So Four Corners aired its expose of the hidden epidemic last night and as much as it pained me to miss out on the X Factor elimination decision, I dragged myself over to channel 2. For what it is worth, my opinion is that it ended up doing a number of things:
a) reinforcing existing perceptions of illicit opiate users as less-than-human
b) portraying opiate use as a surefire path to death
c) presented a misleading depiction of illicit drug use and illicit use of licit drugs
d) evoked compassion for 'innocent' chronic pain 'victims' and 'unsupported' GPs
e) shed light on irresponsible prescribing practices by GPs
f) highlighted the inadequacies of the pain management sector in this country
g) gave no coverage to the role of pharmaceutical corporations
The episode opened with the case of 'party boy' Neumann, a now-deceased "heavy recreational drug user". Such a description is then confirmed with vague details of a 5-day binge which ended with a fatal overdose caused by a combination of alcohol, diazepam and oxycodone. The diazepam was prescribed by a GP, who then prescribed the oxycodone a couple of days later.
From what I can gather from the show's content in relation to Neumann, here was an opiate-naive individual who was looking for a way to come down from a serious party session, presumably involving stimulants (that would explain the 5-day duration and fit the mold of what the mainstream media considers 'recreational'). The interview with his girlfriend did not reveal any drug awareness regarding the very serious risk that was being taken and the mother firmly believes Neumann would still be alive today if the doctor had refused to prescribe oxycodone, with his family believing that he didn't know the potency of oxycodone.
With all due respect to the people involved, I am more concerned about a situation where a supposedly experienced illicit drug-taker makes a concerted effort to use a serious drug which holds significant potential for overdose, especially in an opiate-naive person, and especially when other depressants are on board. Neumann didn't take an opiate that just happened to fall in his lap whilst stumbling around a hotel room in a complete daze surrounded by a raucous party of people. He turned up at a doctors surgery twice in several days for two different depressant drugs and then presumably had the scripts filled at a pharmacy. He must have been reasonably alert to achieve this.
Yes, the death is tragic, but Neumann made incredibly risky decisions - firstly, he partied for 5 days straight and secondly, sought out a full opiate agonist without a tolerance for such drugs. I have been around countless people who take stimulants who would never go for 5 days straight and would not, in their wildest dreams, think about opiate use to come down with, especially if they are opiate-naive. These are the decisions that people who have been exposed to drug awareness within a harm reduction framework are able to make. Or who simply take an informed approach to their drug use. There is nothing in the segment to indicate that Neumann and his friends were provided with or sought out such education (his family believe he didn't know the potency of oxycodone. Really? Then why did he consider it such a "jackpot" to find a GP who would prescribe it?). I also question Neumann's mother's belief because with such an unaware and risk-inclined mindset, he may well have done something equally risky if he was unable to obtain oxycodone. Four Corners mentions nothing about the extreme nature of this behaviour and the viewer is provided with yet another tragic story that has become representative of drug use in the mainstream media, a notion that is reinforced throughout the remainder of the show.
The episode then moves to King's Cross and it is here that viewers are provided with their first description of what prescription opioids actually are: "heroin in a tablet". That's right, a very scientific and in-depth description. Why educate viewers about drugs? The less they know, the better, right? It is also explained that these opioids provide "addicts a cheap and long-lasting high". Not 'people', but 'addicts'. Apart from the fact that non-dependent people also use these drugs, as shown in the introductory example of Neumann, the term 'addict' removes any notion of human involvement. We are dealing with an unfairly stigmatised section of the community and the media needs to be aware of this. Is it unreasonable or onerous to instead state "these drugs provide people with a cheap and long-lasting high"? What is also interesting, especially within the context of King's Cross is that no explanation is given for why these 'addicts' use such strong painkillers. I'm sure the staff at the Medically Supervised Injecting Centre (MSIC) could shine a lot of light on this matter. So instead, the viewer is left merely with a depiction of addicts hunting the streets for their next cheap hit, a depiction that is reinforced later, contrasted against the 'innocent victims' interviewed.
Next up is an interview with Bruce. Bruce, like Neumann
Anyway, back to Bruce. It is revealed that "large parts of his vascular system have been damaged", but what this actually means is unclear. He pulls down his pants when explaining that he used to inject in his legs, but there was still no adequate explanation of the "damage". Bruce makes no mention of pill filters or any other harm reduction measures and instead seems intent only on purging himself in front of the cameras, taking us to scoring locations and showing the manner in which he forged scripts. There is no mention of the many users who don't end up injecting in their legs - instead, another extreme case is shown. The 'piece de resistance' is then delivered when Bruce takes reporters to a hospital ward where he explains that 'addicts' manipulate cancer patients and pensioners out of their medication, "doing them a favour" with "cash for treatment". Wham bam! If you didn't hate 'addicts' before tonight, you sure as hell do now. Of course, the show delves no further and certainly doesn't explain that this is not representative of all people who use opiates.
The Australian statistics, which are alarming, reveal that 80 percent of all overdoses or poisonings are now due to prescription opioids. And a death toll is given, with 61 fatal overdoses in Tasmania in 2007/08. This is indeed alarming and incredibly sad, but is Four Corners sure about this? I ask this question because the harm reduction sector continues to inform people that the vast majority of overdoses are caused by combining depressants, with overdoses rarely occurring due to opiates alone. Now I could be wrong, but admitting such a fact would detract from the demonisation of opiates that the show is indulging in, no? What also comes to my mind is the isolation, ostracisation and clandestine lives that people are forced to adopt when opiates are used, and the lack of adequate overdose education people receive. Further information may be required here.
The next section with Dr Currie is alarming. With seemingly good intention, Dr Currie is actually having to articulate to colleagues that, with regards to 'doctor shoppers', "One of the most important of all, that is that they don’t want you to look at them or do an exam for backs. ‘No, no. I just need the Oxycontin, It’ll be fine I’ve been examined. Had that a hundred times before. No I don’t need that. Just want the Oxycontin. I do not give you permission to communicate with the other six GPs that I have seen or the people interstate. And I do not give you ongoing permission.'" No wonder we are in the situation we are in! GPs who are paid quite well, hold considerable status in the community and who have studied for many, many years need to be reminded of such simple guidelines? Who in their right mind would prescribe a schedule 8 drug like Oxycontin without clear supporting documentation, direct communication with other involved GPs and a physical examination? The only explanation I can come up with is fear of violence. But really, these are rudimentary skills that a low level drug and alcohol worker would be aware of. Something just doesn't add up here.
Suburbia is then brought into focus and "everyday Australians" are juxtaposed against "street addicts". These are "not your typical addicts", Dr Nick Lintzeris explains, with stigma receiving a mention. We are introduced to Ruth who was started on 40mg/day and then found herself on 300mg/day after "she strained her lower back" (are you kidding me! Surely something more serious occurred for such prescribing to be warranted). Ruth explains how she deliberately overdosed to end her life due to the situation she found herself in (her husband found her "off her face" and "dozing off"). Now I'm no psychiatrist, but I am guessing there is more to the picture here. Regardless, the story is indeed a saddening one. However, Ruth then ends her interview with a horror story of wanting to jump off a balcony when withdrawing from opiates and denying herself the remaining opioids in her handbag. Who the hell allowed her to go 'cold turkey' from 300 mg/ day! There is no mention of the need to titrate dose etc., and instead the viewer is left with the 'opiates = death' equation. I can just see the uninformed producers salivating over the balcony story ("Put that in! That's a pearler!"). The poor woman underwent a misguided, torturous and traumatic process that should never have taken place. Who cares, though, right?
Fortunately, Ruth received assistance from Dr Melissa Sui at St Vincent's Hospital in Melbourne who explains that her opioid patients report that the medication has "little to no effect" on pain. Extraordinary stuff, but as a former pain clinic attendee I can tell you that the opioids certainly did have an effect. I still felt pain, but I managed so much better. I know others who would agree. What I found most infuriating were the attitudes of the medical professionals I would encounter (except for one - hello Dr Gisbus!). Of course, there are people who will continue to feel pain but the different stories don't emerge. Now I'm not advocating for opiate-drenched living, I just think the picture is more colourful than what was presented. Ruth's section ends positively as she provides much-needed hope for others who want to get off opioids. I am also glad to report that the inadequacy of the pain management system is then highlighted and Professor Currie makes a good point when he says, "The answer is to talk to the person, see what the person would do best with and often it's not a tablet and particularly it's not Oxycontin."
We are then introduced to Mark who was turned "into a raging addict". Mark politely informs us of how he felt: "I'd rather be dead than live like this, yeah. That, and that sums it all up. That was no, no way to live. No one should live like that. And, and if you if you choose to take the path to take those drugs, um, or ,or if you're in the position where, where you take those drugs, it's where you will end up. It's, it's, it's as plain as that, you know." Gee Mark, I work with a tonne of people who would be dead if they didn't have opiates. So yeah, it's not as "plain as that". It is then revealed that Mark was not properly monitored and his addiction wasn't picked up. Great. It would have probably been worthwhile for the show's producers to discuss daily pick-up options at this stage and the fact that opiates do not agree with everyone. But no, they then go on to describe Suboxone as "an opiate blocker" that Mark explains has "no adverse effects". Well, to be exact, Suboxone is the brand name for buprenorphine that is half antagonist and half agonist. People do experience 'positive' opiate effects and there are adverse effects (it is dependence-forming, causes constipation and dryness of the mouth etc.). Details, details...
The episode then ends with Kos Sclavos from the Pharmacy Guild who suggests that 'Real Time Monitoring', as occurs with pseudoephedrine, could be of benefit with prescription opioids. At least he uses "misuse" instead of "abuse".
And to end this overly-long rant, I can't help but think that we need more advanced types of medication for pain issues and I hope that this show doesn't make things more difficult for people in genuine need. These drugs aren't ideal, but for many people it is ideal for whatever time of their life they are in or for the entirety of their life. Cannabis preparations have also shown to be effective and ketamine infusions are starting to be used as well. At the end of the day, there is a section of the community who will always engage in such drug use and if opioids go away, what will take their place? We have already seen what heroin shortages can create and also the accessing of ingredients/ drugs via other means (the Internet, other countries etc.). The black market has been endowed with so much power by Prohibition that most of us are at its mercy in one way or another.
Here is a link to the episode.