John at the Odyssey House residential rehabilitation facility in Sydney. Credit:Christopher Pearce In the US, about 142 people die every day from accidental overdoses of prescription opioids. About 60,000 people died last year, more than the number who died in the Vietnam War. Only last week, US President Donald Trump was urged by the Commission on Combating Drug Addiction and the Opioid Crisis to declare "a state of emergency". About 50,000 doses of prescription opioids are prescribed for every 1 million people every day in the United States, according to an opinion piece by Stanford University's Keith Humphreys published in the medical journal Lancet last week. In Australia, about 20,000 doses are prescribed for every 1 million people, and Australia ranks eighth among the world's top 30 users of prescription opiates. "Australia is one of a group of countries that is rapidly moving towards the same dangerous territory," Professor Humphreys, the Esther Ting Memorial Professor at Stanford University's school of medicine, told Fairfax Media.

Australia is eighth out of the top 30 opioid producing countries in the world., 2012-2014. Credit:Lancet, July 29, 2017 A former adviser to the White House, Professor Humphreys said the two countries with true prescription opioid epidemics were the United States and Canada. "I wrote the article in the hopes that Australia and nations like it would avoid my country's mistakes and take action before the epidemic takes hold," he said. He urged countries to immediately assess and strengthen all available safeguards against the globalisation of the prescription opioid addiction and overdose epidemic. Legally produced pharmaceutical opioids were the origin of the American epidemic and still fuel the problem, he wrote, often by addicting people who later transition to heroin. He added that heroin and gangs dealing with fentanyl – a prescription opioid commonly prescribed for cancer pain and which is 50 to 100 times more concentrated than morphine – had added to the death toll by strategically establishing markets in areas with high prescription opioid use.

The idea that there are good patients with pain, and then some other group of patients is not understanding the complexity of the problem with opioids. Dr Suzanne Nielsen In 2014, figures released by the Pharmaceutical Benefits Scheme found that just fewer than 3 million people had been prescribed at least one opioid analgesic in the previous 12 months, and warned of increasing rates of oxycodone usage. Australia had a relatively high opioid use per capita, but was nowhere near the same stratosphere as the US, said Suzanne Nielsen, a pharmacist and National Drug and Alcohol Research Centre's senior research fellow specialising in prescription drug problems. Increasingly users of illegal opioids and those who got drugs legally were overlapping. To view them as two separate groups was unhelpful and stigmatising, said Dr Nielsen. People with chronic pain did develop opioid use disorders, and some loss of control occurred. And about 40 per cent of those with substance abuse disorders have had chronic pain, she said. "The idea that there are good patients with pain, and then some other group of patients is not understanding the complexity of the problem with opioids," Dr Nielsen said.

Like most people in rehabilitation at Sydney's Odyssey House, John was a poly-drug user. When he was on methadone, adding prescription opioids gave him the closest thing to the high he got from heroin. He would buy pills and prescriptions written for others who had gone to the doctor for pain-relieving medication. Experts say the chronic use of heroin, oxycodone, and other morphine-derived drugs are underlying causes of opioid dependence (the need to keep taking drugs to avoid a withdrawal syndrome) and addiction (intense drug craving and compulsive use). John also found it easy to get a doctor to prescribe painkillers if he mentioned his "back pain" and went doctor shopping until he found someone sympathetic. Last year John overdosed twice when he shot up heroin that he believed had been laced with fentanyl. Although he said he lost everything, including his three children, friends and the jobs that he held down despite his addiction, he didn't lose his life.

He was luckier than musician Prince who died from a fentanyl overdose in 2016, and many others who accidentally overdosed on prescription opioids alone or mixed with other drugs.



New research released this month found accidental overdoses from prescription opioids far exceeded those from heroin. Researchers at the National Drug and Alcohol Research Centre found 68 per cent of the 668 overdose deaths in 2013 were related to pharmaceutical opioids, a contrast from the heroin epidemic of the 1990s when the majority of opioid deaths were caused by illicit drugs. The figures do not include as many as 200 other deaths where opioids contributed to a person's death. NDARC also found opioid-related hospitalisations among Australians aged 30 to 59 years old had steadily increased over the past five years. And many deaths were caused by multiple drug toxicity, which increases the risk of a fatal overdose. Brain abnormalities resulting from the chronic use of heroin, oxycodone, and other morphine-derived drugs were underlying causes of opioid dependenceand addiction, said experts at the US National Institutes of Health. Like John's use of prescription opioids, if heroin was made harder to get, people would turn to opioids, said Dr Wodak. "When Grandpa Bill gets some oxycodone for his back pain because he has cancer of prostrate ...and needs money to buy for a Christmas gift... he will sell the odd tablet," he said.

"If someone else in the family needs money, they may steal grandpa's pills to sell." Dr Wodak said the adverse effects of the painkillers were significant and underestimated. As for John, he is terrified of heroin. Now about to graduate from Odyssey House's program, he described himself as a careful addict; someone who took care to test small amounts first. But his last two overdoses were nothing like anything he had had in the past. Now he is clean and determined to survive for his mother's sake and to reconnect with his children. "My poor old mum is 86 ... I don't want her to die while I am in rehab or in prison," he said.

His mother had outlived two husbands, including a bad alcoholic, and John's 22-year-old brother, who died from suicide many years ago. "She will say 'I am not going to visit you', and two days later she will be there," John said. "Always dropped off packets of socks and underwear; she's been the only person who has stuck with me. "She's never deserted me." Recommendations Much of American policy was designed to stop the flow of illicit drugs, which Dr Wodak said was close to useless in countries such as the United States and Australia, which have large borders.

To address the growing problem, Dr Wodak made six recommendations, including increasing the availability of medical cannabis in Australia. A study published in the Journal of the American Medicine Association (JAMA) found states with medical marijuana laws had a 24.8 percent lower average annual opioid overdose death rate compared to states without such laws. In 2010, that translated to about 1,729 fewer deaths than expected. Dr Wodak also recommended: Loading

1. Sensibly restrain the prescription of opioids;

2. vastly expand treatment for heroin users and people dependent on other opioids such as methadone and buprenorphine. (To address this need, Odyssey House is opening a range of community services across Sydney.)

3. provide heroin prescription treatment for selected super consumers;

4. open supervised injecting centres in areas with large numbers of fatal and non-fatal drug overdoses.

5. expand naloxone distribution; and *A pseudonym to protect his three children