"For two years, I was a zombie," Panagiotopoulos said. "I missed out on picking up my son, holding him, missed out on everything because I was either incoherent or just unable to do it. I couldn't function at all." Peter Panagiotopoulos has suffered from chronic pain for years but is now off opioids. Credit:Nick Moir But the Rydalmere resident was lucky enough to live within easy driving distance of the pain management clinic at Royal North Shore Hospital. After a second operation, his GP referred him to the clinic and he weaned himself off the medication within three weeks. He now manages his pain with meditation, walking and "mindfulness" techniques. The other Peter, who does not want his last name used, lives 300 kilometres north in Taree, and once worked as a showroom manager. When unexplained pain formed in his feet, arms and legs, his doctor put him on a course of opiate painkillers without further investigation. And it didn't help. Peter returned to the doctor, and each time he did the dosage was increased, until he was taking 35 grams a day. He asked to see a specialist, who put him on another opiate that made him feel worse than ever. Finally he switched to a different GP, who sent him to another specialist, and he was diagnosed with fibromyalgia, a condition that cannot be alleviated with opiates. He is now taking completely different medication.

"Had the physician listened to me in the first place and sent me to a specialist, I honestly think all this could have been brought to a head a lot earlier," Peter says. "I'm so frustrated that instead of looking at the person and trying to treat the person they were just too quick to say, 'This will help,' and then they didn't listen to me when it wasn't helping." On Thursday, the Australian Commission on Safety and Quality in Health Care released its first national atlas on the varying patterns of healthcare in Australia. The map of opioid prescriptions is one of social disadvantage, with dispensing rates higher in poorer, regional areas and decreasing with affluence and proximity to major cities. Opioids are medicines to relieve moderate to severe pain and include "hillbilly heroin" drugs such as endone and oxycontin, as well as patches such as fentanyl for cancer pain and norspan for arthritis. At their best, they provide relief to people with acute pain, cancer patients and those who are in palliative care.

But the vast majority of opioids are prescribed for patients with chronic, non-cancer pain. And a growing body of evidence indicates that they are inappropriate for these patients, with an increased risk of mortality for a benefit that diminishes over time. Paradoxically, patients who take opioids over a long period of time can develop "opioid induced hyperalgesia", where their sensitivity to pain is increased. In the same way that the brain of a person suffering a migraine amplifies normal light and sound to unbearable levels, mild discomfort in these patients is distorted into excruciating pain. Parts of western NSW and the mid North Coast are dispensing opioids at a rate 10 times higher than places such as Epping and Pennant Hills. A lack of options and the crude approach taken by some physicians in regional areas has dovetailed with a population that is more likely to be experiencing chronic pain to create hotspots of alarming use. "People with chronic pain have trouble living in cities because they're not employed," says Malcolm Hogg, a pain medicine clinician and director of Pain Australia. "They end up in regional towns, and often they're not in the regional town but the smaller regional areas around it. And they live there on their moderate dose opioids and disability pensions. "There's a socioeconomic drift out of the cities to these places where it's cheaper to live."

Residents of the mid-North Coast are being prescribed opioids at rates of up to 110,000 prescriptions per 100,000 people, and there is a thriving black market. Several GPs in the region have been banned from prescribing opioids after a crackdown by the health regulator earlier this year, with conditions placed on their registration certificates. But for general practitioners who work in regional areas, there is often little other option for their patients with chronic pain. A course of Medicare-subsidised drugs might cost a patient $6, where the alternative is psychology, physiotherapy and pain management strategies such as meditation that are expensive and a long way from home. Simon Holliday has been working as a GP and addiction physician in the Manning Valley for 20 years and witnessed the changing face of addiction, from heroin to pharmaceutical opiates. "GPs really want to help patients and they act in good faith," Holliday said. "But they're time poor and the more rural and remote you are, the more socially disadvantaged you are, the more multidisciplinary care is inaccessible, either geographically or financially.