‘Overdose hides in plain sight.’


One stakeholder is calling for a national overdose prevention strategy, as a report details the pharmaceutical drugs involved with unintentional drug-related deaths

The Penington Institute has released Australia’s Annual Overdose Report 2021, which examined the 2,227 drug-induced deaths in Australia in 2019, of which 1,644 were unintentional – a key focus of the report.

Drug overdose is a leading cause of death for Australians of all ages, it notes – rising to the second-leading cause of death (behind suicide) for male and female 30 to 39-year-olds, and the third-leading cause of death for both men and women aged 20 to 29, or 40 to 49.

Dr Karen Gelb, the report’s lead author, told the AJP that the fact that most overdose deaths involve pharmaceutical drugs means that “pharmacists need to have really good, open, honest conversations with their patients”.

While measures such as real-time prescription monitoring and My Health Record are a step in the right direction, she said, health professionals need to do what they can to boost their patients’ health literacy, and step up in a constructive manner when they notice concerns with the way their patients are using medicines.

“Having open, non-judgemental conversations are really critical for a pharmacist to do,” she said.

“Avoiding stigmatising people is important – the stereotypical image that people may have of someone who’s using drugs, or who’s at risk of overdose, is likely to be wrong, the data show.

“Perhaps you have an older woman who lives across the road and has had a hip operation and is on strong opioids, and is perhaps unaware of how to take them properly or is confused; or is also taking an old medicine given to her a few years ago, thinking it could help.

“It’s those conversations about how to use medicines safely where pharmacists play such an important role.”

Understanding why a patient might be seeing more than one prescriber is also crucial, Dr Gelb said.

“Some people may have more than one family doctor: do you remember to tell each doctor everything that’s been happening? The community doesn’t necessarily think about that, and it’s where community education comes into it, and that’s everybody’s responsibility.”

Digital solutions are “a valuable part of the puzzle, but only one piece,” she says.

“You don’t want a situation where someone goes into a doctor and is flagged in the system, and the doctor says, ‘you’re doctor shopping, I want you to leave my practice’.

“That’s not a good outcome.

“A good outcome is talking to the patient and understanding what they need, helping them find support, even if they’re not prescribing say, an opioid, and saying ‘I can refer you onto a support organisation or I can link you in with other services’.

“Access to those is not ideal, but it’s back to that issue of people needing to be looked at as a whole person.

“We know there’s often a history of trauma and disadvantage in people who have problematic drug use – how can we support them?”

Dr Gelb said the Institute is calling for a national strategy which facilitates open discussion about medicines and drug use, to prevent overdose.

“This would bring in experts and people with lived experience to get together and identify interventions that can work; and that starts with talking about it, acknowledging there’s a problem, and identifying how we can reduce overdose deaths.”

Meanwhile the Pharmaceutical Society’s National President, A/Prof Chris Freeman, highlighted the importance of improving access to naloxone.

“Whilst it is now available over the counter across the country, the price of this medicine puts it out of reach for many, and a prescription is required in order to receive the PBS subsidy. The current process is simply not working in the best interests of those who need it most,” he said.

“Whilst we welcome short term trials to improve access in NSW, Western Australia, and South Australia, this does not go far enough.

“We need to improve access to this life-saving medicine through all pharmacies across all jurisdictions, by making it the first pharmacist-initiated and supplied PBS item – in doing so, we can decrease the amount of deaths from overdose.

“Pharmacists are Australia’s most accessible healthcare workforce, now is the time to act to make naloxone not only more easily accessible, but affordable – something that will see countless lives saved in Australia,” A/Prof Freeman said.

 

The findings

“Overdose hides in plain sight,” writes Penington Institute CEO John Ryan in his foreward to the report.

“If there are 30 non-fatal overdoses for every fatal one, as research suggests, then there have been
approximately one million overdoses this century.”

“Unintentional drug-induced deaths are not evenly distributed through our communities,” the report noted. “They are proportionally more common in rural and regional parts of the country and among men.

“The rate of unintentional drug-induced death among Aboriginal Australians continues to be far
higher than for non-Aboriginal Australians: in 2019, their rate of unintentional drug-induced deaths was 20 per 100,000 population, compared with 5.9 for non-Aboriginal people.”

Pharmaceutical opioids were involved in half of all poly-substance deaths during the five-year period, the report noted.

Opioids as a class continued to be the primary drug group associated with unintentional drug-induced deaths.

In 2019, there were 882 unintentional drug-induced deaths involving opioids, comprising 53.6% of all these deaths.

The report noted a “dramatic” rise in heroin-related deaths since 2012 – from 67 in 2012 to 442 in 2019 – but warns that deaths involving pharmaceutical opioids had constituted the majority of unintentional drug-induced deaths since 2004.

Deaths involving opioids were further divided into fentanyl/pethidine/tramadol; and oxycodone/morphine/codeine, as well as heroin, methadone and opium.

Of the 2019 deaths involving opioids, 313 involved oxycodone/morphine/codeine, 170 involved methadone, and 167 involved fentanyl/pethidine/tramadol.

Over the last 14 years, deaths involving oxycodone/morphine/codeine increased by 84% (from 170 to 313 in 2019), deaths involving methadone doubled (from 85 to 170 in 2019) and deaths involving
fentanyl/pethidine/tramadol increased by almost 1,300% (from 12 to 167 in 2019).

“The number of unintentional drug-induced deaths involving oxycodone/morphine/codeine has continued to fall since 2017, from 434 to 313 in 2019,” the report notes.

“This may be due in part to the increased difficulty in accessing codeine following the rescheduling of over-the-counter codeine as a Schedule 4 medicine from 1 February 2018.”

Dr Gelb said that the drop in deaths involving this group of medicines could be due to several reasons.

“It may be in part due to the increased restrictions around access to codeine following that rescheduling; it may well have led to a change in prescribing practices,” she said.

“There may also have been a change in awareness [about risks involved with codeine due to publicity around the upschedule], so people may be asking for it less frequently, and they may be taking it more carefully, as well. All these things are likely to play a part.”

The report noted that unintentional drug-induced deaths involving opioids predominantly took place in a “poly-drug context” – with the most common combination, opioids plus benzodiazepines, trebling, from 160 deaths in 2007 to 477 in 2019.

Benzodiazepines themselves remained the second-most common groups of drugs included in this type of death, with 582 such deaths occurring in 2019: 35.4% of all unintentional drug-induced deaths. This was more than double the 16.8% in 2001.

“Deaths associated with multiple drug types are far more common than those associated with a single type of drug,” the report stated.

The report detailed a “sharp increase” in the number of unintentional drug-induced deaths involving four or more types of substances.

“While the number of these deaths decreased from 698 in 2018 to 474 in 2019, there was nonetheless a trebling in the number of such deaths since 2013,” it said.

“Unintentional poly-substance deaths were most commonly seen in middle age, although they were responsible for almost two-thirds of unintentional drug-induced deaths among women aged 60 and above.

“After two years of decreasing numbers of unintentional drug-induced deaths involving a single drug type, 2019 data show a large jump, from 302 deaths in 2018 to 431 in 2019.

“Deaths involving three drug types have slowly increased from 95 in 2007 to 239 in 2019, while those involving the detection of two drug types continue to decrease slowly from a high of 277 in 2012.

“Unintentional drug-induced deaths involving alcohol on its own have remained stable.

“In each year since 2017, there have been more unintentional deaths involving four or more substance types than single drug types, although the gap between the two is narrowing.

“This may be due in part to the number of drugs that can be reliably detected using toxicological testing, but may also reflect increasing trends of poly-pharmacy use.”

Also of interest were the group of drugs identified as anti-convulsants and neuropathic pain modulators.

These deaths had increased “markedly” in the last five years, though they were involved in only 9.4% of deaths (154 deaths).

The report also notes that prescribing rates for pregabalin are “rising considerably”.

It notes that between 2001 and 2014, there were no more than four unintentional deaths involving these medicines each year, rising to 11 in 2015, then 62 in 2016, 112 in 2017 and a high of 166 in 2018.

“It’s certainly something that’s a cause for concern – and are medicines pharmacists should be aware of,” Dr Gelb said.

The report also noted:

  • A “sharp rise” in deaths involving stimulants, including methamphetamine, since 2012.
  • A doubling of deaths involving antidepressants, from 10.5% in 2001 to 20.7% in 2019 (340 deaths).
  • In drug-induced deaths involving only cannabinoids, every death since 2014 was due to synthetic cannabinoids. There have been no deaths related to cannabis alone.
  • There were 256 unintentional drug-induced deaths involving cannabinoids in 2019, accounting for 15.6% of deaths.
  • Deaths involving antipsychotics had increased “markedly” in the last few years, though they accounted for only 12% (197 deaths) in 2019.
  • Among unintentional poly-substance deaths involving pharmaceutical opioids, two-thirds (67.8%) also involved benzodiazepines and 39.6% involved anti-depressants.
  • Among unintentional poly-substance deaths involving methadone, almost three-quarters (73.2%) also involved benzodiazepines, 37.4% involved anti-depressants and one-third (33.7%) involved pharmaceutical
  • Among unintentional poly-substance deaths involving benzodiazepines, 86.2% also involved pharmaceutical opioids and 40.2% involved anti-depressants.
  • The report also took into account drug-induced suicides – noting that since 2012, these had increased substantially in rural and regional Australia, where they have overtaken the rate in capital cities. There were 456 such suicides in 2019, and the largest increase in these deaths over time has been among older Australians.

 

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