Eleven days before she died, Mary Minchev walked into her local medical centre and told her doctor she needed enough painkillers to get through a three-week holiday. Minutes later, she walked out with 168 prescription pills. Among them were some of the most powerful opioids on the market.
It was not the first time the 48-year-old Melbourne mother had obtained such drugs, nor would it be the last. As a coronial inquiry would later find, Minchev was prescribed a range of legal narcotics by at least 31 doctors across 12 different medical centres in just one year.
Some GPs even knew she was a “doctor shopper”, visiting multiple physicians to get multiple scripts to treat conditions including leg swelling, anxiety and depression. Yet, thanks in part to a medical system that encourages quick consultations and lacks the ability to monitor how drugs are dispensed, she was able to continue feeding her addiction.
In 2013 this addiction killed her. On February 26, Minchev inadvertently took too many pills at the north-suburban home she shared with her uncle. He came home and found her face down on the carpet in the spare room.
Her death, in the words of Victorian Coroner Audrey Jamieson, was a “compelling reminder of the perils of opioid and benzodiazepine dependence, and the importance of monitoring and circumventing patients’ misuse of these powerful medications”.
In the United States opioid overdoses claimed nearly 400,000 lives between 1999 and 2017, prompting President Donald Trump to declare a public health emergency. But what most see as a uniquely American problem is now devastating Australian families too.
Data from the National Coronial Information System shows there were 8421 opioid-related deaths between 2010 and 2016 (the last year nationally consistent data was available). Most of them were unintentional, fuelled in part by oxycodone and fentanyl, two of the most commonly abused painkillers available. Today at least three people die from opioid harm in Australia a day, while 150 more are hospitalised.
An investigation by The Age and The Sydney Morning Herald has also found that the same companies that have been linked to – and are being sued over – the US crisis, including Purdue Pharma, are using similar marketing tactics to promote their products in Australia. But knowledge of the problem has had little effect on prescribing practices and governments are under growing pressure to act before it’s too late.
“Clearly,” says Australian Medical Association Victorian president Julian Rait, “to avoid going down the path of the Americans, we’ve got to lift our game.”
Luxury resorts and lobbyists
To understand the rise of opioids in Australia, it’s instructive to look at the evolution of pain management globally.
Opioids attach to receptors in the brain, spinal cord and other parts of the body, reducing feelings of pain. But while they were once reserved for treating pain in cancer patients, those in palliative care and for “exceptional circumstances,” drug companies in the 1990s began to reframe the debate. They began pushing opioids as a safe and necessary way to treat chronic pain more broadly, from back problems and sports injuries to severe arthritis.
At the forefront of this shift was Purdue Pharma, the Connecticut-based company owned by one of America’s wealthiest families, the Sacklers.
In the world of philanthropy, the Sackler name has pride of place at some of the world’s leading institutions. There’s the Sackler Museum at Harvard, the Sackler Gallery in Washington, the Sackler Wing at New York’s Metropolitan Museum of Art. But this dynasty made its fortune from pharmaceuticals, in large part through Purdue Pharma’s signature product, Oxycontin, and the aggressive marketing campaign behind it.
A number of US lawsuits have revealed that sales representatives were deployed to convince doctors about the benefits of this groundbreaking new product, which Purdue claimed would be less addictive than other drugs. GPs were flown into luxury resorts to attend seminars about the need to treat pain more aggressively. Company-funded research was produced, along with sales videos, mugs and gimmick pens.
It was a raging success. Sales grew from $48 million in 1996 to $1.1 billion just four years later. Now, though, Purdue Pharma is facing more than 2000 lawsuits seeking to hold the company accountable for the US opioid epidemic and the thousands of deaths that followed.
The Sacklers come to town
Just two years after it started marketing Oxycontin in America, Purdue established an Australian arm, Mundipharma. The Age and Herald have established that eleven members of the Sackler family were among the Australian company’s original directors, and the family remained on the local board until 2012. Some have since been named as defendants in the US proceedings.
Mundipharma’s spokeswoman said that while the Sacklers sat as directors “they did not have an active day-to-day role in the management of Mundipharma’s business, which was led by a professional management team”.
But when the Australian leg of the family company began its promotional campaign its approach was close to Purdue’s. Transparency reports filed with Medicines Australia shows Mundipharma holds production launch meetings over three-course dinners, sponsors conferences worth tens of thousands of dollars, and runs a “Pain Management Master Class” accredited by the Royal Australian College of Practitioners which almost 5000 medical professionals have taken.
Supporters argue that events like these are a vital and legitimate way to educate doctors. If a patient wants to make sure their GP knows how to use the medicine prescribed, who better to tell you about it than the developer?
But sometimes, the approach has been questionable. Last December, Mundipharma was forced to pay $302,400 in response to 24 infringement notices issued by the Therapeutic Goods Administration over misleading advertising to doctors relating to one of its signature products, Targin.
Asked about its marketing strategies this week, the company said it strictly complies with Australian laws and regulations and supports “safe prescribing”.
“Opioid analgesics are appropriate for carefully selected patients such as patients with moderate to severe chronic pain,” a spokeswoman said.
“Mundipharma is committed to providing the highest standard of accredited educational programs and quality resources for healthcare professionals, in response to their educational needs and in line with ensuring safe and appropriate prescribing of opioid-based treatments.”
‘They’re awesome things, but …’
An estimated 3.24 million Australians suffer from chronic pain, but have limited options to manage it, particularly in rural and remote towns where pain specialists are rare. Appointments, for those lucky enough to get them, can cost hundreds of dollars. By comparison, a government subsidised pack of opioids will set you back about $6.
Many fear that tougher restrictions on prescription painkillers could have unintended consequences for those who genuinely need them just to get by. Two years ago, as the Therapeutic Goods Administration considered tighter regulations, consumers and pain specialists flooded the agency with written submissions warning it not to go too far.
One person suffering with fibromyalgia – a condition marked by pain and muscle stiffness – put it like this: “If this were to happen I can see many chronic pain patients in similar predicaments to myself simply giving up and committing suicide.
“Chronic pain is not an easy thing to live with, and while some people abuse the system, most of us are trying everything in our power to help ourselves.”
Denise “Rustie” Lassam says it’s about getting the balance right. As a teenager, she had an agonising spinal condition, which her doctors would treat using opioids and benzodiazepines. For the next 30 years she was hooked. At one point, she was taking nine 80 milligram tablets of oxycodone a day and between five and 15 Valium tablets. If she ran out of the drugs, she’d tell doctors she had lost her prescription in order to get another script, or hit the streets in search of a dealer selling Valium.
“I did so many things I’m not proud of,” Lassam says. “But addiction is insidious, and really cunning. Slowly but surely it takes over.”
With the help of an addiction specialist, she has managed to kick the benzodiazapines and she’s on a methadone program that has significantly reduced her intake of opioids.
“It’s not about getting rid of them – they’re awesome things – and I certainly wouldn’t want to wake up from an operation and not have something assisting me to deal with what my body had been through, as that would be terrible,” Lassam says. “But having someone on Oxycontin four years after surgery, or 10 years after surgery? That is not on.”
The ‘soft touch doctors’
As the use of opioid pharmaceuticals increased in Australia, so too did concerns about the risks of crime and corruption. In Victoria, some paramedics were discovered to be siphoning vials of liquid fentanyl – which officers are meant to administer to injured patients as a quick form of pain relief. They were using the drug themselves and replacing it with saline.
In Perth, a pharmacist stole staggering amounts of opioids from two major public hospitals, prompting an investigation by the anti-corruption watchdog. And in NSW a coronial inquiry heard stories about pensioners selling old fentanyl patches to drug users on the black market to help pay their bills.
For every shocking headline, there were thousands more families whose lives had quietly been torn apart. Margaret and John Millington, who lost their son Simon 10 years ago, are among them.
Simon Millington was a country boy who embraced life. But on a winter night in 1994, a car accident on a quiet road in the western Victorian town of Nhill changed everything. When he was discharged from hospital, doctors gave him a kit bag of opioids to deal with the pain, sparking a devastating 16-year addiction. He died of an accidental overdose in 2010.
The Millingtons made it their mission to push for reform. A few years ago, they were instrumental in securing an election commitment from both sides of politics to introduce real-time prescription monitoring in Victoria. This April, SafeScript, as it’s known, will become mandatory for all doctors and pharmacists in Victoria.
“We saw a system that was broken, and so many people were slipping through the cracks – including our son,” Margaret says.
Under SafeScript, every time a doctor or pharmacist prescribes or dispenses opioids, benzodiazepines and other high-risk medicines, they will be required to record the information and check the patient’s records for any red flags. If a patient has earlier been “doctor shopping” for drugs at another clinic, alerts will appear. This should empower the doctor to talk to their patient.
“It provides, quick, accurate, and valuable information about whether you should be prescribing something, whether you can do it safely, and what situation the person in front of you might be in,” says Dr Ines Rio, a doctor at the North Richmond Community Health Centre and chair of the Australian Medical Associations’s general practitioner section.
Nick Carr, a GP at the St Kilda Medical Group agrees that medical professionals need something to equip them to deal with doctor shoppers. He’s run workshops teaching GPs to do just that for 20 years.
“Doctors are not very good at saying no,” says Carr. “They worry about things like: “Oh my God, what if the pain is genuine?” Or “what if their anxiety is so bad they have to have valium?”
But Carr also questions how Victoria’s mandatory system will be enforced, or whether doctors and patients could end up having “the dog at my homework” arguments over supposedly lost prescriptions.
And then there’s the big problem: the lack of national consistency.
In 2017, Health Minister Greg Hunt committed $16 million towards the roll-out of an Australia-wide tracking system, putting in place the necessary infrastructure so that states and territories could share their data.
The trouble is, they’re yet to connect. Some jurisdictions like Victoria have gone it alone, while others have made little progress, including NSW, even though it has the highest rate of opioid-related deaths in the country.
Some important changes have been made. In 2018, the federal government made codeine available by prescription only, and the Therapeutic Goods Administration has this year introduced smaller packages for immediate-release opioid products as well as further restrictions on fentanyl patches. But without an interconnected system, people could easily go doctor shopping interstate.
Simon Millington used to do just that, says Margaret, driving from his home in western Victoria to NSW and South Australia, determined to get his next fix.
“They know who the ‘soft touch’ doctors are,” she says.
“That’s why it’s so important for other states to sign up. It will save lives.”
Know more? Contact Farrah Tomazin on email@example.com
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Farrah Tomazin is a senior journalist and investigative reporter for The Age, with interests in politics, social justice, and legal affairs.