1. Trends and patterns in pharmaceutical use in Australia: What can we learn from those who have gone before us? Nicole Lee Roger Nicholas Ann Roche

3. 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

4. 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

5. USA Trends Increased supply of prescription opioids generally 1992-2002 population increased by 13%, prescriptions rose 57% Stimulants 369% increaseOpioids 222% increase

6. 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

7. Australian trends supply Illicit use Non-medical use of painkillers up from 2.5% to 3% Supply far outstrips changes in levels of non-medical use Morphine  Tramadol  Fentanyl  Oxycodone  17x

8. Increasing supply Stable prevalence of illicit use

9. Potential theories Increase in pharmaceutical opioids Increased diversion and illicit use Effects of the ageing population Marketing Knowledge gaps Opioids in chronic pain management

10. Potential theories Increase in pharmaceutical opioids Increased diversion and illicit use Effects of the ageing population Marketing Knowledge gaps Opioids in chronic pain management

11. Diversion and illicit use Heroin Pharmaceutical opioids Fischer & Rehm, 2006

12. Diversion and illicit use

13. Heroin Pharmaceutical opioids Stafford & Burns, 2011

14. Potential theories Increase in pharmaceutical opioids Increased diversion and illicit use Effects of the ageing population Marketing Knowledge gaps Opioids in chronic pain management

15. Ageing population Increase in prescription opioids among older Australians (Roxburgh et al, 2011) NDHS data shows the highest painkiller use among 20-29yo (5.4%) (AIHW, 2011)

16. Potential theories Increase in pharmaceutical opioids Increased diversion and illicit use Effects of the ageing population Marketing Knowledge gaps Opioids in chronic pain management

17. 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?

18. Potential theories Increase in pharmaceutical opioids Increased diversion and illicit use Effects of the ageing population Marketing Knowledge gaps Opioids in chronic pain management

19. 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

20. Potential theories Increase in pharmaceutical opioids Increased diversion and illicit use Effects of the ageing population Marketing Knowledge gaps Opioids in chronic pain management

21. Reduced stigma Increased use in cancer pain Increased use in chronic non-cancer pain Slow release options Pain as the 5 th vital sign Intolerance of undertreated pain in USA

22. 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)

23. 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

24. 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