This week we meet the everyday people who have become unwitting addicts.
ANTON ENUS: Hello. I'm Anton Enus, filling in for Jenny Brockie. Welcome to everyone here tonight. Thanks for joining us. Let's start with Peter. Peter, you had a very bad accident in 2008. Can you tell us what happened?
PETER PANAGIOTOPOULOS: Yeah, I had a work-related accident in 2008. I, um, was unloading some steel at my place of work and I tripped down and fell on my stomach and the steel that I was unloading rolled off and rolled onto my back and I smashed a disc in my lower back, which, in turn, put me out of action. I have had two rounds of surgeries.
ANTON ENUS: How much steel are we talking about here?
PETER PANAGIOTOPOULOS: About a 100 kilos of steel and I was on my stomach for about 45 minutes in excruciating pain. I had basically obliviated a disc in my back and in turn, doing that, severed a lot of nerves in my back and on the left side of my leg. And that's when the roller-coaster ride started.
ANTON ENUS: So as a result of that, you needed two operations. Part of that included infusing parts of your spine. What were you prescribed for your pain?
PETER PANAGIOTOPOULOS: After the first round of operations I was prescribed Endone and Gabapentin and then, in turn, with that, Rivotril. Um, and then in between the first and the second operation, um, it just escalated from there. I was sent home from the hospital about a week after that with a prescription of Endone, which, um, kept me going, um, for about a year after that, um, yeah.
ANTON ENUS: Can you describe what the pain was like and what your reaction was to the drugs?
PETER PANAGIOTOPOULOS: Pain was, um, incredible. I, um, I guess people think that having a tooth pulled or having a sore tooth is painful, but this was 20 times more painful than that. It was uncomfortable, it was just - it was...it was mind-boggling. How much pain I could go through was incredible. But, um, you know, taking the medication seemed to numb the pain. But I found that I always had to top up.
ANTON ENUS: So you kept on topping up the medication. Did that work for you?
PETER PANAGIOTOPOULOS: Um, at times it did. I thought it did. Um, but topping up got a little bit out of control and then I found myself just self-medicating. I would wake up in the morning with excruciating pain and I was prescribed one, I would take three. You know, prescribed two, I would take four. Um, just to try - my understanding was the more you take, the less of the pain you'll have. Um, but that wasn't the case. Um, as soon as the pain would go away, I would be taking more again. So it just, you know, without me noticing, it just started getting out of control.
ANTON ENUS: And prior to that, prior to the accident, did you have any history of abuse of substance or anything like that?
PETER PANAGIOTOPOULOS: Absolutely none.
ANTON ENUS: So it was a completely new experience to you?
PETER PANAGIOTOPOULOS: When I would get a headache, I used to take a Panadol. Even then, I reckon I could count on one hand how many times I had taken a Panadol in my lifetime. In 1991 I had a broken shoulder and took some Panadeine Forte and that was about it.
ANTON ENUS: Alyx, you had a bit of an accident as well. Can you relate to what Peter's saying about the pain level?
ALYX DENNISON: Yeah, absolutely. I mean, it seems like a less serious accident, um, but I was doing the same thing. I was self-medicating. I got to a point where I didn't believe that anyone could know how much I needed but me, because I was the only one who could feel the pain. I got quite aggressive when they took me off the morphine pump. Which I don't remember - my mum recalls.
ANTON ENUS: Tell us about what your injury was in the first place?
ALYX DENNISON: I broke my leg jumping off a retaining wall about this high and I just landed in a bad way and I broke my leg in several places. Um, and I had an ankle reconstruction and, um, yeah. Bit of a freak accident.
ANTON ENUS: So, once you started taking the medication, tell us what happened then.
ALYX DENNISON: Um, well, when they sent me home, I was taking Endone. Um, I had an array of things, I can't really remember it all if I was prescribed one pill, I would probably take three or four. I would take more than I needed. I would self-medicate and I would go to other doctors to get more. I would say that I had lost it, when really I had run out because I had had too much, and, yeah. It's only in retrospect that I realise it was a big problem.
ANTON ENUS: So what was the difference between, say, taking one pill as prescribed and taking three or four?
ALYX DENNISON: Um, just the alleviation of the pain was quite remarkable. I mean, the dose they would tell you to take would do it. But it was a nice feeling. You would get a warm, bubbly sensation all over your body. It was nice.
ANTON ENUS: Do you identify, Peter, with that warm, bubbly feeling?
PETER PANAGIOTOPOULOS: Definitely. Definitely, yeah, I just need to do escape reality. I need to do get out of that, "Well, this is what life's gonna be like." I needed something else to fix it. I needed that magic pill. And as, I mean, as far as I'm concerned, the Endone was that magic pill, but I needed a lot of it to get to that happy place.
ANTON ENUS: Did you get to a stage, Alyx, where there was a kind of tipping point, where you suddenly realised, "Hold on, something's wrong here"?
ALYX DENNISON: Um, yeah, I did. It was months after the accident and I wasn't feeling much pain at all and I remember I was at a party and I went to the bathroom and I saw that there was some Endone in the bathroom. And I took some of that. And then the next day I was like, "Oh, my God. That's really bad. That's... I just stole someone's medication." And that was kind of the tipping point.
ANTON ENUS: Jana, welcome to the show. What was going on in your life when you were prescribed these drugs in the first place?
JANA KOHOUT: The late '90s was a very difficult time for me. At home, we had five boys, aged between five and 25. I was working in a very difficult school, coordinating and teaching full-time. And I also had, um, an elderly father who was ill and unable to look after himself.
ANTON ENUS: So what were you diagnosed with, and what were you prescribed?
JANA KOHOUT: Um, I should say that, uh, I'm still actually on medication. I'm on a very low dose of a Benzodiazepine and also a low dose of an antidepressant. It all started for me in July '99. My mother was dying in hospital. It was just after I visited her in palliative care and I had my first major panic attack. I went to my GP and he prescribed Xanax, or Alprazolam. He warned me to only take it for a short time and to the best of my memory, I only took it a couple of times but I was unable to get the panic under control and it was then that I was then referred to a psychiatrist. The psychiatrist, um, put me on Alprazolam and Prothiaden, daily doses.
ANTON ENUS: Initially, did it help? Did you see a difference?
JANA KOHOUT: This allowed me to go back to work. So as far as I was concerned, yes, it was working. The following year, I was still on Prothiaden and Alprazolam, when I became pregnant with my third child. And, uh, obviously I wanted to come off the drugs for the sake of the baby. My obstetrician advised that this would be the best thing to do. My psychiatrist didn't agree. When I started coming off, he - the symptoms I was having were dreadful and he said, "Look, this is your underlying condition of anxiety and depression. You really need these drugs. You're not doing any good for the baby trying to come off them." So it was between the obstetrician and the psychiatrist. Then just before the baby was born, I decided that I wanted to breastfeed and so I stopped the Alprazolam.
ANTON ENUS: And Alprazolam, we know as Xanax?
JANA KOHOUT: Correct. Correct. And when the baby was born, um, he was having fits in hospital. I didn't really make the connection, but a friend of mine, who's a GP, came to see me and she said, "Look, it would be better for you and the baby if you resume the Alprazolam," which I did. And the fits stopped. Uh...
ANTON ENUS: So, was there a point where you realised that this was turning into an addiction?
JANA KOHOUT: I just kept trusting my doctor, he said, "This is what you need." Now that you mention it, yes, there was a time when I noticed there was a pattern to his prescribing so every time the symptoms would get worse, he would increase the doses and until he got to some sort of limit, uh, where it wouldn't be safe to prescribe any more. And then he would switch me to another drug. And I remember saying to him at one stage, "There seems to be a pattern here." And he laughed. He actually laughed.
ANTON ENUS: We would also like to welcome the Millingtons here tonight, whose son and brother, Simon, is the focus of one of our stories here tonight. Margaret, welcome to you.
MARGARET MILLINGTON: Thank you, Anton.
ANTON ENUS: Your son died of an overdose two years ago. Can you tell us what caused that problem in the first place? What led to the crisis?
MARGARET MILLINGTON: Simon's story started in 1994 when he had a single car accident. He was trapped in the car for four hours before he was found. The seriousness of his injuries led him to be flown to Melbourne. He had a fractured pelvis. He had multiple fractures to his foot and ankle and his hands, he had a closed head injury. When he got to Melbourne he deteriorated and spent eight days in intensive care, where it was discovered that the force of the impact had also damaged the main valve to his heart. And as a result of his initial injuries and stay in hospital, he became addicted to anything and everything.
He tried to beat it many times for himself and for us. Um, the death of his brother in 2004, in a motorcycle accident, also, prompted him to really do something about his life. And he desperately tried to get off everything. He had been to about five different rehabilitations and the discovery of his little girl in 2008 really turned his life around. He said, "Mum, we have to get better now because I have got responsibilities." But even that, the power of his addiction, wasn't enough to sustain him and he died in 2010, sadly. But, um, Simon made a valiant effort to stay clean. But the power of addiction and the power of medications when used for any length of time, it's very, very hard to beat.
ANTON ENUS: He did say to you once, "The drugs take your soul away." Which is a terrible, terrible thing to have to hear?
MARGARET MILLINGTON: And it did. He had no personality. He was always a fun-loving guy. He completely changed. He became extremely unpredictable and, like he said, it took his soul away. There was no person there and he realised that. He had said to us, "I don't want to be like this, but I don't know what to do and how to beat it."
ANTON ENUS: Let's get a comment from Sallie, Simon's sister. You said it was a bit like having two different people there?
SALLIE MILLINGTON: Yeah, it certainly was. There was the Simon that we knew and loved and that we grew up with, and then there was the drug-addict Simon, which we had never seen before. It was like, as Mum said, someone in our home that we didn't know. He was like a zombie, wasn't joking around anymore. He wasn't fun-loving. We just lost him. It was, yeah, awful.
ANTON ENUS: It looks like a pretty happy family shot that you have there.
MARGARET MILLINGTON: Oh, there we are!
ANTON ENUS: Was there any sign before the accident that there was any inclination towards substance abuse?
MARGARET MILLINGTON: Simon was a happy, fun-loving kid who lived in the country. He loved shooting, skiing, fishing, and did all the things with his mates that any kid in the country does.
ANTON ENUS: Malcolm Anderson, you were the family GP at the time treating Simon. What were you giving him?
DR MALCOLM ANDERSON: Well, he had come home from hospital on OxyContin and Benzodiazepines and one's in that difficult situation of needing to continue those medications, it's very difficult to cut someone off once they have been on an established regime, but always conscious of the fact that we didn’t want to increasing the doses. However, he still had considerable pain from his injuries. They were quite significant.
ANTON ENUS: So, he was wanting more and more drugs. What was he saying to you to try and get you to give him more.
DR MALCOLM ANDERSON: "You don't understand. I'm in pain." I would say to him, "Look, we can't give you any more." I would even say, "Son, I can't keep prescribing this for you." But he would plead, he would cry - just become desperate.
ANTON ENUS: We hear a lot of the talk about yellow flags and red flags going up when people are being treated. Did that happen for you? Did you see signs of addiction developing?
DR MALCOLM ANDERSON: I think it was clear that he was addicted.
ANTON ENUS: So, what is the best way forward there?
DR MALCOLM ANDERSON: In that situation, uh, addiction - treatment for addiction is obviously the way to go - Pain management. But remember that we're in a rural area, midway between Melbourne and Adelaide. Those services are not available. Or available at, uh - you can send off a referral and get an appointment in six months, 12 months' time. We're dealing with the here and now, with the patient in the consulting room, trying to deal with the acute pain, and then, of course, the chronic problem as well.
ANTON ENUS: Um, it's also difficult for you, isn't it, because he really was in pain?
DR MALCOLM ANDERSON: Mmm, yes.
ANTON ENUS: It's a bit difficult. You're treating two different things at the same time?
DR MALCOLM ANDERSON: That's right. Yep.
ANTON ENUS: Let's get a comment from Nick Carr, you are a GP working out of St Kilda in Melbourne. Do we have a problem of people becoming accidental addicts?
DR NICK CARR: Yes, we have a huge problem with that happening. The four stories we have heard tonight are incredibly important stories, because none of these people were using substance, none of these people were substance users, they were not drug affected people, they were people who had accidents or illnesses who went to doctors and were started on addictive medications. This is not how doctors should be doing it. Doctors should be much more careful about how they use these medications. And one of the things that I think is crucial is with all these drugs out there, it's us, the doctors, who have to take the responsibility for writing the prescriptions. We're the ones who have to be a bit more careful about how we behave.
ANTON ENUS: Well sitting just behind you is Simon Holliday, you treat addiction as well. How common do you think is this kind of scenario that we are talking about here?
DR SIMON HOLLIDAY: I think it is quite common and I think it's very easy for people to start these sort of medications and then find that they get relief from these medications, so they take some more. And after a while, the cycle keeps going on. Unfortunately, while we would all like these medications to fix the problem, they often - the problem starts creeping up again. And so while they might get temporary relief, they are actually back in the situation where they were at the start. And so they feel that they need to take more of the drug to get better.
ANTON ENUS: Alan Eade, you're a paramedic, working out of Victoria as well. What are you noticing about the kinds of call-outs you get in terms of prescription drugs?
ALAN EADE, PARAMEDIC: The community would love to think that it's all illegal drugs that the ambulance responds to and in the '90s, that may have been the case. Currently, 80% of the substance call-outs relate to prescription medication, only 20% of them are the illegal drugs, so whilst we demonise the illegal drugs, we do far more work because of the prescription drugs.
ANTON ENUS: Margaret Harding, of course, you were a magistrate working in the court system in Victoria for over a decade. Are you seeing a similar thing to what Alan is describing?
MARGARET HARDING, FORMER VICTORIAN DRUG COURT MAGISTRATE: Not in the same way that Alan has, but I guess, if you really are wanting to understand the power of a drug like Alprazolam, people who were on drug treatment orders and who would be managing their heroin addiction, for example, um, might be offered some Xanax, weaken, take the Xanax, and then go out and commit perhaps a bunch of burglaries, which would then cause me to have to cancel their drug treatment order and put them into custody on the imprisonment order. So instead of staying working with the court and with a whole multidisciplinary team, they would then end up going into custody rather than staying in the community and continuing to work to try to manage their lives and manage their dependencies, so that they could have a good life. And I think what perhaps Margaret said in relation to her son, um, that it took his soul, I think that is very much the case. And that certainly is what I feel that I was seeing over almost 10 years, when I was working full-time in the Drug Court.
ANTON ENUS: So what proportion of cases that came before you that fell into this category of, you know, everything falling apart, were related to drugs like Xanax?
MARGARET HARDING: In the last five years of my work in the Drug Court, it was rare for an order to be cancelled for a reason other than Xanax.
ANTON ENUS: That's a pretty strong statement?
MARGARET HARDING: It is a very strong statement. But it's the truth statement and it wasn't heroin, it wasn't ice, um, or amphetamines, it was Xanax that caused people to lose their order. So these drugs are very, very powerful and the effect on the brain chemistry, I think, is what we need to be aware of. The person is no longer themselves in the sense of no longer their true self.
ANTON ENUS: Well, let's get a comment from Dr Gordian Fulde. You head up the emergency department at a imagine Sydney hospital. Are you seeing the same kind of resurgence of these prescription-related problems?
DR GORDIAN FULDE: Absolutely. Australia is the third-highest in the world for OxyContin prescriptions in the Western world. So we have got a problem, I think. People really like to take their drugs, their alcohol. And when it comes to the Benzodiazepine, Xanax, Temazepam, that is a very silent but enormous monster and if you look at the amount that's prescribed in our community, it's massive. And along with that goes the fact that we have a very big and enlarging problem.
ANTON ENUS: Well, tonight we're talking about prescription drugs and the risk of addiction. Nick Carr, where does the problem lie - is it patients, is it GPs?
DR NICK CARR: Well, we have talked a lot tonight about opiates and pain. What I think we haven't talked quite enough about is the benzodiazepines, the Xanaxs, the Valiums and the Temazepams and I think there the problem is very squarely in the lap of the GPs. These are drugs that have a relatively limited role. It's not that we should never use them, but they should be used short-term and in only very limited circumstances. And these are the drugs which are commonly initiated by GPs and I think we, the doctors, have to be much more careful.
I see a lot of patients, as Jana was, went in with panic or an anxiety disorder - comes out with a script of Xanax. I tell doctors, "If you're going to do this, you have to say, I can fix your anxiety today by making you a drug addict for life. Is that what you would like?" That's what you're risking because they are so good, they work superbly well, whether it’s for sleep or anxiety but they are not going to continue to work without this high risk of addiction and escalation of use. So that is what I think we doctors have to be aware about and much more careful with.
ANTON ENUS: Well Ian Thong, you work in regional Australia, a slightly different demographic perhaps than St Kilda where Nick Carr works. Have you ever been in a situation where you have prescribed a drug like Nick was describing, where you thought, "Maybe in hindsight I shouldn't have done that"?
DR IAN THONG: It's a difficult situation. Yes, we do get convinced that we should be prescribing these medications for the panic disorder, for the benzodiazepines, and opiates for the pain - patients with chronic pain. Um, you do get trapped into it. You can be convinced by the patient, and you can - you retrospectively think, "This was the wrong thing and now I need to work out how I'm gonna fix it." Malcolm touched on the difficulty of working in regional Australia, and that is we don't have any support. We don't have any resources. We're undereducated as GPs. And it's always at least 200km to the closest pain clinic, and six months away to get good advice.
ANTON ENUS: Zil Yassine, do you think it's easy for GPs to overprescribe?
DR ZIL YASSINE: Well, I think that’s the path of least resistance and |I think to this end the GPs in a very difficult position, especially in a group practise or country practice. Too many times I have seen patients come in wanting a script and the assumption by these patients is they will get a script within five minutes because for the last three or four months, nobody's really bothered to check their story, or corroborate whether they have visited a pain clinic. The other concern, I guess from the doctors perspective is, the patients are often aggressive and unfortunately some of them are manipulative.
I have had a pharmacist ringing me up, asking me whether I had prescribed a script for Xanax. Obviously the details of my prescribing code had been stolen and had it not been for this savvy and intelligent pharmacist, my whole script pad could have been used. In a group practice, it's very difficult if you're busy - it's generally 10 minutes for a consult and you have a file which is this thick, literally. Not only that but some of the patients are less than willing to tell the full truth, so unless you chase the documentations and say 'I’m not willing to prescribe to you" there may be other practitioners who are willing to prescribe.
ANTON ENUS: Any other GPs who haven't had a chance to speak yet, who would like a chance to speak at this point?
MAN: I'm not a GP Anton, but we know these drugs are addictive. They are prescription drugs, they are prescribed, obviously coming through the GP. GPs today, you don't have your GP on the corner on his own, like it used to be, the family doctor. They are in medical centres. Medical centres are sausage factories. If they have 30 people sitting out there, they want to get them through the door. They don't have the time to go through a person's history. So the easiest thing to do - the patient wants relief of the pain, or whatever their problem is, even if it's a lifestyle condition. The doctor just doesn't have the time to deal with it and the easiest thing is to give them a drug. So the problem really does rest with the doctor, and, I suppose, the big pharmo companies as well. They are pushing the drugs. They don't make drugs to give someone a drug for five months and then they are off it. The best thing is to have that person on it for life.
ANTON ENUS: What do the other GPs think about this characterisation?
DR PRABHAT SINHA: No. I don't agree at all. It depends whether the GP is conscious about this whole situation or not. Any new patient is the policy in my practice, not to be provided with any painkillers of this nature. The patients who are the regular patients of the practice, sure, we know them, and we prescribe the medications accordingly. So, there should be a plan. There should be a policy in the practice, and most of the doctors, if they are conscientious, they follow that policy.
ANTON ENUS: Nick, how do you prescribe Xanax?
DR NICK CARR: Well, I am proud to say I have never initiated a prescription for Xanax in my prescribing life. I have only ever written a prescription for Xanax on the rare occasions when someone's already on the drug and I'm trying to manage their withdrawal from it. I would like to say I think you're absolutely spot on with what you said. No, sorry, not you - this gentleman here. Because all too often, what I see is that doctors do take the quick and easy route. It is, as you absolutely say, quicker and easier, "I have come in with anxiety, panic, insomnia", much easier to write a prescription. It is much more professional to do what is the right thing, which is to talk to the patient, work out what the right treatments are, and not start them on a lifetime of addiction.
ANTON ENUS: Jana, you have very personal experience of the destructive powers of Xanax. What were you warned about when you went on to Xanax? Were you given adequate warning about how addictive this drug is?
JANA KOHOUT: I was given some warnings about the side effects, but these were only the side effects of initial use and not long-term side effects. Nothing about dependence and a developing a tolerance - None of that.
ANTON ENUS: Chrissie Morrell, you had a slightly different experience of Xanax. It actually worked for you, didn’t it?
CHRISSIE MORRELL: Yes, it did. I had a fairly serious nervous breakdown about 18 years ago and I was having tremendous panic attacks and I call my specialist and he said to me, "Well, I'm going to give you some Xanax." He said, "It's a relatively new drug. I'm only going to give you six tablets and I want you to call me when you're going to take them. But don't take them unless you absolutely have to, because they are addictive." And I actually only took two. And each time I called him, and said, "Look, I'm in a frightful state." He said, "Take a Xanax. Let me know how you are in the morning." He really, really monitored me and I think that is very, very important. I haven't had another breakdown. I haven't had panic attacks - I haven't had any of those things. But I did have therapy, which I believe is absolutely the right thing to do. I think that Xanax is a particularly, um - well, it saved my life. I feel is saved my life, because it gives you a feeling of peace. Tremendous peace - I mean, even if - emotional pain is almost as bad as physical pain, in my opinion. And it did give me complete peace.
ANTON ENUS: A feeling of peace, Jana, we heard there. Did you experience that? Do you think that Xanax, in some sense, saved your life?
JANA KOHOUT: No. It suppressed my symptoms to start with and it caused a lot more pain - Down the track.
ANTON ENUS: Well, Anna Carr, you're kind of stuck in the middle of this debate, aren't you?
ANNA CARR, PHARMACIST: Absolutely. Absolutely.
ANTON ENUS: You're a pharmacist.. Can you pick when someone walks into your pharmacy, can you pick someone in real need and someone who's just looking for a fix?
ANNA CARR: Most definitely. I have regular clientele, I have irregular clientele who fit a certain clone, that you know straight away that their come in to buy their Xanax to either take the whole bottle or sell to other people. I'm not sure. I try to engage in conversation with my clientele and then if I thought that it didn't sound too good, I often ring up psychiatrists, I often ring up GPs and I say, "Is that what you want. I have this much of an understanding of the patient. Should we be progressing in this way?" Most of my regulars who are on benzodiazepines, Temazepam, is prescribed like lollipops. Every second person has a sleeping tablet and I engage in conversation, "Do you realise this can be addictive? Do you realise if you take this every day, within two weeks you won't be able to sleep without taking it?" But I'm not saying there isn't a place for these drugs, there is definitely a place in today's society, today’s society is such that everybody is running around crazy. And everybody thinks a pill is going to cure a problem.
ANTON ENUS: So popping pills didn’t really work for you Peter, you had to reassess how you manage your pain. What do you do?
PETER PANAGIOTOPOULOS: Yeah, I had to reassess everything. I didn't want to be on medication for the rest of my life. It was ruining me as a person and it was putting a lot of strain on my family and my relationships with my family. But I do a lot of meditation these days. I attended the Adapt program - that helped me to deal with my pain. It gave me the necessary tools, um, to work with.
ANTON ENUS: Are you in pain right now?
PETER PANAGIOTOPOULOS: Extremely, yeah. Yeah - a lot of pain.
ANTON ENUS: You're still smiling, though.
PETER PANAGIOTOPOULOS: Yeah.
ANTON ENUS: Let’s get a quick comment from Alyx. When you went to the pharmacist, did you get any advice there?
ALYX DENNISON: No, no. I didn't and I would say that I had lost my, um, medication to get another prescription and I looked like a promising youth of the time, so I don't think they questioned me. But, um, I think that the morphine pump was a problem, because they didn't explain to me properly, I think, that, you know, it had a little light on it that would come on when I could press the button again and I would stare at the light. As soon as it went green, I would press it. They should have said to me, "Don't press it unless you really, really need it," because I was just keeping it coming.
ANTON ENUS: Let’s hear from Ian Buttfield, you recently retired as a doctor treating people with addiction. You have argued that, in fact, we as a society are under-prescribing opiates. Why do you argue that?
DR IAN BUTTFIELD: Well, there's not much point in giving a powerful and potentially potent drug if it's working, but you're not giving enough. Obviously, all of us would agree that you want the lowest dose that works. But if you leave someone in pain, half-treated, give them a drug, the sort of thing that happened over there will happen again.
ANTON ENUS: Michael Nicholas, you deal with pain as well. Is this perhaps something to do with our attitudes as a society towards how we perceive pain?
ASSOC. PROFESSOR MICHAEL NICHOLAS, PAIN PSYCHOLOGIST: Yes, I think we have heard earlier how people talk about acute pain and chronic pain. And I think our society thinks of pain as acute pain - that is, it's short term, you take something for it and it will go away. So we've all had a headache, taken a Panadol and it's settled. That is probably our model for pain as a community. And we believe it's a strong pain, you need something stronger. You take it and it will go away. The problem is when it becomes chronic, that model doesn't work and that's what leads into the stories we've heard tonight - people continuing to take short-acting drugs for a chronic problem. You have to change your approach and not treat chronic pain as if it were acute. It will not respond to the same approach to treatment. And that is, unfortunately, either not realised or it's often forgotten. But that's a key message - that our community tends to see pain as just purely related to an injury. Once you're healed, it will be gone.
ANTON ENUS: OK, Nick, someone walks into your consulting rooms and says, "Please help me." What goes through your mind?
DR NICK CARR: It depends on the patient. If it's someone I have never met, then I am very happy to help them, but it's not gonna be with a prescription for an addictive drug. I see no role for addictive medications for patients that I know nothing about.. I can't see how you can justify handing out prescriptions for these dangerous and addictive medications to a patient that will walk out the door and you don't know what they are going to do with them.
ANTON ENUS: Let’s get a comment from Michael Cousins now. We have heard these stories, some of them pretty tragic. But the one common element was that people progressed from a standard dosage to an increased dosage. What do you think prompted people to take that step?
PROFESSOR MICHAEL COUSINS, PAIN MEDICINE SPECIALIST: I think that is the crucial question. All three stories related to the appropriate use of opioids for acute pain. They are good drugs for acute pain. They do the job pretty well. Not for everyone, incidentally, but they do the job pretty well. You can't contemplate using opioids for the rest of your life. So, clearly, something is going to have to be done as early as possible in that chronic phase to gradually change over to other treatments. Which include assessing the three components of the pain - the physical, psychological and environmental factors that may be operating.
ANTON ENUS: Well, let’s hear from Ian Buttfield behind you there, would you prescribe strong pain relief to a patient that you know was addicted to it?
DR IAN BUTTFIELD: The answer's yes, but with very tight control. I mean, I have some trouble with the word 'addiction' and I have even more problem with treating drug addicts as sub-human. Now, you know, some of our colleagues will say, "Well, the first thing is to assess that the patient's properly assessed as needing opiates." So I'm assuming that's been done. But I saw a lot of people where the dose was not high enough. When I say a lot, it's a small number, in relative terms. But those people will hit out and do all sorts... I mean, the consequences of under-treatment of pain are things like suicide, buying drugs on the street.
ANTON ENUS: Nick Carr, does he have a point - is it better to have addiction rather than pain?
DR NICK CARR: I think we're talking from the perspective of someone who's seeing a very, very select group of patients. I don't think this is really representative of what's happening in the widing community, certainly not representative of what's happening in primary care. I think it would be unusual that a GP is faced with people not getting enough opiates, incredibly common they are getting too many opiates and benzodiazepine.
DR IAN BUTTFIELD: I agree on principle, and I certainly agree that Xanax is a disaster. I mean, one of the problems with Xanax is that the tablets are very small. So you have two Xanax tablets, that equals eight Valium tablets three times a day, and you're up to 24. That's the sort of thing we see. What we're trying to do, I think, all of us - is help GPs dot things that would prevent the problem and not leave the gentleman here out in the bush to have to deal with a problem without proper support.
PROFESSOR MICHAEL COUSINS: I think one of the big problems is if pain is regarded still as being a simple problem. And the solution is a tablet. It's not a simple problem. It's very complex and it requires a multidimensional assessment and that means a team. We can do that in tertiary centres, but we don't have the funds to deal with enough patients. It needs to be available at a general practice level and that's why the national pain strategy has been promulgated in this country. It has been agreed to by 150 organisations.
What's happening? It's in the Government's pocket now. We've had State government support from Queensland. We just had last week NSW Government announcing a $6.5 million-a-year program for more funds for metropolitan pain medicine centres, and the creation of new regional pain centres. So that's a big step in the direction of being able to get patients who truly have now chronic pain a multidimensional assessment. That's a revolution that needs to occur in this country and in other countries, because people with chronic pain are not receiving appropriate assessment, and they are not receiving access to enough treatment options. So that's what this state initiative will do.
ANTON ENUS: We're talking about addiction. Let's have a look at real-time monitoring. This is where doctors and pharmacists can have access to real-time information about the history of people's prescription demands. Simon Holliday, how would this work? Is this a solution?
DR SIMON HOLLIDAY: Well, I think this is a wonderful idea. It will really help give doctors confidence in when they are confronted with a pain patient, as to what's going on. We have seen, um, prescription monitoring programs rolled out in about 42 states in the US and what we are finding is that some doctors are refusing to prescribe opiates, because people are being found to have actually consulted the very large number of doctors in the past. And there are a large number of doctors who are feeling more comfortable about prescribing opiates, because this person is more legitimate and more appropriate to prescribe opiates.
ANTON ENUS: It’s not a perfect system of course, we understand it's just related to drugs on the PBS, and so there might be some misreporting of information?
DR SIMON HOLLIDAY: That's right. So, there will be some information that won't be picked up by a prescription monitoring scheme. And so you might find that some doctors will be prescribing drugs that fly under the radar of that. So it won't be perfect, of course, but it will be something additional. We had a case recently in my clinic, who had presented three times and been given some Endone and some Panadeine Forte and another doctor saw him and contacted the current prescription monitoring service and found out that he had had 35 scripts from a very large number of doctors in the past few months. And so we were then able to talk to him about this, the fact that he needed some help and he had a problem and we offered our services to try and help him resolve his very difficult situation.
ANTON ENUS: There is a hotline available to doctors at present, which they can subscribe to. You have some experience with it, Dr Ian Thong. Why didn't that work as well as this proposed system is meant to?
DR IAN THONG: The proposed system is real time. So we're talking probably hours from when the last medication was dispensed or perscribed. But the doctors' hotline relies on information coming back to Canberra and back to their general database, which means it's months delayed, so things can escalate before you even know it's happening.
ANTON ENUS: Margaret Millington, I know it's a very difficult question to ask you, but do you think something like this real-time monitoring might have been helpful in Simon's case?
MARGARET MILLINGTON: I applaud it. We have been pushing for that since we noticed Simon's behaviour with regard to doctor shopping. He would travel endless miles and present at chemists and doctors and put pressure on them. The pressure that an addict puts on doctors and pharmacists is unbelievable. The real-time monitoring system I’m sure - would ring alarm bells. And it would also give the doctors and chemists, who I feel so much for, being at the coalface, some legal way of saying, legally, "You have already got your prescription, legally, I cannot give you another one." And "I'm sorry. You know, come back in a fortnight."
But I know when I looked at Simon's histories, when he was in Kalgoorlie, he would get 30 Serepax one day, two days later, another 30 Serepax and a letter turned up at our place about the PBS warning him, and I said to Simon 'Hey, look what’s turned up here?" and it meant nothing to Simon, all he wanted was his drugs. It doesn't work. He was put on the drug registry. It didn't work. I see the real-time monitoring system as the way to go and I applaud the Government for their planning to implement that - If it's made mandatory - Otherwise it's like a leaking bucket.
ANTON ENUS: Well, it sounds like a great solution. Have any GPs here been given any information about the system?
EDWIN JOHNSON, JANA’S HUSBAND: Anton, please, the direction that this has taken is all about people who are doctor-shopping, people finding sneaky ways of obtaining these drugs, which they shouldn't have. But one of your panel, Jana, has never swallowed a pill, except those prescribed by her doctors, at the exact doses that were prescribed for her and she ended up at the end of 2005, practically a zombie, through trusting her doctor, never questioning his expertise, until she was very, very ill. That's not the end of the story because it took her three more years to find a doctor and she was shunted out of the door by two psychiatrists to find a doctor, willing to assist her to reduce those drugs to the level that she's at today. She's still not clear of those drugs, in 6.5 years, she has never raised her intake of benzodiazepines and antidepressants. She has always reduced them. And that's how long it takes. I would ask the GPs here how many of them have experience of this extremely long period that is required for somebody to come clean from the really large doses.
ANTON ENUS: Any responses? Does anyone know what's happening to the system? Has anyone received any information?
LESLEY BRYDON, PAIN AUSTRALIA: Yes. The system has been approved by the Federal Government as of 1 July. However, because we are a federation, it has to go through various iterations within the states, and they all have different systems, different timetables. And therefore it's going to be a rather lengthy process, if, indeed, any final plan is reached, I believe.
ANTON ENUS: Well, we have contacted every state and territory government, and we're certainly none the wiser as to when we're actually going to see some kind of plan in action.
ASSOCIATE PROFESSOR NICK LINTZERIS, ADDICTION MEDICINE SPECIALIST: There is a pilot scheme already under way in Tasmania that's been operating for around 12 months, 18 months. That actually...
ANTON ENUS: Which is the model for the national system.
ASSOCIATE PROFESSOR NICK LINTZERIS: Yes. That's the model that's been picked up and will be rolled out nationally. However, as pointed out, each jurisdiction, every state and every territory has to implement the program that will suit its own regulations. And we are realistically looking at anywhere from two to three years before we start seeing this program roll out in the larger states, to the point where it will become available to pharmacists and doctors to be able to address some of these issues. Once someone's become addicted to these drugs, it's not as though we can throw them onto the junk heap and say, "That's it. You're a bad patient taking bad drugs." These are still people that have to live day to day, get on with their jobs - take care of their families. We have to start thinking about the strategies in place to help them get control over their substance use, over their medications, and get quality of life back.
ANTON ENUS: The other issue of course with the proposed real-time system is that it's schedule eight drugs that have been targeted. Xanax, of course, not on that list. Margaret Harding, do you think Xanax should be?
MARGARET HARDING: Yes. That's a major, um, thing that can be done, as I understand it, very, very quickly. And it means that before any doctor can prescribe Xanax, they have to receive an authorisation to be allowed to do it. If that was made a schedule eight drug, that would be something that can be done so quickly and I think it also means that doctors can say, if somebody comes in pressuring them, "I have to make a phone call about this." It gives the doctor time to be able to actually think and say, "I have gotta refer to someone else."
ANTON ENUS: It is true, Simon Holliday, that even if people take the drug precisely as prescribed by the doctor, they can still get addicted. They won't be helped by the monitoring system?
DR SIMON HOLLIDAY: Indeed. So people can be taking a drug as prescribed and get into considerable problems. So prescription monitoring won't - isn't the be-all and end-all. We do have to look at a number of other issues. Other questions were raised earlier about how general practitioners sometimes seem to be on a sausage machine, was said. And I think that may reflect to a degree that our Medicare system rewards fast through-put in a general practice. We need to be acknowledging that we've got a big problem in our country and we need to support our health system responding effectively to this problem.
ANTON ENUS: Let's get some final views from the panel. Peter, you have been through some terrible experiences, not just the accident, but the responses to it as well. You've come through it. How would you describe where you're at, at the moment?
PETER PANAGIOTOPOULOS: I'm, um, extremely happy with where I'm at at the moment. I have my life back. I have my family back. I have my life back, to a certain degree. I still, you know, have pain every single day, but, um, the things that I have done to help me cope with that, um, are helping me. There's not a pill that can fix what I have got and I do the necessary things to keep me going during the day, during the night, for the rest of my life, and it works.
ANTON ENUS: And your kids feel like they have got their father back?
PETER PANAGIOTOPOULOS: Definitely. I can't do a lot with them, but... I haven't lifted up my son. It's been four years. When I had the accident, he was three years old. I haven't been able to lift him up ever since but I show love in other ways and he has his father. That's the most important thing, he has a father that can actually walk and physically get around, to a certain extent.
ANTON ENUS: Alyx, to what extent do you think you have moved on from your experience?
ALYX DENNISON: I actually went to - a meditation retreat, shortly after - a year after my accident and I learnt to deal with pain. Um, from a psychological kind of perspective. Um, seeing it as a sensation to stick with and try and manage it mentally and I have found that really effective.
ANTON ENUS: Final word to you Margaret - do you feel that the system has somehow failed you? Do you feel angry about it or have you moved on?
MARGARET MILLINGTON: I'm not angry. I was very frustrated at the time, because we met so many brick walls in trying to help Simon. I have been working on a drug task force since then. My main aim is to bring awareness to anyone at the coalface and to encourage the Government to continue the real-time monitoring and also to let the world know our son mattered, Simon's life mattered and he's not here to see his little girl grow up.
ANTON ENUS: What about you Jana, we know you are still on that journey.
JANA KOHOUT: Yes, I am.
ANTON ENUS: Do you see an end point to it?
JANA KOHOUT: I have stopped counting the days. But, yes, I am on 0.58mg of Valium and 10mg of an antidepressant. I have come down so far, and I'm much better. I'm myself again. I'm able to teach. It's only two days a week, but it's something. And I'm able to, um, enjoy my family again. And I think I'm less of a burden on my husband than I was. So things are looking good.
ANTON ENUS: Well, we have to wrap things up here. But, of course, you can keep talking online. We would love to hear your views. Go to our website or look at Twitter or visit our page on Facebook.