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How would you describe the current situation in New Zealand in terms of misuse of oxycodone?
With due heed to hyperbole, we are looking at a disaster in the making. We have been complacent about the warnings from
the rest of the western world, with harms arising from pharmaceutical opioids overtaking those from heroin. This has reached
epic proportions in the United States, with oxycodone particularly over-represented. Pharmaceutical opioids in the United
States now kill more people than firearms or road traffic accidents, and more than the combined death rates from heroin
and cocaine overdoses. This is shocking and shameful – how can it be possible?
In New Zealand, we have had the good fortune to be last off the starting line, with oxycodone coming to us later. Even
so, it is clear from [national dispensing] data that our prescribing of oxycodone has followed comparable trajectories
to that seen in Australia and the United Kingdom. There is no good reason for this – oxycodone is more expensive than
morphine and more addictive, and is no safer in renal [impairment] or other conditions. And it is not as if we are even
prescribing it for the right reasons – the literature on chronic pain increasingly indicates that opioids are harmful
long term, not beneficial. Chronic pain is not acute pain – the “benefits” of opioids in chronic pain may be limited to
a brief reduction in subjective pain, before tolerance and hyperalgesia negate this, leaving the patient neuro-adapted
to a higher dose.
“New Zealand’s problem prescribing pharmaceutical opioids, with the predictable onslaught of oxycodone, is
a national scandal that should be stimulating profound professional soul-searching.”
Dr Jeremy McMinn
How does oxycodone compare to other prescription drugs of misuse, e.g. morphine?
The appalling aspect of this is that New Zealand has had three decades already of seeing pharmaceutical opioid abuse
and dependence rather than heroin addiction – we, as prescribers, have significant responsibility for these harms.
In New Zealand, patients that end up on opioid substitution treatment [i.e. the methadone programme] mainly initiate
and maintain their pre-treatment addiction with morphine and methadone. The morphine mainly comes from pain specialists,
general practitioners and palliative care physicians, and the methadone comes from opioid substitution treatment (OST).
In recent years, OST services have recognised this, and increasingly adopted greater treatment supervision, more restrictive
dispensing, and more explicit adherence to evidence-based dose ceilings. Other prescribers need to catch up.
What advice can you give to general practitioners for identifying patients who are drug-seeking?
i.e. no legitimate reason for requiring oxycodone
General practitioners need to take control, and use their knowledge of health conditions, prescribing risks and clinical
concern appropriately. Patient choice is not the primary reason to prescribe a drug (although it may be a factor in which
drug is chosen). But if the condition presented is not sensibly treated with the drug requested, do not prescribe it.
Opioids are very likely not to provide a true benefit in pain conditions lasting over a month – just as benzodiazepines
are not justified in cases of anxiety lasting more than two weeks.
Worry about a complaint to the Health and Disability Commissioner should not influence the decision – drug-seeking patients
know that implying they will complain makes doctors fold. If the patient is likely to move on to a different, “softer
touch” doctor, general practitioners can protect their colleagues by making an application for a Restriction Notice and
making sure any documentation reflects the doubts about the legitimacy of the drug request.
General practitioners may know the background history and social/family environment better than any other doctor involved.
It is likely that most people abusing oxycodone, benzodiazepines, etc, are using medications that were prescribed originally
for someone else. Primum non nocere (first do no harm) extends to society, not just the patient in the room.
Any patient that insists on an abusable drug by name, without sufficient diagnostic justification, without supporting
documentation, with stories of lost prescriptions or stolen medications should not receive a prescription. Medical Council
guidance allows for a three day prescription to ease a threatening patient out of an office, but then preparations for
the next consultation must be made. This may include talking with colleagues, arranging a chaperone, and applying for
a Restriction Notice. Overt threats of violence should be reported to the police. Threats of suicide can be discussed
with local emergency psychiatric services.
Chronic pain, current or past addiction to any substance, current or past mental illness, childhood sexual abuse and
family history of addiction are all important risk factors for addiction.
“Many GPs already know that we are fighting to retract an opioid tsunami” Dr Jeremy McMinn
What advice can you give to general practitioners for identifying patients who may be addicted to oxycodone?
i.e. a legitimate need for pain relief which has turned into a dependency
Oxycodone is highly addictive – between 25–33% of regular users will experience features of dependence. With this risk,
all patients with courses lasting longer than one month should be examined for signs of addiction. Requests for increasing
doses and early (or replacement) prescriptions are obvious warning signs. It is essential to consider appropriate urine
drug testing and examining for injections sites. The perceived stigma of these can be reduced by making this a standard
condition of Controlled Drug prescribing.
General practitioners will be alert to treatment that does not achieve a net improvement. Emerging addiction is a powerful,
but sometimes opaque, reason that treatment is not as effective as originally predicted.
Are there any safeguard practices for prescribing oxycodone which can help to avoid inadvertently
contributing to drug misuse or addiction?
Prescriptions of any abusable medications that may last longer than a month should be subject to the 10 Universal Precautions*[to
be discussed in the next edition of Best Practice Journal]. The gist of these precautions is an explicit contract covering
treatment duration, dose parameters, outcome measures, side effect safeguards and defined review dates.
Patients (and doctors) should be aware of the relative lack of good evidence that oxycodone is genuinely effective after
one month, contrasted with the wealth of evidence of harm. Oxycodone dose ceilings in primary care should be no more than
60 mg per day (broadly the equivalent of morphine 100 mg per day). After this, specialist review or re-thinking is required.
Outcome measures should be measurable change in function, not subjective pain score – the pain always eases with a dose
increase, but temporarily, just as it always flares with a dose decrease, temporarily. Safeguards for oxycodone prescribing
include universal use of urine screens, examination for injection sites and regular discussion with the dispensing pharmacist.
A key advantage of some degree of treatment contract is that it allows the prescriber to back out of prescribing that
is getting out of hand. The subsequent re-think can include seeking specialist advice for pain and addiction.
*Gourlay D, Heit H, Almahrezi A. Universal precautions in pain medicine: a rational approach to the
treatment of chronic pain. Pain Med 2005;6(2):107-12.
What issues are you seeing among patients as a result of oxycodone addiction?
I am seeing patients who tell me how easy it is to get oxycodone – and it is cheap. My impression is that most people
find it straightforward to convince a doctor to prescribe for them, although clearly some doctors (and some regions) are
easier than others. For the ones that do not go directly to a doctor, they can buy from other individuals or from doctor-shopping
rings. These rings can include older women, who may not trigger the same suspicions. I have been surprised how much oxycodone
seems to travel by New Zealand Post between regions. It is just a matter of time before the street oxycodone “market share”
People presenting voluntarily for treatment are still mainly presenting with morphine addiction, with methadone a close
second. Virtually everyone has added some oxycodone into the mix of what keeps them going, but addictions driven only
by street oxycodone are infrequent so far. However, I am not reassured by this – presentations for OST are usually very
late: most people struggle with their own attempts to manage before they resign themselves to the restrictive rigours
I am also seeing a new cohort of patients, who are coming semi-voluntarily. These are the people who have received a
long term prescription for pain which has tipped over into problematic use. Most have to see me because the original prescriber
has become aware of problems and has wisely, if often belatedly, made further opioid prescription contingent on addiction
assessment. Frequently, the problems arise from the short acting nature of the “pain”, opioid-on/off effects, tolerance,
aberrant use, etc. A transition to a longer acting opioid, i.e. methadone or buprenorphine (in the form of Suboxone) is
usually required. Frequently these patients do not wish to characterise themselves as “addicts”, but do nonetheless have
features of opioid dependence. There may be some good prognostic factors present in this cohort, but a prolonged period
of opioid substitution and related counselling still seem to be required.
It surprises me how often general practitioners seem to feel committed to continue a course of opioids started in hospital
or recommended by a pain specialist – even though the use of opioids is clearly starting to go wrong. General practitioners
usually have the best overall knowledge of the patient – in my opinion, this may trump the often more narrow and frequently
time-limited recommendations of specialist care.
“General practitioners should not hesitate to bring their own knowledge to bear, even if this can be challenging
initially to align with the specialist recommendations.”Dr Jeremy McMinn
What advice can you give to a general practitioner managing a patient with an oxycodone addiction who wishes to withdraw?
The best advice is unhelpfully retrospective – do not get there in the first place. In opioid dependence, prevention
is absolutely better than cure, as the opioid withdrawal failure rate without a period of substitution is nearly 100%
- even if we had the best addiction resources, which we patently do not. Opioid substitution is the mainstay of managing
opioid dependence, but funding exists for only around 5400 patients (with an expected need of at least 10 000 New Zealanders).
What is the recommended withdrawal regimen?
Withdrawal requires realism, compassion and determination on both the patient and doctor’s part. Most people will require
a stabilisation phase of two to four weeks to clarify the daily amount, which may include swapping to a longer acting
opioid of the same equivalence. Given the Misuse of Drugs Act, general practitioners will have limited scope to use methadone
or buprenorphine, but consolidating an Oxynorm and Oxycontin regimen into a set twice daily regimen of oxycodone as sensible
pain management will be required.
After this stabilisation, a steady reduction should be agreed within a reasonable timescale. Factors such as prior treatment
duration, size of total daily dose and important upcoming events, come into play when considering the rate of reduction.
However, a reduction contained within one to three months should be agreed, with the reduction increments calculated back
from this date setting.
Larger dose drops may be easier at the start of the reduction, with smaller drops later reflecting a larger proportion
of the total daily dose. Neuro-adaptation plateaux, where the reduction is held for one to two weeks, may be sensible
periodically, especially if the patient is struggling. Putting the dose back up is rarely sensible – a hold in reduction
to allow the easing that comes with neuro-adaptation is more realistic than an oscillating rising and dropping dose.
What supportive treatments may be required?
The main support is one of compassion whilst maintaining a focus on the prize. Delaying a reduction restart, or providing
unwise courses of other abusable drugs (benzodiazepines, zopiclone) will promote a sickness role and treatment failure.
Patients need reminding that the discomfort is temporary and will abate. Levels of underlying distress need monitoring,
and involving the educated support of family members may be useful. Excessive use of other substances from other sources
(e.g. alcohol, cannabis, Nurofen Plus [containing codeine], a family member’s opioids) should be addressed.
Loperamide for diarrhoea and non-opioid analgesics for withdrawal aching may be useful. Off-label use of clonidine may
be considered for the hot/cold feelings and aching, but will require blood pressure monitoring: courses should be limited
to two weeks. Quinine is no longer recommended.
What issues are there in terms of prescribing legitimate pain relief in the future?
Opioids are only part of the treatment of pain, and probably a much smaller part of chronic pain treatment than previously
thought. Earlier problems with opioids mean that all potentially abusable future prescriptions may present risks, such
that they should be avoided altogether or only provided within closely monitored parameters.
Patients who have experienced problems with opioids need more care, although commonly feel they receive less. A pain
condition for which opioids were problematic could be framed as a “treatment resistant” condition and it may be legitimate
to seek other less available treatments. In particular, access to non-pharmacological pain strategies may need to be emphasised.
Patients and prescribers should be explicitly discouraged from equating the removal of opioids with the removal of all
What other support systems are available for patients who have a prescription drug addiction?
Prescription drug addiction is a double act – both the patient and the doctor have, to some extent, entered into drug
dyscontrol, drug salience (exclusive importance) and dysfunction. These need to be addressed, and prescription monitoring,
dispensing restrictions, and use of the 10 Universal Precautions are good ways to achieve this. In particular, solid external
controls on abusable medication availability are the keystones to preventing and managing prescription drug addiction.
For those who have ongoing opioid problems, the mainstay of opioid management will involve the local specialist Opioid
Treatment Service, often with some degree of shared care with the general practitioner. Input from specialist Chronic
Pain Services may also be required: in many regions there is regular liaison between Addiction and Pain services already
Addiction support can also be available through non-government organisations, including the Alcohol & Drug Helpline,
Salvation Army, CareNZ, 12-Step Programmes (e.g. Narcotics Anonymous, Alcohol Anonymous & Al-Anon) and Tranx.
The Alcohol & Drug Helpline (0800 787 797) and local DHB Addiction Services will usually be able to advise on local
availability of addiction supports.
We would like to thank Dr McMinn for his willingness to speak out on these issues. We hope that this interview has challenged
your thinking in terms of your own prescribing of oxycodone. We plan to publish a follow-up series of articles, expanding
on some of the issues Dr McMinn has touched on, including examining the role of oxycodone in acute, short-term and long-term
pain management and strategies for safe and rational prescribing of strong opioids.