How I became a ‘tramhead’ In depth
Prescription opioid use in New Zealand has risen dramatically and doctors are accused of inadvertently creating thousands of addicts. Tony Wall reports.
Ever since she was diagnosed with leukemia as a child, Sequoia King has known pain. ‘‘It progressed from being kidney pain to being unable to move – I couldn’t roll over in bed without feeling like my organs were being crushed,’’ the 23-year-old says from her flat in Miramar, Wellington.
Her body is like a tapestry of her journey – an intricate tattoo on her abdomen signifying her struggle through depression, a dagger on her forearm a gift from a friend when she finally beat her addiction.
She was given intravenous painkillers at 12 or 13 – she believes that’s when her vulnerability to opioids began. As an adult she got hooked on tramadol – a ‘‘weak’’ opioid used to treat mild to moderate pain in New Zealand, for everything from sports injuries to caesarean sections.
She became a ‘‘tram-head’’ – the colloquial name for someone who abuses tramadol – at one point taking 1000mg a day. The maximum recommended daily dose for chronic pain is 300mg. It was easy to get hold of – she’d simply ring her doctor and get a repeat prescription.
King went cold turkey about a year ago – quitting abruptly without any outside help – a process she describes as like being dragged through hell. Now she wants to warn others. ‘‘I want other kids to be aware of what these type of drugs can do to you. ‘‘I was really messed up because of these drugs. I have friends who still take them recreationally; they don’t realise what they’re doing to themselves.’’
MORE AND MORE
Opioid use in New Zealand and other Western countries has soared over the past couple of decades. According to the Opioid Atlas, which collects prescription data from district health boards (DHBs), the number of people dispensed strong opioids such as ocycodone, morphine, methadone and fentanyl rose from 63,000 in 2011 to 77,000 in 2016, a 22 per cent increase.
Pharmac says total opioid prescriptions, including repeats, rose 34 per cent in the past decade. Tramadol and codeine use skyrocketed by 277 per cent and 91 per cent respectively.
A Health Quality and Safety Commission (HQSC) investigation into opioid prescription found almost half those dispensed a strong opioid had a ‘‘trigger event’’ in a public hospital in the week prior, suggesting the prescriptions were generated in hospital.
Strong opioids such as oxycodone and fentanyl – linked to the deaths of musicians Prince and Tom Petty – have received a lot of publicity but experts warn weaker opioids like tramadol and codeine can be harmful and addictive and doctors are advised to prescribe the lowest effective dose for the shortest possible time.
There’s anecdotal evidence New Zealanders are some of the world’s biggest users of tramadol and other prescription opioids. In 2015, a Global Drug Survey (GDS) study of prescription drug use found 38 per cent of more than 2000 New Zealand respondents said they had used opioids in the past year, against 14 per cent globally. This was driven mostly by codeine (33 per cent compared to 10 per cent globally) and tramadol (9 per cent/2 per cent).
Professor Adam Winstock of University College London, founder of the GDS, says the survey is self-selecting so must be viewed with caution. But he says it’s rare for opioids like tramadol to be in the top 10 drugs people report using and suspects Kiwis have turned to prescription medications for recreational use because of the difficulty of getting illicit drugs into the country. ‘‘You go ‘Really? There’s that many people in New Zealand who need chronic opioid pain relief? I wouldn’t have thought so.’ ’’
TROUBLE WITH TRAMADOL
Pharmacist and addiction medicine specialist Carina Walters is doing a PhD on the misuse of prescription and overthe-counter opioids in New Zealand and is looking for participants to study. There’s no good data on how many people are addicted to opioids here, she says, but guesses can be made based on the US National Institute of Drug Abuse’s estimate that between 8-12 per cent of people prescribed opioids over several months become dependent. According to the Opioid Atlas, 9701 Kiwis were dispensed a strong opioid for more than six weeks in 2016 – which would mean around 970 potential addicts.
Walters, formerly senior addictions pharmacist for Community Alcohol and Drug Services in Auckland, says over the past decade or so there’s been a big shift in the types of opioid users presenting for treatment. ‘‘It’s gone from mostly people who’ve come through an illicit pathway to people who’ve developed their dependence through legitimate access – prescriptions or over the counter.’’
With tramadol in particular, Walters says, people underestimate its abuse potential.
‘‘There’s a sense [among patients] that, because a drug is prescription or over the counter, it’s less harmful, less risky and they wouldn’t sell it to you if there was a problem. But all opioids can have the effect of you developing a physiological dependency, because you develop tolerance and when you take them away you get all those withdrawal symptoms – nausea and diarrhoea and the rest of it.’’
King had been abusing tramadol for the better part of two years when she suddenly stopped taking it. ‘‘I was bedridden for about two weeks with fevers and pains and
Addiction medicine specialist Carina Walters
‘‘... all opioids can have the effect of you developing a physiological dependency ...’’
throwing up all the time – it felt
. . . like someone was tapping at every point on my body with a little hammer.’’
Walters says stopping opioids suddenly is not the best way for addicts to get off them – it’s recommended they slowly taper off, or use a substitute opioid such as methadone.
King was studying production design and sculpture in Auckland in 2015 when a friend offered her some pills, a codeine/ paracetamol combination left over from a broken bone, for her severe period cramps. ‘‘It took away the pain and I hadn’t had no pain before.’’
She took the pills most days for about three months, but then started to throw up every time she took them. ‘‘It was like my body knew it was poison.’’
She stopped, but a few months later after some major stress in her life she took some tramadol pills at her partner’s house. A few weeks later she saw her doctor about her chronic pain and mental health issues. He gave her 150 tramadol tablets for the pain, as well as antidepressants. ‘‘He just prescribed it and from then on I didn’t need to see him again ... I just had to call up for a re-script.
‘‘It got to the point where tramadol was doing a better job at keeping me awake, happy and living, that I never took my antidepressants.
‘‘At the time I didn’t think anything of it – until I started to lose weight and look undead. By the end of 2016 I was heavily addicted to it.’’
After a relationship breakdown she took all the tramadol she had, overdosing and ending up in hospital. Her boyfriend had kicked her out and she would sell tramadol to make cash and even ended up doing sex work for about three weeks after she was offered a place to stay with other working girls.
She says her doctor continued to renew prescriptions for about a year, before she moved to Wellington. ‘‘Once I had to go in for a sickness certificate to get the benefit renewed – he was asking if there was anything else he could put me on.
‘‘I refused, and said ‘This is the only thing that works for me’. He was a lovely person but he really didn’t know what he was doing.’’
In Wellington, her new GP was happy to renew her prescription after checking with his colleague in Auckland.
King believes doctors need to be more careful about prescribing opioids. ‘‘I’d like it if they could try and understand where these kids’ pain is coming from instead of just chucking drugs at them, like ‘this will fix it’. It’s like ‘no, you could potentially kill someone’.’’
‘LEGITIMATE DEALERS’
Winstock says opiates are useful for pain for just a few weeks or months. ‘‘Long-term opioids for most pains aren’t terribly useful, but the script just gets continued, or the patient turns up saying ‘oh I got this from the hospital’, so the doctor just continues it.
‘‘Doctors need to take a much greater level of responsibility for effectively being legitimate drug dealers.’’
Stuff asked the New Zealand Medical Association, which represents doctors, whether over-prescribing of opioids is a problem. A spokesperson said ‘‘none of our members have raised any concerns with us’’ and pointed to the Medical Council’s statement on good prescribing. The guidelines say it’s never appropriate to prescribe medication with a risk of addiction or abuse to a patient who hasn’t been fully assessed in person, and list warning signs which suggest a person is seeking the drugs for nontherapeutic purposes.
The Medical Council doesn’t monitor doctors’ prescribing, but can take action if notified by the likes of pharmacies or the Ministry of Health’s medicines control team.
In the past five years just six doctors have been found guilty of professional misconduct in relation to over-prescribing, only one involving opioids.
Some medical professionals have told Stuff that Medsafe, the body that regulates the pharmaceutical industry and the medicine supply chain, should do more to monitor doctors’ prescribing habits.
Roger Brooking, clinical director of Alcohol and Drug Assessment and Counselling, says he once investigated a GP for the Medical Council who had been prescribing ‘‘massive amounts’’ of codeine to a patient for years. The council only found out about the doctor because the police found the patient was selling the opioids, Brooking says.
Medsafe group manager Chris James says its role is not to regulate healthcare professionals, but it does monitor the prescribing of controlled drugs through information provided by pharmacies. If Medsafe does identify concerning prescribing practices, it can demand a clinician hand over case information.
King manages her pain in other ways now, including smoking cannabis, which she hopes will be legalised. She says people don’t realise how dangerous opioids can be. ‘‘I still feel the effects of it even now. It’s done nothing but ruin my body in a way I can’t take back.’’