NSW Deputy State Coroner Harriet Grahame has called for a drug summit, attention to real time prescribing, better access to drug substitution programs and better pharmacy takeup of naloxone
She made the recommendations following an inquest into the deaths of five people who died from multi-drug toxicity following accidental overdose, and one who died of heroin toxicity, again after an accidental overdose. Drugs implicated in the multi-drug toxicity cases included heroin, fentanyl, alcohol, and benzodiazepines.
Magistrate Grahame said it was clear that NSW has a significant, growing problem with opiate and opioid overdose, both licit and illicit.
“While figures are notoriously difficult to interpret, it is clear that the number of deaths is continuing to increase,” she said in handing down her findings. “2016 recorded the highest number of drug deaths in twenty years.
“Many of these deaths were caused by a combination of drugs, including prescribed opioids, heroin and benzodiazepines. If the death rate continues to trend upwards, as it has in the United States, the annual death toll could reach many thousands over the next five years.”
Yet the country’s most populous state appears to have “few coordinated strategies” in place to deal with the issue, she said.
“Any examination of road death statistics, for example, will show how effective a coordinated approach can be at reducing harm and death. And yet, in relation to opioid overdose, creative thinking at a government level appears to have stalled.”
Saying she was “deeply troubled” by the evidence submitted in the inquest, Magistrate Grahame said that this evidence “clearly establishes that many opiate and opioid related deaths are genuinely preventable if we, as a community, are prepared to rethink our approach to drug policy”.
Strategies to curb supply of illicit drugs have been unsuccessful, Magistrate Grahame said, citing evidence from Former Federal Commissioner of Police, Mick Palmer, who had told the inquest that despite increased efficiency in conducting significant seizures and arrests, police were not able to make much difference.
She called for another NSW Drug Summit, which she said should bring together experts from a fields including health, social policy and law enforcement.
“Importantly the voices of drug users and their families must also be heard,” Magistrate Grahame noted.
“The summit should aim to give full consideration to any evidence based suggestions and be prepared to rethink the way we approach these issue sat a fundamental level, rather than be content to just tinker around the edges of the debate.
“It will take courage to face the failure of our current drug policies to keep citizens safe.”
One of the clearest themes emerging from the inquest was the “urgent” need for increased drug treatment in NSW, she said, though it is difficult to assess the true size of the unmet need.
One expert who gave evidence at the inquest said between 40% and 60% of the people who want treatment are unable to access it, a statistic which the coroner called “frankly horrifying”.
The cost of methadone and other substitution services is also a significant problem. Harm minimisation proponent Dr Alex Wodak gave evidence at the inquest that “the dispensing or co-payment fee can take a significant proportion of the income of a person on a low income or government benefit,” the coroner noted.
“This can have the effect of delaying a patient’s entry into treatment or cause their early exit from programs… if provided through the private system, a substitution program could cost up to $80 a week.
“This is unacceptable.
“In submissions at the conclusion of the proceedings NSW Health expressed the view that the funding of medication dispensing via community pharmacies is primarily a matter for the Commonwealth.
“While the court accepts the difficulties that are sometimes involved operating within a federal system, there are well established avenues for states to pursue these issues with the Commonwealth if they are considered a priority.”
There is ample evidence to support programs dispensing medicinal heroin being trialled in NSW, she said.
She outlined a need to further roll out naloxone, including more education for GPs about the benefits of discussing the medicine whenever prescribing opioid drugs.
Pharmacist Angelo Pricolo had given evidence that pharmacy take up rates of naloxone were “disappointing,” she said, with only 5% to 10% of pharmacies stocking it and less than 100 naloxone kits sold through pharmacies across the whole country.
“There is a clear need to educate and encourage pharmacists about the importance of providing this drug,” Magistrate Grahame said, adding that there was evidence that some pharmacists did not want to encourage drug users to enter their pharmacies, and some were “ignorant of naloxone and its usefulness”.
She said that because several prescription opioids including fentanyl and oxycodone – as well as benzodiazepines – were implicated in several of the six deaths examined in the inquest, it was necessary to look closely at how these medicines are being prescribed.
“Evidence was received that suggests many general practitioners may not possess the requisite skills and training, or have all the information they need (including, for example, about naloxone and alternative pain management measures),to ensure that safe opioid prescribing takes place,” the coroner noted.
“The evidence at this inquest indicates a need for improved monitoring of the prescribing of certain types of drugs.
“A system that has the capacity to immediately identify a patient’s current prescriptions could clearly assist doctors and pharmacists to prescribe and dispense more safely. Doctors and pharmacists would be able to identify patients who may be struggling with their medicine use.”
Such a system was “years away,” however, she said, citing evidence given by Judith Mackson, Chief Pharmacist and Director of the Chief Pharmacist Unit within NSW Ministry of Health, who said NSW’s system was still in a design stage and that NSW was committed to waiting on the Commonwealth system, instead of implementing a stand-alone system for NSW.
The coroner made 26 recommendations, including that NSW’s Department of Health facilitate and host a drug summit; provision of intranasal naloxone to NSW ambulance officers, paramedics, GPs in areas with high prevalence of overdose, and Emergency Departments; and that attention be turned to a NSW real time prescribing system.
She urged attention to be given to improving the affordability of drugs substitution programs (methadone and buprenorphine) for all drug addicted people wanting to access them, and consider alternative programs for those who have not been suited to traditional programs.
Magistrate Grahame also called for consideration of additional medically supervised injection rooms, and support for greater availability and accessibility of non- pharmaceutical pain management strategies, including hydrotherapy, counselling, physiotherapy and mindfulness training.
“Further research should also be undertaken into the use of medicinal cannabis in chronic non-cancer pain as an overdose prevention strategy.”
She also recommended the Pharmacy Guild consider what educational activities could be developed for pharmacists on naloxone, its safe use, importance of stocking in community pharmacies, and the availabilityof nasal spray naloxone from early 2019.