Last week at the Pain Management Research Institute (PMRI) symposium on Descending the Analgesic Ladder, we heard a compelling journey as Paul Hotz shared his lived experience of managing chronic pain.
Paul is a successful Sydney based businessman. A karate black belt holder, Paul had a busy lifestyle, but also one that was very active and rewarding. A decade ago, Paul had surgery on his knee, which was unfortunately complicated by a complex infection. This and subsequent treatment left him suffering severe pain, and Paul found himself discharged on a high dose of opioid analgesia, specifically OxyContin.
One thing led to another. Debilitating post-surgical pain, loss of functionality and an increasing dependence on opioids saw Paul grow estranged from his family and support networks. With his opioid dependence rising to over 100 OME a day, his physical health also suffered. His wife found him collapsed at home one day and unresponsive due to an opioid overdose.
Research has established that taking opioids long term can paradoxically increase sensitivity to pain, and along with tolerance to its benefits, can contribute to the need to increase doses to dangerously high levels. These features of opioids also contribute to the inability of opioids to provide sustained benefit in many patients with chronic pain. While people may continue to take opioids to manage their pain, this can often expose them to potential and sometimes fatal risks. Many people living with chronic pain conditions who use prescription opioids do not identify themselves as being at risk of overdose – but the statistics demonstrate otherwise.
Opioid related mortality is the major reason why we must address how we manage chronic pain. So far, we have seen a steady increase in our regulatory response to managing opioid related harm, with the up-scheduling of codeine, restrictions on prescribing for stronger opioids emerging, and an extension of opioid monitoring systems (such as SafeScript in Victoria). It will be important for the clinical workforce to adapt to these changes and provide compassionate, supportive care for those in pain in order to maximise the community safety benefits of these changes. Some concerns are emerging in the US that rapid regulation and de-prescribing can also produce harms, with distressed patients feeling abandoned subsequently also being at risk.
Providing increased safety for those that remain on opioids should also be part of the strategies to improve safety and reduce the opioid drug related death toll.
We now also have another tool in our toolkit, namely increased access to Naloxone, a drug that can reverse the effects of an opioid overdose. It can be injected or be delivered through a nasal spray.
From 1 December, the Government is investing $10 Million in a pilot program, which will initially run in NSW, WA and SA, to make naloxone available free to people who may experience, or witness, an opioid overdose.
Importantly, under the trial Naloxone will be also be freely available as a nasal spray, a new product that has only recently been listed on the PBS. Naloxone will be available free to all people who use opioids (both illicit and prescription) and anyone who is likely to witness an opioid overdose from a range of sites including pharmacies, alcohol and other drug treatment centres, and needle and syringe programs.
The Department of Health is working with the participating states to support their existing Take Home Naloxone programs and to provide information and training on the pilot to frontline health professionals, peak bodies and other stakeholders. It is important that the pain community consider this program as part of the range of potential treatments and supportive services suitable for people in pain.
Naloxone will not fix all the problems we have with opioid related harm. It’s not the solution to pain management and the overreliance on prescription medications we have across the country, but it does provide a safety net… a safety net that can help us catch some of the most vulnerable people in our communities. And it will actually save lives.