Everyday Aussies, not ‘Doctor Shoppers’, at Heart of Opiod Prescription Crisis, Experts say
It’s the innocuous prescription at the end of a six-minute consultation with a GP that usually starts it.
It might be a family member who’s undergone some minor surgery, your colleague who did their back at work, or the 20-year-old who was injured at soccer.
The path to prescription opioid addiction is often as mundane as it is potentially fatal. Overdose deaths from prescription opioids outstrip those from heroin and ice.
But while the stereotype of a prescription drug addict is a determined patient who tricks multiple doctors into prescribing heavy-duty pharmaceuticals, in truth only a fraction of those at risk are doctor shoppers.
Most are not even aware they have a problem.
Findings from the Victorian Coroners Court show that in seven out of 10 pharmaceutical drug overdose deaths, the deceased had only been to see one GP.
Health and pain management experts, outspoken GPs, addictions counsellors and grieving family members have told The Law Report the doctor-shopping narrative has served to disguise what lies at the heart of the issue: a medical system that structurally supports problematic prescribing practices.
“We often think of people going from doctor to doctor, and they’re often [the cases] that get a lot of prominence,” Matthew Frei, clinical director at the Turning Point Alcohol and Drug Centre, said.
“But I’m sorry to say, it’s individual doctor prescribing that’s the issue. In most of the deaths, doctor shoppers are not the issue.”
Addicts with Mundane Backstories
Former ice addict Jarrad Weir is intimately familiar with what a stereotypical drug user is supposed to look like.
Now an addictions counsellor at high-end recovery centre The Cabin, he’s seeing more and more clients who are addicted to prescription opioids, and says their backstories are often mundane.
“My opioid addiction clients vary from one housewife at the moment, to a corporate high flyer, through to students and blue-collar workers,” Mr Weir said.
“They are people who have never really smoked weed — they’ve never touched any sort of drugs, they really are not big drinkers, they’ve never even smoked cigarettes.”
He divides the problem into two main categories — those who were prescribed opioids after having surgery, and those prescribed them for injuries suffered through sport or at work.
Anna McMahon’s son Robert fell into the latter category. When a forklift crushed his leg at work, he spent two years in and out of hospital and doctors’ offices, as he recovered from complications that arose after surgery.
He was prescribed a range of opioids throughout that time, and became depressed.
Mr McMahon was asleep in his friend’s car when he died from an overdose of prescription medication, including the powerful opioid MS Contin. He was 23.
“I didn’t have any idea of how my son could die from prescription drugs,” Ms McMahon said.
Tracing her finger over a list of medications prescribed to her son in the month prior to his death, she asks why a doctor would prescribe 2,000 tablets to her son in four weeks.
She confronted her son’s GP after his death. She said it was evident his past medical history had not been taken into account.
“I asked the doctor if he knew that Robbie was a chronic asthmatic — and he said he didn’t. I asked him if he called the hospital or previous clinic — he said no,” she said.
“He said [Robert] was an adult, and he should know what he was asking for.”
It’s been over a decade since Mr McMahon’s death, but overdoses from prescription opioids have only risen.
In 2013, the last year for which national data has been compiled, 668 people died from opioid overdoses — the overwhelming majority of which involved prescription drugs.
“Our overdose mortality statistics continue to rise,” Suzanne Nielsen, a senior research fellow at the National Drug and Alcohol Research Centre at the University of New South Wales, said.
“That’s been a consistent pattern over the past 10 or 15 years, so despite increasing awareness of the problem, we haven’t yet managed to really turn that trend around.”
Policy Response Targets Doctor Shoppers
In July, the Federal Government announced $16 million in funding to help establish a national Real-time Prescription Monitoring System.
The idea is to give doctors, GPs and pharmacists an instant record of a patient’s history of prescribed medications, which will immediately flag situations where a patient has visited multiple doctors to obtain prescriptions.
It comes after years of lobbying from coroners, doctors, pharmacists and drug and alcohol treatment specialists.
“I think it’s a critical step, but it’s just one piece in an overall response,” Dr Nielsen said.
Sam Biondo, the Victorian Alcohol and Drug Association’s (VAADA) executive officer, agrees that for too long, the perception has been that overdoses occur due to patients covertly seeking prescriptions.
“Pharmaceutical deaths in this country aren’t centre stage because we focus on the most stigmatised, public part of the problem, which is street-based using, marginalised individuals, usually through a law and order lens,” he said.
“We don’t look at what’s happening in our own backyard or at home.”
Incentives for ‘Fast Medicine’
Opioid addiction can be incredibly difficult to identify and treat in patients who don’t fit the doctor shopper stereotype.
“There is actually a lot of shame and stigma,” Dr Frei said.
“I think people who are prescribed drugs, who get their medication from a doctor and a pharmacist, are often quite embarrassed to go near a treatment service.
“They do tend to be at that high-functioning end of the range, people with a background of tertiary education and a job.
“They don’t see themselves as having a problem.”
Mr Biondo said “sloppy prescribing practices” have helped fuel rates of prescription opioid addiction.
But he and others conceded the issue was complex, and patients’ transactional expectations of visits to the GP, where patients expect to walk away with some form of pharmaceutical treatment, was also a factor.
Paul Grinzi, the chair of the Royal Australian College of General Practitioners Victorian Drug and Alcohol Committee and a private practice GP, said structural barriers were in part to blame.
“There is the issue of our society and government, through Medicare, incentivising what I could call fast medicine,” he said.
“There are incentives to keep things moving from a GP clinic point of view, rather than spending time in understanding patients … both from the business but also from the ability or willingness for patients to pay a gap payment (for a longer consultation).
“It’s a challenging situation, especially when it’s a patient you haven’t seen before.”
More Accountability for GPs
Dr Grinzi, whose work also involves training other GPs, said doctors needed to take a longer-term approach to treating chronic pain.
“To manage pain — especially if it’s persistent, long-term pain — takes a fair bit of planning … I honestly think it’s impossible to do it in one visit,” he said.
“If they’re in here just for the script, I may well curtail the interview very early, because my job as a health professional is to ensure the safety and appropriateness of the script.
“Just coming in like you go to a supermarket, and buying what you want, isn’t how I practise medicine.”
Dr Grinzi said doctors needed to be held accountable for their prescribing practices — and, looking at a photo of her son, Ms McMahon agrees.
“We need to start looking at the source, and the source is where the prescribing is happening,” she said.
“Until that changes and doctors actually become more accountable and more responsible for what they’re doing, it’s not going to change.
“The first thing they need to do is care about the patient. We need to bring care back into health care, because I think that’s what’s missing.”