One little pill
For Jessica Khachan and Rustie Lassam, one perfectly legal prescription painkiller began a spiral to addiction. Ingrid Pyne investigates the opioid epidemic and meets two of its brave survivors.
Around Christmas, the time of miracles, Sydney mum Jessica Khachan was told it was a wonder she was still alive. Her weight had plummeted from 55kg to 30kg, her blood count was dangerously low, her face was an unnatural grey-green, and doctors at Westmead Hospital in western Sydney had just discovered an ulcer on the brink of bursting. “The specialist said to me, ‘That’s the biggest stomach ulcer I have ever seen’,” recalls Jessica, 44. “It’s a miracle you are still here.’”
How Jessica got to this point is a story as mundane as it is horrifying. Two years earlier, in 2010, she had been prescribed the opioid hydrocodone to relieve pain from routine wisdom-tooth surgery. When her script ran out, she went to the chemist and bought a pack of Nurofen Plus – then another. Like a growing number of Australians, she quickly became addicted.
Two pills a day became six, then eight. Within two years, Jessica was taking 90 Nurofen Plus per day – not in one gulp, but throughout the day, just to keep going. “They made me feel normal,” Jessica tells The Weekly. “They made me feel able to get up and do things. I didn’t feel high on them, but if I couldn’t have them, I’d lie in bed. The minute I swallowed a few pills, I’d be able to get on with the day.”
By Christmas 2012, with her health in crisis for no apparent reason, Jessica’s perplexed family insisted on taking her to hospital. Jessica was scared, ashamed and deep in denial. “I didn’t know I had a problem,” she says. “I knew about people in recovery from alcohol addiction or other drug problems, but I’d never heard of anyone who had a painkiller addiction.”
Experts warn that Australia’s addiction to prescription opioids is reaching crisis point. Our use of opioid-based painkillers has quadrupled in the past decade, levels of prescription opioid overdose are at record levels, and prescription drugs account for almost three-quarters of all accidental drug-related deaths.
At last count, in 2013, 11.4 per cent of Australians admitted to misusing prescribed drugs, up from 7.4 per cent in 2010. Surprisingly, the two groups with the largest increase in misuse are women in their forties and men in their thirties.
The majority of them are “everyday people” like Jessica who have become unwittingly addicted to the drugs, according to Dr Hester Wilson, a general practitioner and drug addiction specialist.
“The people I see are mostly middleaged men and women. They have started on opioids, not to get high, but to cure their pain – be it endometriosis, a motor vehicle accident or back pain,” she says. “But once they start on them, they find they cannot stop. When they try, they experience withdrawal symptoms such as nausea, vomiting, insomnia, the shakes, goosebumps. Plus there is this overwhelming craving to use the medication again.”
Rustie Lassam knows that feeling all too well. At 16, in the grip of puberty, she went to a doctor for back pain, and was prescribed Panadeine Forte and Valium. To her, the drugs felt like heaven. She started having a few more pills each day. And so began a downward spiral into prescription drug abuse that would last more than three decades and utterly derail Rustie’s life. By 32 she’d been married and divorced twice. At the peak of her addiction she was was taking nine 80mg tablets of opioid Oxycontin and five 5mg tablets of Valium a day, while also getting Pethidine injections from her doctor. “And this is from someone who grew up in a nice, middle-class
Prescription drugs account for threequarters of all accidental drugrelated deaths.
family, went to church every Sunday and did Meals on Wheels with Mum,” says Rustie, dispelling the stereotype of an opioid addict.
Her “rock bottom” moment was when she found herself in the shower rubbing her pregnant belly, and apologising to her unborn son for all the damaging drugs she was putting into his bloodstream.
“I know what a baby needs for healthy development, yet I couldn’t stop myself,” Rustie, now 56, tells The Weekly. “It was horrific. The drugs came first, second and third.”
Bee Mohamed is the chief executive of ScriptWise, a not-for-profit organisation dedicated to preventing prescription drug misuse. She says many of us take a casual approach to painkillers because a trusted medical professional typically gives us the script. “But up to 30 per cent of people who use opioids for more than 10 days are at serious risk of becoming dependent,” she warns.
With dependency comes addiction and, in some cases, death. According to the Penington Institute, there were 1137 fatal accidental drug overdoses in Australia in 2014, up 61 per cent on 2004, with prescription painkillers (like oxycodone, morphine and codeine) responsible for 411 of those deaths and prescription relaxants (like Valium or Xanax) killing 438 people. By contrast, ecstasy and amphetamines were linked to 188 of those deaths.
To put the problem into context, the number of people dying accidentally from prescription drug overdoses surpasses the road toll in Victoria. “If this many people were dying from asthma or acute appendicitis we would be calling it a national emergency,” says Dr Wilson.
Yet the volume of opioid scripts written by our doctors keeps growing as the drug is prescribed for an ever-increasing range of conditions, such as endometriosis, back pain or osteoarthritis (despite limited evidence of efficacy). About 20,000 doses of prescription opioids are prescribed for every one million people every day in Australia, putting the country at eighth among the world’s top 30 users of prescription opiates. This compares with 50,000 doses of opioids prescribed per one million people every day in the US, where a staggering 142 people die daily from accidental overdoses of prescription opioids.
“The doctors give them out like lollies,” says Rayleen Fagan, a mumof-five from Melton in Victoria, her rage crackling down the phone line. “Just last week, I had surgery for a back problem and the doctor prescribed me [the opioid] Endone. Had I listened to him, I would have a back problem and a drug addiction. But luckily I have the knowledge.”
Rayleen’s knowledge is hard won. For 25 years, she watched her sister, Anne, battle a chronic addiction to codeine, an active ingredient in Panadeine Forte and Nurofen Plus. Anne would spend her days doctor shopping, she would feign headaches in order to raid her friends’ medicine cabinets, and her relationship with Rayleen and other family members broke down as they begged her doctors to stop prescribing the drugs. The battle ended six years ago.
“My sister went to sleep on the couch on Christmas Eve and never woke up,” says Rayleen. “Her body was full of prescription medicines.”
Today, Rayleen will take only half a Panadeine Forte when the pain from her back surgery becomes unbearable. “I won’t even take a full one,” she says. “I feel they are toxic. It wasn’t just losing my sister, it was everything I went through with her before she died. These drugs are evil.”
Opioids have been in use for thousands of years and are essential to medicine, particularly in the management of cancer and acute pain from surgery and injury. “But the benefits of these drugs tend to be overstated and the risks of addiction grossly understated,” warns Dr Wilson. She argues that addiction should be classified as a predictable side-effect of opioids, in much the same way as rashes, vomiting and diarrhoea are.
“Addiction is not an indication that the individual is a bad person or immoral. It’s just the way our biology interacts with this medication,” says Dr Wilson. “We need to remove the stigma and know that this could happen to anyone. It could happen to you, it could happen to me.”
In an opinion piece in The Lancet medical journal last year, Stanford University’s Keith Humphreys urged developed countries like Australia to learn from the mistakes of the United States, where about 60,000 people die each year from prescription opioid abuse – more than the number who died in the Vietnam War.
“Countries should immediately strengthen all available safeguards against the globalisation of the prescription opioid addiction and overdose epidemic,” Humphreys said. “Central to such efforts should be the formulation of prescription practice guidelines, the development of relevant legislation and regulation, the training of medical professionals, the creation of putatively public health-orientated activist groups and the certification of heathcare facilities.”
Yet much of what has been done so far in Australia to arrest the opioid epidemic has merely tinkered around the edges of the problem.
Tasmania and Victoria have both committed to introducing a system of real-time prescription monitoring which allows doctors to check a patient’s immediate prescription history, preventing the practice of doctor shopping. ScritptWise’s Bee Mohamed says these are important first steps, and that other state governments need to see prescription monitoring “as a long-term investment
“We need to remove the stigma and know this could happen to anyone.”
that will relieve pressure on the hospitals, and therefore costs”.
Yet drug monitoring programs cover only part of the problem. Dr Wilson, who has worked with coronial authorities, says she is increasingly seeing accidental opioid overdoses in mums and dads who’ve either mixed their prescription drugs, taken the pills for longer than advised, or consumed alcohol while on the medication.“We all have this image of ‘doctor shoppers’ but in most cases, people are taking their medication as directed, and these drugs can still cause overdose that leads to respiratory arrest and death,” she says. Indeed, findings from the Coroners Court of Victoria show that in seven out of 10 pharmaceutical drug overdose deaths the deceased had been to see only one GP.
Meanwhile, citing the increasing incidence of over-the-counter codeine dependency, the Therapeutic Goods Administration (TGA) ruled that, from February this year, pharmaceuticals containing codeine would be available only on prescription. And in March, the Australian and New Zealand College of Anaesthetists (ANZCA) and its Faculty of Pain Medicine called on 34 leading medical colleges and associations, including the Royal Australian College of General Practitioners and the Royal Australasian College of Physicians, to review their approach to pain management.
“The community is being flooded with prescription opioids,” ANZCA President Professor David A. Scott tells The Weekly. He believes that rather than hand out painkillers, “doctors need to take a multidisciplinary approach to pain management, which could include physical therapy, exercise, behavioural or psychological counselling”.
As in the United States, Australia provides the ideal environment for excessive opioid prescribing. For one, we have a consumerist culture which demands a quick fix from our doctors. Second, general practitioners are encouraged to run short, sharp medical consultations.
“GPs are not incentivised to spend time with patients looking for alternatives,” admits Dr Wilson. “Accessing counselling, getting patients to do more physical activity, attend hydrotherapy or acupuncture, or see a physiotherapist – particularly in rural areas – is much harder and more expensive. And the Pharmaceutical Benefits Scheme gives us a great rate on medications.” In January, the TGA announced it was considering barring GPs from prescribing stronger opiates, leaving that job to specialists.
The other problem is the hospital system, where patients are regularly discharged with more opioids than they are likely to need. “Long-term opioid use often begins with treatment of acute pain,” says Professor Scott. “Many patients prescribed an opioid for pain management will still be taking an opioid one or two years after discharge.” He says that it is the responsibility of doctors to give patients a strict time frame for use and an appropriate weaning schedule. “If we have a role in starting this problem, we have to take a role in stopping it,” he says.
Mum-of-two Jessica Khachan believes that without her family’s support and intervention, she would not be here today.
“There’s a lot of shame and fear and a lot of people get embarrassed about substance abuse issues,” admits Jess. “I remember I felt like I was the only one going through this. I felt like I couldn’t tell anyone what was going on. I was really scared to even mention it to my doctor.”
The message brave women like Rustie, Jessica and Rayleen want to get out is if you believe you have an opioid addiction, help and support exist.
“You are not alone,” says Jessica. “Many, many people have gone through this. There are recovery services and there is help out there. You don’t need to feel ashamed.”