A change in the supply of pharmaceutical morphine could inadvertently lead to more overdoses by people who inject opioids such as morphine and heroin, a University of Auckland expert warns.
Due to funding changes, slow-release oral morphine tablets will soon only be available in the form of capsules (m-Eslon). Once remaining stocks are exhausted, slow-release tablets will no longer be available in Aotearoa New Zealand: the 10mg and 100mg strengths have already run out.
Dr Rhys Ponton, a professional teaching fellow in the University’s School of Pharmacy, says this change will have minimal impact on patients who require treatment with morphine; and a potential benefit is that capsules are easier to swallow.
However, it could have the unintended consequence of driving up opioid overdoses and fostering a new generation of opioid users, something for which our health services are “woefully under-prepared”, says Dr Ponton who is involved in ongoing research into illicit/recreational injected drug use in New Zealand.
Due to the scarcity of imported heroin in New Zealand, recreational drug users have traditionally sourced prescription morphine tablets and converted them to a crude form of heroin using a complex ‘cooking’ process. The conversion process from morphine in capsule form, though, is more difficult, and instead drug dealers have already begun selling pre-converted heroin as a powder.
“This is a new phenomenon and poses a significant overdose risk as people are not easily or reliably able to gauge the amount of drug present, compared to a professionally produced, pharmaceutical grade tablet made with a fixed dose of morphine,” says Dr Ponton, who wrote a letter with Jason George, harm reduction lead at the New Zealand Needle Exchange Programme, outlining their concerns in the latest [Friday 13 March, 2020] New Zealand Medical Journal.
“There are also anecdotal reports that the powdered heroin is also being marketed to those who wish to smoke it, rather than inject it. This may lead to a new generation of opioid users.”
Another risk with the new, pre-converted heroin powder is that it can be cut (diluted) or substituted with powdered fentanyl. “Anecdotal reports suggest such illicit fentanyl has been sold as heroin in at least one major New Zealand city,” the letter authors write.
“Ironically, until now, the presence of morphine tablets on the market has ensured that people are able to accurately measure their opioid intake and this is likely to have contributed to New Zealand’s relatively low overdose death rate (approximated to be between 35 and 47 deaths a year, although thought to be higher),” they write.
“In comparison, the overdose rate in Australia, where the illicit opioid market includes powdered heroin, is significant: 438 heroin-induced deaths in 2018, with pharmaceutical opioids compounding these.
The letter concludes: “New Zealand is woefully underprepared for a shift to an illicit powdered opioid market, which could lead to further issues such as fentanyl entering the supply chain.”
Dr Ponton stresses he and Mr George are not calling for a return to the use of the tablet form, nor promoting the misuse of pharmaceutical products. Rather, they are seeking to raise awareness among health workers.
“New Zealand medical teams and first responders (including paramedics) need to be aware of this increased risk and prepare for a potential rise in opioid overdoses. And, we may need to increase the availability of the opioid overdose reversal agent naloxone to allow friends and family of opioid consumers to treat an overdose with minimal delay.”
There are currently approximately 5500 people on opioid substitution treatment for opioid addiction in New Zealand.