This week, TheJournal.ie is taking a closer look at Ireland’s relationship with illegal substances. More people in Ireland are using drugs than ever before. We’ll look at why that is… and the possible consequences.
IRISH DOCTORS ARE prescribing increasing amounts of the same highly addictive painkillers associated with a health epidemic in the United States.
Figures seen by TheJournal.ie show that prescriptions of 10 powerful opioids – a class of drug whose derivatives include morphine and heroin – rose by almost 20% in nine years.
In 2009, doctors in Ireland issued 1,463,359 prescriptions for fentanyl, oxycodone, mephedrene, hydrocodone, morphine, codeine, percocet, hydromorphone, oxymorphone and tramadol.
In 2017, that figure rose to 1,739,110 prescriptions, while 715,699 prescriptions for the drugs were issued across the country in the first six months of this year.
These drugs were a factor in the deaths of almost 200 people a day in the US last year, and prompted Donald Trump to declare a national health emergency last October.
Does the recent rise in prescriptions here mean Ireland should be worried about an opioid crisis of its own?
Practical prescriptions
Opioids refer to a family of drugs which act on opioid receptors, including drugs derived from flowering poppies, and can be both natural (like kratom) or synthetic (such as heroin and morphine).
They work by binding opioid receptors to the brain, spinal cord and even the gastrointestinal tract, and are used medicinally to treat pain, with side-effects including feelings of pleasure, relaxation, and contentment.
Doctors administer opioids such as those listed above as painkillers, usually for moderate to severe forms of pain and often as a patient awaits or recovers from surgery.
In fact heroin, whose chemical name is diamorphine, was first synthesised for medicinal use in 1897 by a chemist working for German pharmaceutical giant Bayer.
Dr Maitiu O’Tuathail of the National Association of General Practitioners explains that while an increasing amount of opioids have been prescribed in recent years, there is no suggestion that doctors are doing so inappropriately.
He suggests that one of the reasons behind the rise in prescriptions is practicality.
“Many strong opiates are prescribed in pain clinics in hospital,” he tells TheJournal.ie.
“For medical card patients, these hospital prescriptions then have to be transcribed onto medical card prescriptions by the patient’s own GP, so the patient can get them.”
Dependence
However, O’Tuathail also suggests that opioids are being used as a stop-gap solution to long-term backlogs on HSE waiting lists.
He claims that a large number of those who are prescribed powerful painkillers would not need them if they were treated sooner.
“Many of these people are on waiting lists as they await an intervention that would treat their pain, such as a hip replacement, knee replacement, or other such procedure,” he says.
This creates a worrying side-effect which may lead to an even bigger problem for Ireland’s health services.
After prolonged use, opioid users develop a tolerance to the drugs and their regular dose loses effectiveness, meaning they need to take bigger and more frequent doses to achieve a painkilling effect.
However, this leads to a dependence on the drug, as the body’s natural ability to produce dopamine – also known as the ‘reward’ chemical – becomes disrupted when a person takes an opioid.
If a dependent user stops taking the drugs, they experience harsh withdrawals which can only be relieved by taking more of the drug, or waiting it out until the body returns to normal.
Other drugs may also be needed to ensure a person functions normally.
“Patients who wait years and years for procedures gradually experience their pain increasing, leading to increased analgesia requirements,” O’Tuathail says.
They can develop side effects of the opiate medications, such as constipation, which then requires the prescribing of other medications.
Health crisis
Two of the more potent opioids being prescribed by Irish doctors are fentanyl and oxycodone.
Prescription figures for oxycodone, largely blamed as the main drug behind the crisis in the US and nicknamed ‘hillbilly heroin’, are particularly stark.
In 2009, Irish doctors issued 92,112 prescriptions for the drug, but that rose to almost 141,000 prescriptions in 2017 – more than a 50% increase in nine years.
The drug is usually prescribed to relieve severe pain after surgery, but has become the most widely abused prescription opiate in the US.
It’s believed to be so prevalent because it is prescribed to such a wide variety of patients, particularly those suffering from cancer and those with chronic pain.
But dependence on the drugs is also a factor, something O’Tuathail suggests is being mirrored on this side of the Atlantic.
“There can be a prescribing cascade,” he says.
“This is a significant contributor to the increased prescription of opiates, and could easily be resolved if patients received the treatment they require promptly.”
Meanwhile, Irish prescriptions for fentanyl – which can be up to 50 times more potent than heroin – have fallen in recent years, although more than 67,000 were issued to Irish patients in 2017.
The drug has also presented a risk to recreational drug users, with samples of cocaine and heroin here found to have been cut with fentanyl, which amplifies the potency and potential dangers of both drugs.
Only a small amount of fentanyl is needed to produce thousands of doses, so the drug is easy to conceal and transport, and provides considerable profit to criminal gangs.
A number of reports have already linked it to the deaths of drug users in Ireland.
Dysfunctional
The Health Research Board has already expressed concern over the risk these new drugs are presenting.
Reporting on new estimates of problem opiate use last year, the board said their emergence created a challenge because of their unknown quality.
“Individuals that use these new products are at higher risk, as toxicity levels are substantially higher than similar drugs,” the board said.
With Ireland’s rate of drug-related deaths the third-highest in the EU after Estonia and Sweden, the country would seem particularly at risk of an opioid epidemic similar to that being experienced in the US.
So how can this be prevented?
Earlier this year, the British government announced a review of evidence about the scale and nature of problems being presented by the abuse of prescription medicines.
A similar measure could be effective here, although a monitoring process already exists to track prescribing patterns compared to the national average so that large, unexplainable deviations can be detected.
O’Tuathail ultimately believes that the problem lies with the health service, and suggests that the public should demand more to prevent the problem spiraling out of control.
“What we need is real action to address waiting lists,” he says. “The increase in opioid prescribing is reflective of how dysfunctional and broken our health service is.
“Until the public make the health service their number one priority, politicians won’t listen and these problems won’t be resolved.”
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