Issue 21 / 11 June 2013

OXYCODONE is an effective analgesic and its use has increased substantially in the past 10 years. However, the well documented increase in adverse effects in parallel with increased usage is a cause of concern for doctors and legislators.

That concern resulted in the mayor of New York imposing limits on prescribing of oxycodone by doctors in hospital emergency departments (EDs) in an attempt to reduce its misuse, which is seen as a major social problem.

The adverse effects of oxycodone relate to its opioid effects and include addiction (“Hillbilly heroin”), non-therapeutic misuse, respiratory depression and death in overdose.

Opioids are the prescription drug class most commonly used for non-medical purposes. Australia is currently ranked 10th highest for use of opioid medications and third highest internationally for oxycodone consumption. The misuse of prescription and over-the-counter medications is increasing in Australia. While opioid prescriptions doubled between 2000 and 2011, prescriptions of oxycodone increased sevenfold.

Prescription opioids have surpassed marijuana as the most common drug for people initiating drug misuse, and in all age groups prescription opioids have surpassed heroin and are now second only to marijuana use. Hospital admissions involving prescription opioids increased 170% in Victoria between 2000 and 2009.

The total number of prescriptions for oxycodone has increased significantly. In 2000 very little OxyContin was prescribed in Australia; 5 years later it was one of the most commonly prescribed opioids for chronic pain.

We recently studied the prevalence of oxycodone misuse in the ED at St Vincent’s Hospital, a teaching hospital in the centre of Sydney, and found a statistically significant increase in presentations because of oxycodone misuse between 2007 and 2011 from 5.83 to 28.48 per 1000 drug-related presentations.

OxyContin is prepared as an 80 mg slow-release tablet and this slow-release mechanism is easily circumvented by crushing the tablet. This large dose of oxycodone may be driving the increase in ED presentations by enticing more people to misuse and by increasing the likelihood of overdoses with the higher doses.

The increase in ED oxycodone-related presentations raises questions about its safety as well as prescribing policy. It is clear that oxycodone is an effective analgesic for severe self-limiting pain and, when it is prescribed in this circumstance, the potential for misuse is limited.

However, oxycodone is fast becoming the prescription drug of choice for chronic and subacute pain, where the potential for addiction and misuse is higher. Other commonly used analgesics such as paracetamol, non-steroidals and codeine formulations are less effective than oxycodone and all have adverse effects.

It is therefore difficult to recommend curtailing prescribing of oxycodone when there is a genuine need for analgesia and there is not an alternative that is safer and/or more effective.

As a profession we have an obligation to treat pain safely and effectively. We can see the benefits of oxycodone for analgesia but we are also aware of its adverse effects and the potential for misuse.

We believe the profession is also obliged to formulate safe prescribing guidelines for oxycodone which will minimise its misuse while guaranteeing patients with severe pain its benefits.

Hospital doctors in New York were incensed earlier this year when the mayor restricted prescribing of slow-release oxycodone and limited their prescriptions of standard oxycodone to 3 days’ supply. In Australia we have the opportunity to formulate safe usage practices before it is done for us.

Professor Gordian Fulde is the director of the Department of Emergency Medicine, St Vincent’s Hospital, Darlinghurst, conjoint professor at the University of Notre Dame and conjoint associate professor at the University of NSW. Associate Professor John Raftos is a senior specialist in the Department of Emergency Medicine at St Vincent’s Hospital and conjoint associate professor at the University of NSW.

The authors acknowledge John Brennan and Madison Reynolds, medical students at the University of NSW, who contributed significantly to the St Vincent’s research as part of their independent learning projects in 2012.
 

10 thoughts on “Gordian Fulde

  1. David Lindholm says:

    The evidence for using opioids for chronic pain is scant at best while evidence for harm is overwhelming and growing. Opioid induced hyperalgesia, immune suppression gonadal suppression is real. Low dose buprenoephine may be a less toxic option in the longer term with pain efficacy at least as good and probably better in the long term. Non opioids like amitriptyline Duloxetine pregabalin are far more evidence based and used in conjunction with cognitive behavioural, social and exercise based therapies are far more likely to be helpful. Strong opioids should only be used for short term pain except in rare highly selected and closely supervised patients. 

  2. judith o'malley-ford says:

    It is not common practice for GPs to commence opioids. That is not where the probem lies. I am a GP of some years and have seen that opoids are commonly commenced in hospitals, even for relatively minor complaints. It’s not the GP you should be targeting but hospital staff including VMOs. Once some patients are commenced on opioids, it is difficult to get them off, and it sometimes escalates to doctor shopping. GPs are in the front line of having to manage the problems that are not of our making.
     
     

  3. prof fulde says:

    we thank Dr  J O’Malley-Ford for her entirely valid commment. It is reasonable for acute reversible conditions with  significant pain to be prescribed oxycodone as it is effective and well tolerated, also we have a duty to provide good analgesia especially discharging patients who may need to stay at home to recover.

  4. Phillip Chalmers says:

    Working as a GP in a rural area has me initiating opioid analgesia frequently.

    Apart from the genuine need of people in severe acute pain from conditions which will be cured or improved in a short time, we have a huge proportion of patients with severe pain caused by conditions which would be treated successfully if they had private health cover and could get to the orthopaedic specialist of their choice but do not.

    Public lists are long, very long, and I for one am not prepared to leave people in strong pain because they are poor or improvident.

    The sufferers feed back that they have been returned to real life and can see themselves holding out until the belated surgical spot is allocated to them.  These are not drug-seeking liars and layabouts seeking to get cheap highs.

    Medicare and state health systems must find a solution to this – we will then drop our use of these medications being demonised by wowsers.

  5. Dr G Reynolds says:

    I work at a public hospital drug clinic, and oxycodone and over-the-counter opioids are creeping up in frequency  as the problem drug among new patients seeking opoid substitution treatment.

  6. Sue Ieraci says:

    Judith is correct that strong analgesics are often prescribed following emergency department care. I wonder if this is an unintended side-stream effect of the (well-motivated) targetting of pain-relief as an important factor in Emergency Medicine. Perhaps we should think more carefully about simple analgesics and non-drug pain-relief modalities – especially for injury – at the time of discharge. A single initial opiate dose may be reasonable, with some re-thinking about follow-up analgesia. Good splinting, elevation and ice/hot packs might help reduce the need for strong analgesics in limb pain. It is young men who more commonly present with injury, and are also at risk for dependence – and maybe less pain-tolerant and impatient.

  7. Jim Goutzamanis (AMA member) says:

    As an ED Doc I agree with Dr Judith O Malley Ford that we are probably overusing it in an ED situation based on as Sue Ieraci states “the drive for targetting pain relief” (with KPI’s being for example time to anagesia) and subjective pain scales rather than objective measurements such as resting tachycardia, tearing and elevated BP. I agree with Sue’s approach limiting opiates and using other modalities also.

    One cannot disagree with Pacdoc that in  patients suffering  genuine severe pain oxycodone is warranted.   Chronic pain clinics and Specialists are few and access to them in public clinics is very limited and with huge delays. Pain management is then left to ED access and GP’s. who take the brunt of these conditions and ongoing mangement.

  8. Department of Health Victoria Clinicians Health Channel says:

    Holding up PBS listing of useful potential replacements for potent opioids is also a problem. Until the arrival of pregabalin you would not know there was such a problem as neuropathic pain, judging by PBS listings. If all the PBS gives you is codeine, tramadol and strong opioids then that’s what ppl will get. I agree with the authors that there is probably too much oxycodone in the community, but overdoses are a perrenial problem in ED. Better community mental health support, better access to destigmatized adiction services, effective preventive education of young ppl and some progress on the completely bungled national real-time prescription database are all parts of the the puzzle that need co-ordination and a long-term strategy to succeed. Better access to pain medicine services would be nice as well, but at current funding levels is unrealistic, so primary care must lead the way.

  9. Dr F T SCheelings says:

    It is my view that the over-prescribing of opiates from emergency departments and hospitals in general is due to poor teaching and supervision.  Time and time again I am astounded when my patients see me, after attending ED for what are often minor complaints (sprained ankles, musculotendinous injuries, post surgery) and are given opiates as first line therapy.  We have bred a generation of soft induividuals who have absolutely no tolerance for even minor pain, as opposed to the previous generation who accepted that some pain was accepted and endured.  We are really using sledge hammers to drive in nails.

  10. Frank New says:

    I agree with the comment re limited supervision, of junior doctors, but also of the patient’s ongoing progress.

    I have personally encountered many problems as a consequence. My (late) father discharged Christmas Eve with a new prescription of Oxycodone from the Junior doc, with no easily available medical services at his Nursing Home till after New Year. He was quickly pie eyed, and fortunately I was available to stop this. Others without medical relatives were less fortunate.

    Much more serious problems persist however. The DEATH rate from opioid medication taken AS PRESCRIBED is increasing – information from QH DDU. This is not suicide or recreational abuse or diversion. It is bad prescribing / management, especially as this should include timely followup, and use of appropriate outcome assessments – sutained improvement of FUNCTION to support continued prescription, with no serious adverse effects, short or long term.

    Sedative effects cannot reliably be assessed during a clinical interview. Patients wake up for this. The secretary can inform when they are asleep in the waiting room. The wife can say whether they fall asleep in the lounge before they DRIVE to the surgery.

    This is a developing serious health problem, iatrogenic.

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