who are genuinely out of their medication and need it!

As it is doctors who are seeing a patient for the first time (eg in a GP practice or emergency) have the following options:

1) Hand it out assuming the patient hasn't doctor-shopped, running the risk of having been manipulated (common)
2) Refuse to give the patient any medication without more information, running the risk of refusing to give pain relief to someone who needs it (common)
3) Obviously getting more information from the patients' last GPs, other GPs that may have been involved and possibly pharmacies is the current ideal situation but may not be viable if it's after hours
4) Sending the patient to a chronic pain specialist is necessary but sadly is difficult to access. Even in the private sector often the waiting list is 6 months and in the public sector it's more like 12-18 months which is unacceptable for people who are in pain and may have complex medical/psychological/social requirements and comorbidities. It's easier to access for inpatients in hospital but it's not ideal.

Doctors definitely don't want to contribute to patients being in pain. But they also don't want to contribute to overdoses, the black market drug trade or uncontrolled addiction. Both pain and misuse are huge problems and it's very difficult to work out what the situation is if you don't know the person well and have no information.

Having a centralised database would solve a big chunk of the problem.

But the next step of course is pain management- working out what the best way of helping people with their pain. Sometimes desensitisation and drugs like gabapentin and pregabalin which specifically treat chronic nerve pain are much better than more opiate. We need more pain specialists and pain clinics!! Not to mention that only a few practitioners are trained and legally qualified in things like methadone prescription for people who are either prescribed methadone for pain control or are street opiate addicts and are transitioning to a legal opiate. We need a service which is open 24 hours a day for people in crisis!

Doctors and patients are both stuck between a rock and a hard place with a combination of difficult issues all centred around opiate drugs.

PS I remember tearing my ACL, a painful knee injury, and being scared about requesting some stronger opiate pain relief (none had been offered to me), which I needed because I was in so much pain, in case someone thought I was "drug seeking". Misuse of opiates is actually very common in the health related professions.

March 29, 2013 @ 3:13pm
Show previous 13 comments
by lach50

if the powers wanted to they could have a live system that could immediately look at scripts cashed nationwide - The cynic in me says they dont want this as they also need the back market as the system is far from perfect and stretching the conspiracy theory a bit further one could even suggest a policy of genocide - thinks about it before writing the theory off immediately. Afterall they are only addicts anyway

April 23, 2013 @ 5:21pm
by Linda Dom

I don't know what is going on but I've been on patches [Norspan] for a few years due to chronic pain and I can asure you, when I go to the Dr it's a call to Canberra for the approval number. I've recently changed clinics and yes felt like I was being treated as a junkie till I transferred over my files. in fact off to see the rhuematologist tomm. I still battle with chronic pain even though on a high dose. But I've learnt to pace myself, somewhat.
i certainly don't feel any high on my patches but at least I'm functional.
Sick and tired of the stigma of being a chronic pain sufferer. i can't help it. I've had to retire much to my financial detriment.
Another thing I've noticed is with the high influx of Asian Drs they are much more reluctant to treat chronic pain seriously. Being treated like a junkie and a malingerer is a total insult.
the shortage of specialised pain Clinics doesn't assist either especially for rural residents.
So, it will be interesting tomm after my 4 hr drive to see the specialist and how his attitude has changed due to all the junkies abusing our rights as patients, and in treating chronic pain.
I can't work out how that get all their drugs, from my experience it's totally regulated. Never once have I said a patch has fallen off or lost one. Totally honest and its been a hassle of late!

April 29, 2013 @ 2:22am
by JEN

i lost my brother at the start of the year to patches...WORSE THAN HEROIN

September 18, 2013 @ 4:39am
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