Harmaceuticals: special forum on fentanyl injection and overdoses

Transcription

1 Harmaceuticals: special forum on fentanyl injection and overdoses Report on discussions and recommendations. October 2012

2 For more information, contact: Anex 600 Nicholson St Suite 1 Level 2 Fitzroy North 3068 T: F: Every effort has been made to present all information accurately. Anex accepts no liability for and does not indemnify against any loss or damage that may result from any actions taken based on the information contained in this report. Copyright 2012 Anex Photograph: a fentanyl-related ulcer on a patient who presented in Wagga Wagga. 2

3 Contents 1. INTRODUCTION TO HARMACEUTICALS FORUM ON FENTANYL 6 2. BACKGROUND What is fentanyl? Use of fentanyl patches Prescriptions in Austsralia Reports of overdose 8 3. DISCUSSION AT THE AUGUST 21 FORUM Part of an overall increase in opioid prescription Sudden emergence regionally Report of young people and fentanyl from Wagga Wagga Sources Geographical extent Comment from NSW Police Overdose numbers Injecting-related injuries and disease Data availability and sharing Regional or reflective of the national? Confidentiality Notification of apparent regional issue Known for some time, but insufficient action Education and awareness Border issues Policing Opioid Replacement/Substitution Therapy shortage 16

4 3.18. Fentanyl dosage within hospital settings Hume Medicare Local Naloxone provision for potential overdose witnesses Apparent reversal in overdoses in Albury Investigate and re-think prescription practices RECOMMENDATIONS CONCLUSION ANNEXES Agenda and format Presentation by Professor Bob Batey Newspaper coverage of the forum, 22/8/ REFERENCES 26 4

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6 1. Introduction to Harmaceuticals forum on fentanyl Anex is a not-for-profit public health agency. Our programs generate and convert evidence-based knowledge into enhanced wellbeing for individuals and communities affected by drug use. Anex convened a special Harmaceuticals forum in Wodonga on August 21 following reports of overdoses and harm involving injection of material extracted from fentanyl patches in the Albury- Wodonga and Wagga Wagga area. These disquieting events became apparent to Anex through the general dialogue that it maintains as part of its regular work of liaising with frontline services on matters of importance. The Border Mail newspaper had also covered the matter. On June 14 Anex alerted relevant Australian, NSW and Victorian Government Ministers to these concerns, as well as the NSW and Victorian Coroners Courts. A notification was also lodged with the Australian Health Practitioners Regulation Agency. The August 21 forum was held at Gateway Community Health in Wodonga. The purpose of the forum was to gather information from frontline service providers so that it could be provided to relevant government authorities for their consideration to assist prepare a response. The forum involved 72 participants from across the drug use harm minimisation spectrum. It included representatives of law enforcement (NSW), ambulance services, General Practitioners, addiction management, pain management, Needle and Syringe Program (NSP) staff, people prescribing and dispensing pharmacotherapy, alcohol and drug treatment, Justice, Aboriginal health, youth services and mental health services. The Hume Medicare Local was also represented. A draft of this report was sent to participants for feedback. Recommendations based on the forum discussions and subsequent participant feedback on the draft report are included on Page Background 2.1. What is fentanyl? The powerful opioid fentanyl was developed in According to the Encyclopedia of Toxicology, fentanyl stimulates mu-opioid receptors in the central nervous system (CNS). It alters the body s response to pain. Fentanyl can produce profound CNS and respiratory depression through mechanisms common to other opioids. Fentanyl is times more potent by weight than morphine (Lofton and Philip 2005: 323). Further, in humans fentanyl overdose leads to the classic triad of symptoms consistent with the opioid intoxication syndrome: miosis (pin-point pupils), respiratory depression, and CNS depression (sedation). Additional toxic effects of fentanyl include bradycardia (slow heart rate), hypotension, decreased gastrointestinal motility, euphoria, and acute lung injury (Lofton and Philip 2005: 323). 6

7 2.2. Use of fentanyl patches The United States Food and Drug Administration states that, in patch form, fentanyl is intended for treatment of moderate to severe pain in opioid-tolerant patients experiencing chronic pain when other pain medicines do not control pain well. It states that fentanyl is not to be used to treat mild pain or pain after surgery. Australia s NPS website (formerly National Prescribing Service) states, with no reference to pain severity: Reserve fentanyl patches for patients with chronic pain and established opioid needs who are unable to take oral morphine. The NPS factsheet did note that the new matrix patch formulation patches may eliminate some means of misuse that existed with reservoir patches, but the potential for creative misuse remains (NPS 2006) Prescriptions in Austsralia One of the few papers examining fentanyl misuse in Australia was published in 2007, and was based on prescription data up to late It noted that there were very low numbers of patches being prescribed and that fentanyl did not appear to be a major threat to IDU in Australia (Gibson, Larance et al. 2007). This was before the rapid increase in fentanyl prescriptions demonstrated in the graph below. 600,000 Fentanyl Prescriptions in Australia (non-anaesthetic, PBS only) (Source: Australian Statistics on Medicine ). 500, , , , , Prescriptions 9,568 41,418 59,429 72,342 84,716 94,886 99, , , , ,564 In 2006 the Australian Pharmaceutical Benefits Scheme listing for fentanyl was amended to make it available for people reporting chronic non-cancer pain (NPS 2006; Loveday, Dev et al. 2010). According to Australian Statistics on Medicines reports covering the years , it appears as though there was more than a 5000 per cent increase in the number of fentanyl prescriptions (opioid analgesics, not anaesthetics) recorded against the Pharmaceutical Benefits Scheme from It increased by more than 400 per cent in the five years to This has occurred as prescriptions of other opioid analgesics, such as oxycodone, have also increased rapidly (Rintoul, Dobbin et al. 2011). 7

8 2.4. Reports of overdose Fatal overdoses from fentanyl, or involving fentanyl, have been reported internationally for many years, including in Sweden, Canada and the United States (Green, Grau et al. ; Kramer and Tawney 1998; Arvanitis and Satonik 2002; Firestone, Goldman et al. 2009; Fischer and Rehm 2009; Talu, Rajaleid et al. 2010). In 2002 the Medical Journal of Australia reported on a case of fatal overdose in Tasmania from injecting fentanyl from a patch (Reeves and Ginifer 2002). At that stage fentanyl patches were formulated with a reservoir from which the fentanyl gel could be extracted. By approximately 2009/2010, Queensland Health had become aware of fentanyl overdoses occurring. In that State an earlier (2008) grouping of overdoses in the Gold Coast area, which were reported as possibly attributed to a bad batch of heroin, are now thought to have possibly been related to fentanyl. In 2010, Queensland Health issued information for drug injectors via select NSP outlets in response to fentanyl-related incidents, including overdoses. The information cards are now available in other parts of Queensland where fentanyl is identified as an issue. Queensland Health s concerns and responses were presented to the 2010 Australasian Professional Society on Alcohol and other Drugs Conference (Loveday, Dev et al. 2010). Data provided to Anex by the Tasmanian Coroners court indicates fentanyl toxicity was detected in four cases between 1995 and Discussion at the August 21 forum 3.1. Part of an overall increase in opioid prescription The forum was told that fentanyl should be viewed as part of the broader issue of the increased opioid-based pain management medication prescribed for licit and illicit use. It was felt that the perception of fentanyl as being part of first-line pain relief was unnecessary Sudden emergence regionally It was reported that in Albury fentanyl use amongst clients of alcohol and other drug services came to the attention of health staff in approximately 2009/2010, with a higher incidence of fatal overdoses becoming apparent in the last 18 months in particular. Albury ambulance service reported noticing a spate of overdoses earlier this year. Local officers became aware of fentanyl use through reports from people who had overdosed (non-fatally) or were present at the scene. In June it was reported that they had attended to assist one female three times. Wagga Wagga-based health staff indicated that it was being reported via some Opioid Substitution Therapy clients as early as A participant noted it has been pretty consistent in the amount I hear about it from people who inject opiates. Usually it s part of a bigger picture of opiate use along with OxyContin. It was reported that some clients even identify fentanyl as a drug of choice. One worker said: 8

9 I ve looked after patients who ve experienced drug withdrawal, addiction, infections and mental health problems because of fentanyl. I ve seen patients abusing fentanyl from all wards of the hospital, including maternity. The forum heard anecdotal reports that, in at least one area, syringes pre-filled with diverted fentanyl had been on the market. This has not been confirmed, however. 2008/2009 was also identified as an approximate onset period of fentanyl injecting in Wodonga. The forum was informed by sources working directly with a Wodonga pharmacotherapy and NSP client that the client had claimed to have introduced the fentanyl extraction and injection technique to the city following a period of living on the Gold Coast in Fentanyl injection and overdoses were being reported in the Gold Coast area by that time. The person had returned to Wodonga by He said the first time he found about it was from an experience in Queensland where he learned how to do it. And he came back here and showed some people what do with fentanyl patches there was a group of them who used to smoke dope here, and then heroin he was showing his mates the new stuff he d learnt. This account reveals the potential for innovations in drug use to diffuse throughout networks quickly. Wodonga staff felt the issue began to become more obviously serious in People began to coming into NSP with stories of so and so overdosing. There were lots of stories of near deaths, ambos reviving people etcetera. We started to make some inquiries we thought maybe were lucky, that it would pass and transfer to something else. Then suddenly there were a lot of deaths, and particularly so many near misses. It was reported that evidence of injection and overdose began to be apparent in Tumut, NSW, at least two years ago Report of young people and fentanyl from Wagga Wagga It was also reported that some Juvenile Justice staff in the Wagga Wagga area had become concerned by reports that some of their clients who are teenagers may have been injecting fentanyl. Anex has spoken with an alcohol and drug (including needle and syringe provision) professional in the western Sydney suburb of Mt Druitt, who reported that a 17-year-old girl from Wagga Wagga had approached her seeking withdrawal from fentanyl treatment. That professional said that she was told by the girl that she had initiated drug use with fentanyl rather than transitioning to it from other illicits such as either heroin or, or other pharmaceutical opioids Sources There is a significant fentanyl black market in the area, with prices reported as being $100 for a 25 microgram patch (or patch section), $150 for 75 micrograms and $200 for 100 micrograms. 9

10 The reliability of these prices is supported by the comments of an alcohol and other drug counsellor from north of Albury: I had a client last week a woman who was 24 who used half a patch in one go. She says it s about $2 a microgram. Frontline health staff, whose views are based on their discussion with clients, told the forum that it was common knowledge among them that a small number of doctors were known to be prescribing fentanyl which was later able to be misused. Doctor shopping was an issue with fentanyl misuse, as it is more generally. It was reported that some prescribers in the area think that the patches are less prone to abuse. A local doctor has described being told by a marketing representative promoting fentanyl that it was not possible for it to be injected. The forum heard that it was plausible that many GPs are not aware of its potential for its diversion into illicit injection. Patients were reporting that most of the prescriptions that end up on the street are coming from a relatively small number of prescribers. It was reported that features of these prescribers, were isolation, uncertainty and lack of self-confidence. A lot of these GPs are working in solo practices or in practices where there is not adequate support, it was reported. 1 Another health worker noted that fentanyl availability was reflective of the shift in the supply chain and diversification of the trafficking networks for pharmaceutical drugs more generally. Talking about opiates, in the good old days when there was heroin around there were probably three or four dealers in Albury that supplied the area. They took the risks. They were quite entrepreneurial they went down to Melbourne, got their drugs, brought it back here and made a reasonable profit. A couple of years ago a client told me that they had contact with people for the supply of opiates. People who are legitimately prescribed fentanyl may on-sell into the black market. An example given was that of a pensioner selling it to support a gambling addiction. One participant who works with clients mentioned that he/she was aware of fossil pharming and provided the following scenario: there is a form of organised doctor shopping in which older people who could be legitimately prescribed pharmaceutical drugs, including fentanyl, were being coordinated by a gang. The organised group has recruited people to arrange appointments for the elderly people and taken them to GPs where they would be prescribed drugs. A portion is kept by the patient, but other amounts are taken by the gang and then sold into a black market. According to this worker, this has been reported as occurring in both Albury and Wodonga Geographical extent There were apparent differences between NSW and Victoria regarding the number of places that fentanyl misuse has either been confirmed or is thought to be occurring. It was regarded as commonplace in Wodonga. Some Victorian health staff reported that they are aware that people from Echuca and Shepparton have used fentanyl illicitly. This information was from Wodonga-based staff working with at least one client from those areas, but it was not able to be 1 Subsequent to the forum, one nurse working in a GP practice in the Albury area said she had observed cases in which patients had telephoned and asked for the script to be faxed directly to a pharmacy, and that on occasions this was actioned by staff in the GP s clinic. 10

11 confirmed that those people were using it in those towns (ie, they had moved to Wodonga). There were no other reports from within Victoria provided at the forum. Health staff covering Leeton, Tumut and Batlow (all NSW) all reported established fentanyl misuse, as well as overdoses. 2 A frontline worker from Leeton reported three recent overdose fatalities and said: I am seeing a lot more first-time users who would not normally have access to heroin who are being introduced to it at a party etc these are first time users. A clinician based in Tumut and who works regionally said: Clients of ours have told my managers that it s been around for two or three years. it s definitely a regional problem. I have a few clients using fentanyl. And recently had a client who passed away at the beginning of August from overdose. He was a fentanyl user, but we are not quite sure if it was fentanyl or not. That participant also said fentanyl use and overdoses were known to be occurring in Batlow, which is a small town with about 1000 people in between Canberra and Wagga. Following the forum Anex has been contacted by a health professional working with injecting drug users in Dubbo. The worker has spoken with clients who use fentanyl. They have reported that peers have fatally overdosed with fentanyl. There has also been an unconfirmed report of overdoses in Yackandandah (Victoria). As discussed below, there is now Victorian Coroners Court information that shows fentanyl-related overdoses are occurring elsewhere in Victoria, particularly in regional areas Comment from NSW Police NSW Police Force reported that fentanyl misuse should be seen as part of the broader issue of pharmaceutical drug misuse. It was noted that there has been a growth in the illicit market in pharmaceuticals in NSW over the past several years generally, particularly for opioid analgesics. Anex has been informed by the NSW Police Force that anecdotal reports of fentanyl misuse first came to police attention in approximately According to the NSW Police Force: Since that time, fentanyl misuse, including overdoses, has been brought to the attention of NSW Police in a number of areas across the state, particularly in Southern and Western NSW. NSW Police Force has and continues to work with the NSW Health Ministry to address this issue. 3 2 The population of Leeton Shire is approximately 11,000; Tumut Shire approximately 11,000; and the town of Batlow A health worker from Dubbo, which is in the Western region, contacted Anex post-forum and said that a client had spoken of six known fentanyl overdoses in the last six months or so. The health worker said two clients were reported injecting fentanyl. A client has informed the worker that one of the problems people had was the variation in the potency after fentanyl had been extracted from patches. 11

12 3.7. Overdose numbers Without access to established and verifiable data it was not possible to ascertain the number of known fatal or non-fatal overdoses attended by ambulance and/or police. Health staff who work with clients with direct and indirect fentanyl misuse experience stressed that their clients report significant numbers of non-fatal overdoses that don t finish with an ambulance attendance. In the lead-up to the forum, a health worker and Inspector Wadsworth of NSW Police Force in Albury examined the police database and found four known deaths in the Albury area in the previous 12 months in which fentanyl may have been involved, and a report of an Albury man fatally overdosing in Melbourne. As stated above, overdoses are known to be occurring in places such as Albury, Wagga Wagga, Leeton, Batlow and Tumut. It was also reported that a fentanyl-related overdose had occurred in Yackandandah, but this cannot be confirmed at this point. (Prior to the forum, Mr Laurie Evans from NSW Ambulance in Albury said that, even as a manager who did not regularly attend callouts, he had been to three fentanyl overdose callouts in the April-to- June period, one of which was fatal. Inspector Wadsworth said he had recently been to a fatal overdose where fentanyl was found in the flat in which the deceased passed away.) In August 2011, the National Coroners Information Service (NCIS) reported that, following a search of its database for the period from July 2000 to December 2010, it had identified 17 unintentional deaths that involved illicit abuse of fentanyl patches. Most were in Queensland and most occurred in 2010 (Haas, Pearse et al. 2011). The National Drug and Alcohol Research Centre (NDARC) reports that it has conducted analyses on fentanyl related deaths in Australia over the period 2000 to 2011 and while numbers remain modest at this stage, this is an important issue that requires ongoing monitoring. It is hoped that this analyses will be published by early Injecting-related injuries and disease Injecting-related injuries are known to be particularly problematic among people who inject pharmaceutical opioids, such as crushed MS Contin for example (McLean, Bruno et al. 2009). The forum was told: Processes of getting it can involve cutting it up into bits and soaking it in a liquid such as vinegar or lemon juice and heating. It s hardly a sterile procedure. We also think it may get contaminated with glue and fibres form the patch which may explain the high incidence of infection and vein damage. The forum was told of one case study: A 35-year-old opioid-dependent male injected cooked patch. Develops fever rigours, feels very unwell and is admitted to Albury Base. Septic pulmonary emboli is then diagnosed. Transferred to Melbourne in critical condition, he recovers after six weeks and is transferred back to Albury Base Hospital. 4 correspondence to Anex, September 27,

13 3.9. Data availability and sharing There was general discussion and agreement that the emergence of fentanyl and its negative health consequences when misused revealed that early warning systems should be improved. Published overdose data, for example, is some years behind and, as it stands, the current overdose spike in that area is unlikely to be reflected in official data sets for possibly several years. There was consensus that, as is often discussed, far better real time monitoring systems should be available. Concerns were raised about barriers to data sharing capacity across the border. Ambulance service data collection and analysis systems in NSW do not appear to offer as much potential for examination and analysis as those in Victoria where detailed annual metropolitan callout reports have been available for a number of years and regional data is also now being collated and will be reported on. There was agreement that there should be rapid assessment-style research conducted to inform responses: I would like some very good research and information about how to provide adequate harm reduction advice to clients when they come to me. What do we do in the meantime until it s sorted? Regional or reflective of the national? Only one participant expressed a view that the fentanyl use was not an apparent regional issue ; rather, that it was a local manifestation of a national issue. The consensus of the discussion was that, although there may well be past and emergent fentanyl misuse elsewhere, the reasons why it was more pronounced in this particular southern NSW region seemed to be unknown. It was felt that one possible factor was the capacity for, at least in terms of Wodonga residents, travelling to NSW to seek a prescription and the fentanyl itself without that data then being accessible to Victorian GPs and/or pharmacists, and vice versa Confidentiality It was apparent from discussions that, with regards to Albury-Wodonga, there was a strong view among frontline drug and alcohol workers that certain doctors are known by clients to be prescribing fentanyl rather loosely to people who then use the drug for non-medical purposes. At no stage during the discussions were any particular medical practices, doctors or pharmacists named. Several people who work directly with clients, such as those in a drug counselling or pharmacotherapy role, noted that they were unsure of an appropriate response when they were informed that particular doctors were known to be over-prescribing. Clients come in and they will disclose a script source. We get such information and we do nothing with it due to confidentiality. Where do you go with that information? Or another comment: 13

14 I had one GP telling me about another GP prescribing it wrongly. Where do you go with that information? Notification of apparent regional issue The forum was informed that Anex had passed on workforce concerns regarding prescription of fentanyl to drug injectors in one nearby NSW town to relevant authorities. 5 The meeting was informed by Anex that the notification was unable to be acted upon by the NSW Health Care Complaints Commission because it did not specifically name a doctor or a patient. Anex was informed by the NSW Health Care Complaints Commission that the matter would be referred to the NSW Pharmaceutical Services Unit. Experienced health professionals felt it was extremely restrictive that a both a doctor and a patient would have to be named in order for the NSW Health Care Complaints Commission in order for it to pursue a notification through the Australian Health Practitioner Regulation Agency. The forum felt that having to name a doctor and a patient was problematic for a) ethical reasons, and b) the likelihood that a patient in a position to know first-hand about doctor-shopping would put their lives at risk if they dobbed in a doctor or chemist Known for some time, but insufficient action The forum was told that experience internationally showed that: Any drug that has a bunch of street names is clearly a drug which is now out there and is being used in a dependent fashion by people because it s good. And if you look at the names, it does some pretty dramatic things to you. Why is it (fentanyl) becoming more popular, more abused and perhaps more prescribed? If you look at what about a drug makes it more likely to be a drug of abuse, it is characteristics that we see here. Fentanyl has a rapid onset of action, rapid rise to very high efficacy levels, a potency effect and a short half-life. It is going to be popular on the streets. The forum was informed that Queensland Health had taken steps to address fentanyl misuse as early as Fentanyl misuse in the Albury and Wagga Wagga areas was discussed at the 2011 Australasian Professional Society on Alcohol and Drugs Conference (Batey, Clarke et al. 2011). The forum was told that health staff became concerned about the issue and discussed it within some services during Senior advisors have been made aware of concerns about fentanyl in the course of normal service-level discussions. 5 An official notification was made to the Australian Health Practitioner Regulation Agency. This was made on June 14. In NSW notifications to APHRA are passed to NSW Health Care Complaints Commission. Relevant Federal and State Ministers were also notified of the concerns. This occurred on June 14,

15 There was a strong sense in the forum that this issue could have been investigated and then addressed earlier. The forum heard that there have been concerns within some elements of health departments that discussion of fentanyl s misuse potential could lead to some people becoming aware of it and then attempting to misuse it. There was a strong view amongst the participants that the matter should be raised and addressed, particularly with regards to formulating public health messages based on harm reduction principles for the benefit of injecting drug users. One health professional with direct experience with fentanyl injectors summed up the sentiment with: I do not agree that we should not be talking about it. To me that is a bit like saying don t talk about alcohol in case anyone works out you can get drunk off it. There was a strong sense that apparent delays in addressing fentanyl from a strategic, planned and funded public health perspective within the region should not be replicated in other areas should the issue already exist, or evolve into a serious matter of concern Education and awareness The forum heard that part of the problem was that, even among some GPs, there was insufficient understanding of risks associated with prescribing opioids. There is also, it was reported, a significant lack of awareness about the legal framework for prescribing. I m surprised how many doctors do not know about the regulations and rules for prescribing S8 drugs. Also, there is a misunderstanding that opiates have a limited role in the management of chronic pain. Most doctors that I talk to think that if you give enough you will get good pain relief and that is not true. And there is also a significant lack of awareness of the markers of dependent behaviours and the signs to look for. A senior medical professional told the forum: One of the issues is that a lot doctors don t realise the potency of fentanyl. You are talking about drug that is going to last three days. So a 100mg patch is like the equivalent of 1500 milligrams of morphine. It s a huge dose at least 400mg a day equivalent. Most GPs wouldn t prescribe that (in morphine form), but they will give them a patch that is essentially the same thing. I think there is an education problem. Police and ambulance (NSW) reported that they had only quite recently become aware of fentanyl misuse and its dangers in the Albury-Wodonga area. Alcohol and other drug workers in areas where it has become a problem, such as Wodonga, Wagga Wagga and Tumut, reported that they had learned about fentanyl through necessity. They feel that there is still insufficient understanding of it among the workforce, which should be addressed as a matter of priority. 15

16 A health worker said he had tried to inform a doctor who clients told him was known to be a good source for fentanyl: I had contacted a doctor (and said) that I was concerned about one of his clients providing the community with fentanyl patches for injection. He (the doctor) assured me that the manufacturer had assured him that that was impossible that the drug could not be removed from the matrix that it was in. I assured him that what I was telling him was probably more of an expert opinion than what he was getting Border issues It was apparent that Victorians were able to travel to NSW and be prescribed fentanyl and other drugs. Those transactions would not be available for checking by a Victorian doctor and/or pharmacist Policing Illicit prescription drug markets are difficult to police. While possession of heroin is obviously illegal, it is not illegal for an individual to possess fentanyl prescribed to them (for example). The forum heard that police are experienced in dealing with criminals trafficking illicit drugs, but are far less experienced in dealing with the fact that the source of pharmaceuticals are doctors. It was suggested that doctors need to keep an eye out on your fellow doctors about who is giving this drug. It was agreed that police may have a role to play in overdose prevention through increased awareness of fentanyl (and other opioids) and its properties Opioid Replacement/Substitution Therapy shortage Opioid Replacement Therapy (ORT, known as Opioid Substitution Therapy in NSW) resources in the Albury-Wodonga area are stretched. Only one GP is an active prescriber, covering both the cities. In Wagga Wagga, it was reported that there is one prescriber who does half a day a week in the public system at the hospital, and she also has some private clients. On the whole, the forum was told, there is serious shortage of prescribing doctors. A result is that many people wishing to access ORT/OST in either of the cities and/or surrounding areas unable to do so without having to wait for lengthy periods of time. A frontline drug treatment worker said: The lack of participating doctors as well as pharmacists, either public or private, is a major contributor to continued pharmaceutical misuse more generally. It s easier for people to get an addictive opioid pill than it is for them to get on a methadone or buprenorphine program. We often have to inform people that they can t necessarily get on treatment when they need to, so to avoid physical and psychological trauma of withdrawal they may need to keep medicating themselves on an illicit until a place becomes available. 16

17 3.18. Fentanyl dosage within hospital settings A number of participants said that there was an increased tendency for people to begin using fentanyl while in hospital for surgery etc. Details were not provided, but the forum was told that people are leaving hospital on fentanyl, which puts them at risk of developing dependencies Hume Medicare Local The Hume Medicare Local (HML) came into existence on July 1, On July 2, its predecessor organisation, the Wodonga Regional GP Network, issued an alert on fentanyl misuse potential which was prepared by Dr Malcolm Dobbin, Senior Medical Advisor (Alcohol and Drugs) with the Victorian Department of Health. A GP who is on the Board of the Hume Medicare Local attended the forum. He raised the matter at the HML meeting following the forum on the same day. The HML Board Meeting determined to investigate ways in which it can be actively engaged in addressing this issue constructively. The HML includes towns such as Mansfield and Wangaratta to south, Cobram (all Vic), Finley and Jerrilderie to the north-west and Corryong and Holbrook to the north-east (all NSW) Naloxone provision for potential overdose witnesses Some participants felt that the particularly serious issue of fentanyl, given its high overdose risk profile, warranted development of a program to make naloxone hydrochloride available to drug users and their friends/families. Naloxone (often known by the tradename Narcan ) is the opioid antagonist that reverses overdoses. Programs have been established in rural USA, for example, to reduce opioid overdose deaths caused by pharmaceutical drug misuse in some rural areas. It was felt that the Albury-Wodonga area would be a logical site for a pilot of such program of some form Apparent reversal in overdoses in Albury The meeting heard that, in the case of Albury, callouts to ambulance involving fentanyl appeared to have been reduced since early July. This is after the notification to authorities was made in mid-june Investigate and re-think prescription practices The forum was told that there is a definite legitimate role for fentanyl prescription, but not of the form in which it appears to be occurring in that area at least. Numerous participants with extensive experience said there should be a re-think, including in the way it is promoted through its marketing representatives. One participant who had clients who have died of a fentanyl overdose summed it up as: There is a time for drug companies to think about their marketing, what they are marketing and for us to say enough is enough. If there s a preparation 17

18 where medication is made so it can t be injected, with the inclusion of naloxone, why isn t that being used? The forum was told that this issue could be likened to that of pethidine, which was eventually curtailed after information concerning its misuse became evident. 4. Recommendations Participants provided verbal and written recommendations during the forum, the bulk of which are recorded below. By far the most commonly expressed recommendations concerned the monitoring of prescriptions to address doctor shopping, recognising that it is an issue and therefore responding to it, and education of GPs as well as people working with affected populations (especially needle and syringe program workers). Recommendations are: An investigation be conducted into the emergence of (and responses to) fentanyl misuse in the Albury-Wodonga and southern NSW area. The investigation to include examination of the detailing and other marketing strategies of the relevant pharmaceutical suppliers. A review of official complaints notification procedures be conducted based on this case study so that where knowledge of such a problem exists it can be acted upon as soon as possible to prevent harms. The current requirement that, in order for a notification to be investigated, a specific doctor/pharmacist (for example) and a specific patient be named, should be removed. Action-oriented research be conducted with people who use fentanyl illicitly to assist in addressing contributing factors and informing responses, particularly health promotion strategies based on harm minimisation principles. That governments, manufacturers, suppliers and responsible industry bodies such as the Australian Medical Association recognise fentanyl as a particularly concerning illicit drug issue and take steps to inform relevant parties. A comprehensive education and workforce development strategy be implemented to address fentanyl prescription and misuse, within the context of pharmaceutical drug misuse more generally. Immediately, to educate frontline workers such as NSP and pharmacotherapy staff about fentanyl so that they understand it and are able to discuss it appropriately with clients. A communications strategy be designed and implemented specifically to reach people who illicitly use fentanyl to promote risk reduction messages, especially concerning overdose risks and responses. 6 Improved and additional education for all doctors, their staff and pharmacists, to increase understanding of pain management and treatment, drug dependency risk, consequences and treatment. 6 Note that this recommendation is not to be interpreted as providing information to all NSP clients through all services (for example). Any information, education and communication strategy should balance the need for risk-reduction and other overdose prevention messages against advertising fentanyl s misuse capacity. 18

19 The Hume Medicare Local and the Murrumbidgee Medicare Local initiate an awareness and support program aimed at better informing pharmaceutical prescribers, pharmacists and allied health professionals. Place limits on the strength and quantities that can be prescribed through non-specialist GPs. Increase specialist pain management capacity amongst the medical workforce. A program be established to promote provision of naloxone hydrochloride (Narcan) to potential opioid overdose witnesses in the Albury-Wodonga area. Review and improve relevant data collection, collation, analysis and reporting systems to ensure the earliest possible detection in drug trend shifts. Provide particular attention to misuse and overdose outside metropolitan areas and among people not reflected in research that focuses on injectors only. Detailed examination of fentanyl overdose data be promptly produced and disseminated by the National Coroners Information System. Implementation of a genuine real-time monitoring system for doctors and pharmacists and other (to be identified) relevant health professionals. That it be mandatory rather than optin. That the Intergovernmental Committee on Drugs discuss and respond to the growing issue of fentanyl misuse and related health consequences such as overdose. Independently-produced factual information about potential and actual fentanyl diversion and misuse be made compulsory for pharmaceutical companies to provide to doctors when marketing fentanyl products to GPs and/or pain management specialists. All fentanyl scripts and other opioids to be a Pharmaceutical Benefits Scheme Authority Item scripts. Increase availability of (and improve quality of) drug treatment options in regional and rural areas. Urgently review and address growth in opioid pharmaceutical drug prescription as pain treatment in Australia. Review of fentanyl disposal procedures in hospitals, aged care and other relevant settings. 5. Conclusion The forum was a rapid response to an emergent crisis. It succeeded in better understanding the extent of fentanyl misuse in the southern NSW/Wodonga region. While not known conclusively, it may be that the apparent reduction in fentanyl overdoses as of late July/August is a result of intervention by authorities following the June notification by Anex in response to frontline service concerns. The exercise has revealed that there has been far too little known formally about the issue. Frontline staff in the region have been concerned for at least two years, and these concerns are based on 19

20 actual experience with clients. Their information appears not to have been reflected in formal published documentation to date. The fentanyl experience highlights how illicit drug problems can emerge quickly while responses can take far longer. This needs to be acknowledged and addressed. People who work with fentanyl-using clients, particularly NSP workers, are calling for informational support. It is not surprising that knowledge of how to divert and use fentanyl for illicit injection can, apparently, be transferred quickly through word-of-mouth and (presumably) demonstration. It reveals that such innovations can diffuse quickly, which should be sufficient to demonstrate that it is likely to also occur in other areas as people and ideas migrate temporarily and permanently. Steps should be taken to reduce the likelihood that this occurs, to avoid preventable morbidities and mortalities associated with fentanyl. Overdose data is not adequately analysed and reported at the national or state level in Australia frequently enough. More needs to be done to use the frontline experience of professionals from a range of agencies to better inform policy makers. The Albury-Wodonga area and its fentanyl problem warrant consideration of enabling a program to educate potential overdose witnesses on naloxone provision and application to reverse opioid overdoses. Even highly experienced frontline health workers are concerned about fentanyl, and more so than about other illegal or legal opioids. They are in urgent need of being provided with adequate training and other forms of workforce development so that they can treat fentanyl in line with recognised and established harm minimisation protocols. The forum was a one-off unfunded exercise that brought numerous agencies together at the community level. As fentanyl is likely to be presenting similar problems elsewhere in Australia, either already or in the future, similar local-level awareness-raising should occur. There is now growing evidence that fentanyl is contributing to deaths amongst drug injectors in Victoria beyond the Wodonga area. More needs to be done to work systematically with the medical profession to educate them not only with regards to fentanyl s potential for misuse, but in pain management more generally. Improved law enforcement and health sector cooperation has an important role to play in addressing the diffusion of pharmaceutical drugs and its consequences. 20

21 6. Annexes 6.1. Agenda and format The forum lasted for four hours and included 72 participants from law enforcement, ambulance services, general practitioners, Needle and Syringe Program staff, people prescribing and dispensing pharmacotherapy, alcohol and drug treatment, Justice, Aboriginal health, youth services, mental health services and more general nursing. Professor Bob Batey was the keynote speaker. The forum included a panel session comprising: Innes Clark Clinical Liaison Nurse Murrumbidgee Central Health District, Wagga Wagga; Martin Eames Pharmacology Nurse, Gateway Community Health, Wodonga; Laurie Evans Ambulance Area Duty Manager, Albury; Alan Fisher Clinical Nurse Consultant, Murrumbidgee Local Health Network, Albury; Inspector John Wadsworth NSW Police Force, Albury; Dr David Tillett General Practitioner, Wodonga and Albury practising GP; Dr Brett Tod-Hunter Pain Management Specialist, Albury-Wodonga. The forum was held under the Chatham House Rule. 7 A female resident of Albury, Ms Bernadette Williams, whose mother passed away from a fentanyl overdose in 2011, spoke. NSW Police Force member Ms Katie Hall Senior Policy Officer (Illicits) was a participant and also spoke as part of the panel session. Panel presentations were followed by a Question and Answer session. Next was an open discussion and information exchange, and the forum concluded with a discussion regarding recommendations. 7 One journalist from the Border Mail regional daily newspaper attended the presentation by Professor Bob Batey, but was not permitted to attend the subsequent sessions. 21

22 6.2. Presentation by Professor Bob Batey Professor Batey s presentation to the forum included the following slides: A potent opioid 100ug equivalent to 10mg morphine (100x more potent) The pharmacokinetics of fentanyl fit a threecompartment model, with a distribution time of 1.7 minutes, redistribution of 13 minutes, and a terminal elimination half-life of 219 minutes Many reports First Australian report 2002 Fentanyl Tea Bag 2004 Hysterical reports appeared and led to a risk management approach Don t mention the war 22

23 No one wants a new problem Marketing has been strong and built on the message that we MUST relieve pain & Opiates are great for pain BUT NOT FOR CNM pain Scripts are being used excessively Fentanyl is seen as first line for all sorts of pain Patches are the key currency now Patients are selling them People are stealing them Patients are overdosing 23

24 Recognise that we have been here before with pethidine Accept that fentanyl has a significant dependency potential Advise users of the potency of fentanyl Prescribers & Patients Think seriously before prescribing it Assess pain patients fully and repeatedly Use all other options for pain relief for CNM pain BEFORE using opioids Even consider administering it with +naloxone Acknowledge that fentanyl does cause problems 24

25 6.3. Newspaper coverage of the forum, 22/8/

26 7. References Arvanitis, M. L. and R. C. Satonik (2002). "Transdermal fentanyl abuse and misuse." The American Journal of Emergency Medicine 20(1): Batey, R., I. Clarke, et al. (2011). Fentanyl Trans-dermal Patches, extent and risks of abuse Australasian Professional Society on Alcohol and Drugs. Firestone, M., B. Goldman, et al. (2009). "Fentanyl use among street drug users in Toronto, Canada: Behavioural dynamics and public health implications." International Journal of Drug Policy 20(1): Fischer, B. P. and J. P. Rehm (2009). "Deaths related to the use of prescription opioids." Canadian Medical Association. Journal 181(12): 881. Gibson, A., B. Larance, et al. (2007). The extent of diversion of Fentanyl for non-medical purposes in Australia: what do we know?. Sydney, National Drug and Alcohol Research Centre, University of New South Wales,. Technical Report No 265. Green, T. C., L. E. Grau, et al. "Epidemiologic trends and geographic patterns of fatal opioid intoxications in Connecticut, USA: 1997â 2007." Drug and Alcohol Dependence 115(3): Haas, S., J. Pearse, et al. (2011). Fatalities from illicit use of slow release opioid (fentanyl) patches in Australia. Forensic and Clinical Toxicology Meeting Melbourne. Kramer, C. and M. Tawney (1998). "A fatal overdose of transdermally administered fentanyl." Journal of the American Osteopathic Association 98(7): Lofton, A. and W. Philip (2005). Fentanyl. Encyclopedia of Toxicology. New York, Elsevier: Loveday, B., A. Dev, et al. (2010). Fentanyl abuse in Queensland - Identification of emerging pharmaceutical drug misuse. Australian Professional Society on Alcohol and Other Drugs 2010 Conference. Canberra, ACT. McLean, S., R. Bruno, et al. (2009). "Effect of filtration on morphine and particle content of injections prepared from slow-release oral morphine tablets." Harm Reduction Journal 6(37). NPS (2006). Fentanyl patches (Durogesic) for chronic pain, NSP Medicinewise: data/assets/pdf_file/0016/23731/fentanyl.pdf. Reeves, M. and C. Ginifer (2002). "Fatal intravenous misuse of transdermal fentanyl." Medical Journal of Australia 177: Rintoul, A., M. Dobbin, et al. (2011). "Increasing deaths involving oxycodone, Victoria, Australia, " Injury Prevention IP Online First, published on January 7, 2011 as /ip ).((doi: /ip )). Talu, A., K. Rajaleid, et al. (2010). "HIV infection and risk behaviour of primary fentanyl and amphetamine injectors in Tallinn, Estonia: Implications for intervention." International Journal of Drug Policy 21(1):