Economic conditions and opioid overdoses - Q&A

Thanks for this very informative presentation. I have a question relating the introduction of Naloxone in Australia in response to accidental overdoses: do you think it may help to address the problem or is there a possibility that overall prescriptions even increase as risk is perceived to be lower in combination with Naloxone?

Naloxone is an opioid antagonist (antidote) which temporarily reverses overdoses, allowing medical help to arrive, therefore potentially preventing lethal outcomes. However, it must be administered quickly in an emergency, thus having it readily available is critical. In 2016 injectable Naloxone was rescheduled from Schedule 4 (prescription-only medication) to Schedule 3 (over-the-counter). Since 2019, the first intranasal naloxone spray was made available in Australia, making it much easier to administer and likely improving uptake.

I have not looked at this yet, and think there is more scope for research on whether there are unintended consequences of access to Naloxone, especially in Australia. Studies from the US have been mixed with one study showing that naloxone access led to more opioid-related emergency room visits, but no changes in mortality.

Hi John! great talk mate. Only question I have surrounds the idea that during unemployment all kinds of deaths (suicide etc) will increase. While I acknowledge any death is bad, just interested in where opioid overdose fits in the mix? e.g. what percent of increase in total deaths during unemployment is attributed to overdoses. 

Our study only focused on poisoning deaths, which include suicides related to overdose, but not all suicides. There are studies for other countries though that have shown that suicides in general increase when the unemployment rate increases.

You have analysed deaths, but what about the prevalence of use? Have you looked at unemployment and use?

It is difficult to look at general use as opioids can be prescribed, but prescription drugs or illegal opioids (e.g. heroin) can also be bought on the street market. There are some surveys of course which capture self-reported drug use, but often they are only cross-sectional and do not capture longitudinal information. We have looked at opioid overdose hospitalisations and found consistent results with opioid overdose deaths.

A question for John Ryan - what kind of effect on pharmaceutical and illicit opioid use could we see from the introduction of a program like SafeScript in Victoria?

This is John de New answering - John Ryan would know more. There is the concern, that SafeScript makes it more difficult for people to access the drugs they rely on, which could lead to substitution of prescription drugs with illegal drugs such as heroin. There is also the concern that people might have to suddenly come off their drugs, leading to dangerous withdrawal symptoms, without offering a clear pathway to accessing treatment. Opioid substitution therapy (OST) is widely recognised as an effective opioid use disorder treatment. OST is a form of treatment where the drug of dependence is substituted with controlled opioid medication with substantially lower risk of harm, such as Methadone or Buprenorphine. There are several barriers to access treatment, especially in rural communities. While any GP can prescribe an opioid, special certification (if the GP treats more than 5 patients in total at his/her practice) is needed to prescribe OST which impacts on availability of treatment. Additionally, there are a limited number of pharmacies dispensing the medication, which is especially a problem in rural communities. Pharmacies also charge a dispensing fee which can make OST potentially more expensive than consuming illegally obtained pharmaceutical opioids.

Why do you think opioid deaths relate to lagged rather than current unemploymeent?

A death related to an opioid overdose is an extreme outcome, that does not typically happen immediately after one starts taking opioids or increases their opioid use. Rather, an addiction develops over time. It therefore makes sense, that economic conditions impact on opioid deaths with a lag. The lag time in our model is one year.

John, if you're modelling very small rates (5 per 100k I think you mentioned?), OLS isn't really going to be the best option right? Also, putting dynamics into the model might negate the unemployment effects?

This is a good point. Our outcome typically varies between 0 and 16 deaths per 100,000 people in each region. We have estimated various models and the results have been robust.

How sure are you that a death defined as unintentional is not a suicide?

We cannot be sure of this. We use the classification that the coroner has determined, however it is likely that it is not always clear whether it was a suicide, and thus some suicides might be classified as unintentional. However the vast majority of cases are such that no evidence of intentional suicide was found, and we go on the basis of what the coroner, a medical specialist, has found. So, the categories could also be "evidence of intent" and "no evidence of intent".