A few days before he died of a drug overdose, Sally’s (not her real name) younger brother called her to make plans.
“Someone had given him gold-class movie tickets and he wanted to take me to see Batman v Superman,” she told a coroners court this week. “He was looking forward to our regular Sunday family dinner and he was talking about all the TV shows that he wanted to watch.
“And then he was gone.”
In May 2016, Sally’s brother, RG, who cannot be named because of a court order, was found dead in the unit where he lived alone on Sydney’s northern beaches.
A “smart, funny and frustratingly charismatic” 22-year-old with a “quick wit, a cheesy grin and a cutting sense of humour”, RG nonetheless had a long history of drug abuse. Beginning from the age of about 15 when he began drinking alcohol and smoking cannabis, he had progressed to amphetamines, cocaine, heroin and methamphetamine.
He had attended drug rehabilitation and was on a methadone program but had apparently relapsed.
On the day he was found dead, his parents had gone to pick him up from his apartment before the Sunday dinner he had been looking forward to. They found him slumped over on his knees on the lounge-room floor, surrounded by drug paraphernalia.
A toxicology report found he had died of an overdose from a combination of drugs, including the prescription opioid fentanyl.
RG’s death is one of six examined this week by the New South Wales deputy coroner, Harriet Grahame, as part of a special inquest into the rise of opiate addiction in the state. The inquest was established after the coroner’s office noticed a spate of opiate deaths across Sydney within a few weeks in May 2016.
Initially, investigators feared the deaths might have been linked to a bad batch of imported opiates. The truth may be more unsettling. Far from an outlier, the deaths were what counsel assisting the inquest Peggy Dwyer described as merely a “snapshot” of the scale of opiate-related deaths in the state which she were at “record levels in Australia and internationally”.
All six deaths examined by the coroner this week were the result of an overdose from various opiates. Fentanyl, in particular, was found to be a contributor in three of the six cases. But only one of the six had a valid prescription for the drugs they died from.
Developed in the late 1950s by a Belgian chemist, fentanyl is a synthetic opioid up to 100 times more potent than morphine. It came into widespread use in medicine during the mid-1990s with the introduction of the transdermal patch that releases the drug into the patient’s bloodstream over two or three days.
But like its prescription opioid cousins, misuse of the drug has become part of the problem of opiate addiction. Fentanyl abusers commonly extract the drug from patches in which it’s sold. It is then injected, smoked or even chewed. But the drug’s potency means it poses a particular risk of overdose: the difference between drug-induced oblivion and death is wafer-thin.
In the US, where opioid abuse has sparked a public health crisis, fentanyl is at the front line of overdose deaths. Opioid overdoses increased by about 30% across the US in just 14 months between 2016 and 2017, and fentanyl deaths shot up by 540% between 2013 and 2016.
According to the the US Centre for Disease Control and Prevention, the rate of deaths caused by synthetic opioids such as fentanyl jumped from 3.1 per 100,000 in 2015 to 6.2 per 100,000 in 2016. In October last year the US president, Donald Trump, declared it a public health emergency.
Now the question being asked by Australian health authorities is whether the same magnitude of crisis could be exported here.
In Australia, opioid deaths increased by 60% in 2011 and 2015 compared with the previous decade. Deaths caused by pharmaceutical opioid overdoses now exceed heroin deaths by between two and two-and-a-half times.
Most of those deaths were caused by accidental overdoses of oxycodone, morphine and codeine but over the past decade fentanyl has emerged as an increasing contributor to the spiralling casualty count.
According to the National Coronial Information System, fentanyl was at least partly responsible for 130 opioid-related deaths between 2007 and 2011. Between 2013 and 2017 it had risen to 230. Dwyer said misuse of the drug was a “particular concern” for NSW police. Between March 2016 and February 2018, opiates were responsible for 26% of drug overdose deaths in the state, and 32% of those were directly attributed to fentanyl.
But beyond sheer scale, there has remained an important distinction between the issue in North America and Australia.
Dr Marianne Jauncey, who runs the medically supervised drug-injecting centre in Kings Cross, told the inquest this week that there was an important difference between misuse of prescription and illicit fentanyl.
Opiate addicts access prescription fentanyl through either so-called “doctor shopping” or by buying on-sold prescription versions of the drug from dealers.
Illicit fentanyl analogues meanwhile are produced mostly by chemical companies in China who custom-design variants of the drug. The drug’s potency makes it appealing for commercial dealers because they can charge more for smaller quantities but the drug’s analogues can be more dangerous than pharmaceutical-grade fentanyl because slight changes to the drug’s formula can make dosage harder to gauge for users.
In the US and Canada, the importation of illicit fentanyl has been a major driver of the rise in overdose deaths. A recent US Senate subcommittee report investigated the presence of online fentanyl dealers and identified more than 500 sales totalling $230,000 involving six online sellers, mostly from China. The subcommittee also identified seven people who died from fentanyl overdoses after sending money and receiving packages from one of the online sellers.
Authorities believe most users in Australia are still accessing prescription-grade fentanyl. A drug user who gave evidence at the inquest this week said a 100-microgram patch of fentanyl sold for about $100 in Sydney.
But Jauncey said she feared it was only a matter of time before the more dangerous illicit fentanyl became more widely available.
“The reality is I can’t gaze into a crystal ball and I don’t know what future holds [but] my concern is that as far as I’m aware much of illicit fentanyl is produced in China and we know that there are already strong illegal trade routes between Australia and China,” she said.
“The only protective factor is the size of our market, which pales in comparison to North America. Other than that I can’t really see why we wouldn’t get it.”
The inquest heard evidence that illicit fentanyl had been picked up by Australian customs in some seizures, and this week the Guardian contacted online sellers based in North America and China on a drug-selling marketplace on the dark web.
All claimed to be able to distribute fentanyl analogue products to Australia. One China-based distributor said packages were sent via Germany or South Korea to avoid detection.
The barriers to naloxone
Part of this week’s inquest in Sydney looked at the availability of naloxone, a drug which can overturn the effects of an opioid overdose.
Naloxone is listed as a schedule 3 drug under the pharmaceutical benefits scheme, meaning it can be accessed from a pharmacist without a prescription.
Dr Nicholas Lintzeris said that, in NSW, emergency departments would begin trialling handing out the drug to people who overdose. It follows a separate trial in which 500 take-home kits of naloxone were distributed to health workers and opioid users.
But he told the inquest that there are still issues with its distribution.
Prescriptions are limited to the intended user of the opioids, meaning family members of opioid users are not able to access the drug if they are no its intended user.
And, he said, the stigma attached to drug users still acted as a barrier to access.
“It’s the same kind of discussions that we were having 30 years ago,” he said.
During the inquest – which will resume in August – the deputy coroner said RG’s story showed that “people who died from opiate overdoses are our brothers, our children, our community members.
“This is not a strange class of people … This is happening across our community.”