Associate Professor Suzanne Nielsen, PhD MPS, is the Deputy Director of the Monash Addiction Research Centre in Melbourne and an NHMRC Career Development Fellow. Nielsen has been a registered pharmacist for over 20 years, and her research has led to a greater understanding of how to identify and respond to prescription and over-the-counter drug-related problems. Nielsen will deliver a plenary at the upcoming 42nd Annual Scientific Meeting (ASM) of the Australian Pain Society, to be held in Hobart from April 10-13, 2022. In the lead up to the ASM, Nielsen spoke with Lincoln Tracy, a research fellow from Monash University, Australia, about her journey through researching drug-related harms, her secret life as a volunteer bike mechanic, and more. Below is an edited transcript of their conversation.
What was your path to becoming an addiction researcher?
When I was a trainee pharmacist, I was working in a community pharmacy with a large methadone program. I developed a real interest in treating opioid dependence during this time, because I found working with the people in the program was very rewarding from a clinical perspective.
A big part of the rewarding feeling is the amazing improvements you see in people’s lives once they come into these treatment programs. In my pharmacy work I often saw people at a later stage in their lives and things were deteriorating for them. The number of medications they’re on would increase, and sometimes the picture wouldn’t be optimistic. But with this client group, people got better—their lives really came together.
After I was fully qualified, I moved to the UK and was headhunted for a job in a specialist drug treatment clinic—basically because I was the only pharmacist willing to do methadone treatment. The clinic ran trials around injectable methadone and heroin, as well as other novel treatments. That’s where I got a real taste for research and how this field could go beyond methadone dosing. When I returned to Australia, I continued doing specialist clinical work in addiction treatment, but also started honors and then a PhD around treatments for opioid dependence.
How significant of a problem is opioid use disorder in Australia?
I think the best way to describe it is to say there are two problems side by side. On one side of things, Australia is a very high opioid prescribing country—in the top 10 in the world at times. Over the years there was a shift from predominantly using opioids in acute pain or palliative setting to it being commonly used for chronic pain. It took a while for the problems with long-term opioid use in chronic pain to emerge, and now [opioid prescribing] is starting to come down, as there’s been a lot of work focusing on quality opioid use. We now know the long-term benefits of opioids don’t always outweigh the risks, and that many patients don’t do well in the long-term. We are now responding to this first problem by initiating opioids in fewer patients.
At the same time, we have this cohort of patients who were started on opioids a while ago—when prescribing longer-term and higher dose opioids was more common—so the second issue is how we respond clinically to the needs of this cohort. It’s one thing to put strategies in place to prevent people starting opioids so they won’t become opioid dependent. How we meet the needs of those people who are already on a high dose of opioids and may need treatment for opioid use disorder, is challenging. It’s been nearly a decade of playing catch-up in educating clinicians and patients so that they know that providing opioids might not be best in the long term. It takes time to adapt, and we don’t want the pendulum to swing too far in the opposite direction. There are a small number of patients for whom opioids may be appropriate and will provide good clinical outcomes—we need to get better at identifying who those patients might be and supporting other patients to safely cease opioids with appropriate supports.
What are some of the other challenges associated with researching opioid-related harms?
One of the biggest challenges is determining what works, particularly in the opioid policy space. There’s been a bunch of policies and interventions rolled out to respond to concerns around opioids. That makes it challenging to do research because you want to try and work out what is going on with multiple simultaneous interventions. For example, if we see opioid prescribing go down, which is the bit that worked? If we’re seeing people ending up being cut off their medicines, what is contributing to that? Can we do a better job of implementing policies and evaluating them as we go? If so, we will be better able to know what contributes to better outcomes.
Another thing which is really challenging is being fast enough to pick up unintended harms that may happen with these rapid changes in policy. If we see a shift towards increased prescribing of less monitored medicines, or people being pushed towards illicit opioids or other things that might be not safe or effective, we want to know this sooner rather than later. We need to have measures in place to identify if and when these unintended harms occur. We are currently doing a lot of work using overdose data from ambulance services, primary care, and hospital data to identify where these unintended harms are emerging. Using these kinds of data sources allows us to monitor such harms in a time-sensitive manner, which is important.
What’s something in your area of research that we don’t currently know, but that you hope we have an answer for in five or 10 years?
I think getting a good handle on how to best use prescription monitoring programs to have positive outcomes for patients is an area we are trying to understand. There has been a huge change in the information clinicians have available to them and this is something where we’ve seen unintended consequences in the US. Prescription monitoring is now implemented in all, or almost all, states in the US. But we still don’t have good evidence to know what these programs do for opioid prescribing and harms. Part of how we overcome this is having robust evidence. We are lucky we’ve got good data systems here [in Australia] and we should be able to be to investigate outcomes from the prescription drug monitoring program use, not just at the population level, but at the patient level to look at what the impacts on individual patients or groups of patients.
We’re also lucky that we have a more accessible treatment system in Australia. We’ve seen a lot of knee-jerk reactions in the US where at-risk patients suddenly can’t access opioid medication anymore, but there’s not necessarily other ways they can access treatment for opioid dependence. We know that when people are suddenly cut off from opioids there are increases in suicides and sudden mortality for a range of reasons. So, it’s important that patients—particularly those who we feel might be experiencing opioid dependence—aren’t cut off from their medicines without being put on a different treatment pathway. I think it’s critical that the kinds of conversations we have as clinicians and healthcare providers are along the lines of “how can we make things safer for you”, rather than “I can’t prescribe for you any more”.
Another area is how we can effectively deliver prevention strategies like take-home naloxone and opioid-safety education for people who are prescribed opioids and are at immediate risk of an overdose. We have developed brief tools prescribers can use in a structured way to screen and identify patients who might be at risk so we can immediately get things in place. This is key, so the risks are at least addressed in the short-term while longer term strategies are put in place for pain management. A key part of having naloxone work effectively is educating patients and their families about the signs and symptoms of opioid toxicity that they need to keep an eye out for, and how to use the naloxone if the absolute worst happens. We see coroner’s reports of patients who never wake up, who have stopped breathing overnight due to opioid toxicity. Many of these deaths could have been prevented. For example, someone else might have been home and heard signs of respiratory distress, but thought it was just snoring and therefore didn’t do anything. Naloxone is now available as an intranasal spray, rather than an intramuscular injection. The spray is much more accessible and simpler to use and has really helped in educational efforts—like having conversations around what to do if someone is displaying signs of opioid toxicity. If those symptoms are not recognised, naloxone won’t work. I hope in the coming years we can learn how to better implement overdose prevention for people who are prescribed opioids.
You’ve previously published on observing increases in heroin-related deaths following the introduction of a harder to injury form of oxycodone. What changes have come about because of that work?
That study used both ambulance and emergency department data and was pivotal in identifying this previously unobserved trend. Specifically, when oxycodone was reformulated, we saw a shift of from prescription opioid overdoses to heroin overdoses. This finding was an unintended consequence of the reformulation and has since spurred on a program of work in Australia to look at unintended consequences in general. This work highlighted the importance of looking at other prescription opioid policies and strategies to make sure we don’t see similar unintended consequences.
We’re just starting to get the data on prescribing from prescription drug monitoring programs and are starting to see the impact those kinds of interventions are having. We are focusing on identifying the populations who are most affected and whether there are the populations that the interventions were targeted at. We want to know if the high-risk people who are prescribed opioids where changes are seen, or are we simply reducing opioid supply to the lower risk people or those prescribed opioids for cancer pain? I’m really looking forward to seeing those results.
The other main policy change that we’ve been looking at has been codeine rescheduling. We saw that hydrocodone rescheduling in the US led to mixed outcomes. Codeine rescheduling was controversial at the time, so a lot of effort was made to educate people about the role—or lack thereof—of codeine in chronic pain management. A key part of this was ensuring consumers understood there may be better options out there for them. And all the effort paid off—we’ve seen good outcomes from the codeine rescheduling in Australia. It’s been great to have research and to see policy changes implemented which led to good outcomes for patients. It gives us a lot of confidence moving forward.
Finally, what’s something most people don’t know about you?
I have a secret life as a volunteer bike mechanic. I learned a lot of these skills during my postdoc at UCLA, where we worked to provide bicycles as an affordable form of transport for undocumented workers and people who were homeless. I currently work with a non-profit we’ve established in Melbourne called the St Kilda Bike Kitchen, and we teach people how to fix and maintain their bicycles. We have run several programs in Sydney and Melbourne where we provide bikes to underserved communities, such as asylum seekers, so they’ve got affordable transport. It’s completely unrelated to my research, but a really rewarding part of my life.
Lincoln Tracy is a postdoctoral research fellow in the School of Public Health and Preventive Medicine at Monash University and freelance writer from Melbourne, Australia. He is a member of the Australian Pain Society and enthusiastic conference attendee. You can follow him on Twitter (@lincolntracy) or check out some of his other writing on his website.
Lam T, Kuhn L, Hayman J, et al. Recent trends in heroin and pharmaceutical opioid-related harms in Victoria, Australia up to 2018. Addiction. 2020;115(2):261-269. doi:10.1111/add.14784