Trends and patterns in pharmaceutical use in Australia: What can we learn from those who have gone...
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Trends and patterns in pharmaceutical use in Australia: What can we learn from those who have gone before us?
Nicole LeeRoger Nicholas
Ann Roche
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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
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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
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USA Trends
Increased supply of prescription opioids generally
1992-2002 population increased by 13%,
prescriptions rose 57%
Stimulants 369% increaseOpioids 222% increase
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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
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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
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Increasing supply Stable prevalence of illicit use
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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
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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
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Diversion and illicit use
Heroin Pharmaceutical opioids
Fischer & Rehm, 2006
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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
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Diversion and illicit use
Heroin Pharmaceutical opioids
Stafford & Burns, 2011
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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
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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)
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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
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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?
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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
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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
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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
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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
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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)
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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
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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
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