Trends and patterns in pharmaceutical use in Australia: What can we learn from those who have gone before us?

Nicole LeeRoger Nicholas

Ann Roche

Trends in pharmaceutical supply

Source: International Narcotics Control Board Tables of Reported Statistics 2009. Available from http://www.incb.org/incb/en/narcotic_drugs_2009.html

19971998

19992000

20012002

20032004

20052006

20072008

0

20

40

60

80

100

120

140

160

Australia

USAKg/m

illio

n po

pula

tion

60kg per million population

USA Trends

High prevalence of non-medical use

2010 non-medical use of prescription medicines was second only to marijuana

among young people

Nearly half of the world’s consumption of morphine and

99% of oxycodone but only 4.7% of the world’s population

Largest per capita non-medical use in the world

USA Trends

Increased supply of prescription opioids generally

1992-2002 population increased by 13%,

prescriptions rose 57%

Stimulants 369% increaseOpioids 222% increase

USA trends

Illicit use has remained high but stable for the last decade

Past month non medical use by young people declined between 2002 and 2010

Number of new illicit users is stable

Illicit use not increasing

Australian trends

supply Illicit useNon-medical use of painkillers up from

2.5% to 3%

Supply far outstrips changes in levels of

non-medical use

Morphine TramadolFentanylOxycodone 17x

Increasing supply Stable prevalence of illicit use

Potential theories

Increase in pharmaceutical

opioids

Increased diversion and illicit

use

Effects of the ageing population

Marketing

Knowledge gaps

Opioids in chronic pain managemen

t

Potential theories

Increase in pharmaceutical

opioids

Increased diversion and illicit

use

Effects of the ageing population

Marketing

Knowledge gaps

Opioids in chronic pain managemen

t

Diversion and illicit use

Heroin Pharmaceutical opioids

Fischer & Rehm, 2006

Diversion and illicit use

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

0.0005

0.001

0.0015

0.002

0.0025

AustraliaUSA

Diversion and illicit use

Heroin Pharmaceutical opioids

Stafford & Burns, 2011

Potential theories

Increase in pharmaceutical

opioids

Increased diversion and illicit

use

Effects of the ageing population

Marketing

Knowledge gaps

Opioids in chronic pain managemen

t

Ageing populationIncrease in prescription opioids among older Australians (Roxburgh et al, 2011)

NDHS data shows the highest painkiller use among 20-29yo (5.4%) (AIHW, 2011)

Potential theories

Increase in pharmaceutical

opioids

Increased diversion and illicit

use

Effects of the ageing population

Marketing

Knowledge gaps

Opioids in chronic pain managemen

t

Marketing of opioids in the USA

• Significant marketing changes with the introduction of oxycodone in the US (Van Zee, 2009)

• Period of liberalisation of use of opioids for treatment of chronic non-cancer pain

• Promoted with unusual intensity• High intensity academic detailing and incentives

• Direct to consumer advertising in the USA• Tighter controls in Australia – protective?

Potential theories

Increase in pharmaceutical

opioids

Increased diversion and illicit

use

Effects of the ageing population

Marketing

Knowledge gaps

Opioids in chronic pain managemen

t

Knowledge gaps

Lack of awareness among prescribers, dispensers and

the community

Ineffective and incoherent prescription

monitoring programs

Lack of a comprehensive national prescription

monitoring

Manchikanti, 2007

Potential theories

Increase in pharmaceutical

opioids

Increased diversion and illicit

use

Effects of the ageing population

Marketing

Knowledge gaps

Opioids in chronic pain managemen

t

Opioids in chronic pain management

Reduced stigmaIncreased use in cancer pain

Increased use in chronic non-cancer painSlow release options

Pain as the 5th vital signIntolerance of undertreated pain in USA

Why do we care?

Harms increase with increases in licit or illicit use and supply

Association between opioid pharmaceutical potency and morbidity in the community (Dasgupta et al., 2006)

Large steady increase in deaths after the introduction of oxycodone in Canada (Dhalla et al., 2009)

Increase in deaths including oxycodone associated with increased supply (Rintoul et al., 2011)

Increase in emergency department visits tracks supply (Wisniewski et al.,2008)

Increase in drug poisonings associated with supply (Paulozzi et al., 2006)

What can we do?• Focus on QUM• Education and information for prescribers, pharmacists

and community

Most increase in supply is related to

legal use• Reduce opportunities for misuse and diversion• Increase methadone places

Some increase among current illicit users

• Monitor and control supply• Enhancing the role of pharmacists in monitoring and

advice

Harms associated with licit and illicit supply

• Provide early and effective pain management• Access to non-pharmaceutical responses

Increases in opioids for non-cancer pain

What can we do?

• Electronic recording and reporting of controlled drugs (ERRCD)• Monitoring supply• Identification of prescription shopping• Prevent dispensing of lost prescriptions• Flag problem prescribing or dispensing