Going without food or constant, unbearable pain is the reality a Kiwi woman with chronic pain is facing after changes to opioid prescription rules.
Last year, the Government changed the prescribing limits of opioid drugs from a maximum of three months to one. The changes, which came into place in October, affect painkillers such as tramadol and codeine.
The Ministry of Health has said it will reduce the risk of harm associated with opioid drugs while ensuring access to those medicines for people who need them.
But several doctors and pain experts Newshub spoke to have said the changes, while in line with guidelines, are highlighting a massive shortage of specialist chronic pain care in Aotearoa.
And, for Palmerston North woman Heather*, it is having devastating consequences.
Heather never expected her life to look like this but an accident in 2004 changed everything. She picked up a heavy stack of lever files and injured herself in the process. Then, after surgery to fix the injury, she caught an infection and developed complex regional pain syndrome.
Complex regional pain syndrome is a chronic condition that can last for life and there is no cure. Heather said it's "ruined" her life.
I don't live like other people nowadays. It's been a long time. My life ended when I got this condition. It's ruined my whole life.
Heather regularly uses tramadol to help manage her pain but the changes have made accessing it harder and more costly. It's an added cost she can't afford.
She is already struggling to get by on ACC during the cost-of-living crisis and said she's facing going without food to afford her medicine.
While the medicine itself is subsidised, it costs her $30 to get a script from her doctor, which she now has to pay every month instead of every three months.
"It's expensive. I'm on ACC so my income is limited and I just can't do that.
"It really stressed me out thinking, 'How am I going to find this extra $30 a month for something that I need'"?
Heather already lives on a tight budget and said she will have to buy fewer groceries because there's nothing else left to cut out.
"We don't get takeaways anymore because we can't afford it. I am just going to have to give up more food."
While Heather is upset about the changes, GPs are broadly supportive, including General Practitioners Aotearoa chair and pain fellow at The Auckland Regional Pain Service Buzz Burrell. Dr Burrell said the issue is a lack of specialist pain doctors which many people are forced to rely on opioids even though they don't work for long-term pain and can make the issue worse.
One in five people in New Zealand have chronic pain but the country only has about 25 percent of the pain specialists we should - leaving patients and under pressure GPs with very few treatment options, Dr Burrell said.
This means GPs often rely on opioids to treat chronic pain. But in a cruel twist of fate, Dr Burrell said long-term opioid use can make things worse.
"Long-term opioid use, in particular, does two things which, surprisingly enough, is not particularly well advertised. One thing they do is there's something called opioid-induced hyperalgesia.
"Basically, that's where pain is made worse instead of better as a result of long-term opioid use.
"The next thing they do is something called opioid-induced endocrinology and to cut a long story short that's where the body's hormones are suppressed by the opioids.
"That's not funny, women develop osteoporosis, men develop impotence and feminisation and the adrenal glands lose the ability to respond to acute physiological stress safely."
In other words, opioids "are making things worse" and damaging patients' bodies, he said.
"It's all because we are not looking after people with chronic, persistent pain the way we should be doing - that is plugging them into physiotherapy, plugging them into health psychology and getting away from a biomedical model. It's... heartbreaking."
Heather is also hitting out at poor communication of the changes. She said she only found out about it when she went to the pharmacy to pick up her prescription in January.
Instead, she was told they were now monthly and she would have to see her doctor - something she couldn't do because they were on leave. While she did manage to get a prescription, it wasn't until she had suffered through three days of agony without any pain relief.
"I didn't get any sleep. I didn't have any rest - it was terrible," she said. "I don't think that anybody should have to deal with that.
"If you need to take time tramadol or painkillers, there is a reason why and you shouldn't be inconvenienced or have more cost put on you."
She has a simple message for the Government.
"I just want someone to listen. Just be fair to people who are in pain, it's not their fault.
"It wasn't my fault. It was an injury which I got surgery for and then got an infection and it ruined my whole life. I don't live like other people nowadays. My life ended when I got this condition."
GPs say prescription changes are highlighting real issue
Dr Burrell isn't alone in raising concerns over a lack of proper care and incorrect use of opioids.
It's a view shared by Royal New Zealand College of GPs medical director and Tauranga GP Luke Bradford, who said while the changes aren't perfect, they're the right call overall.
Dr Bradford said throwing painkillers such as tramadol at people with chronic pain is a "sticky plaster and it's not particularly good one at that".
However, he said without access to pain specialists, the prescribing limit change is putting further financial pressure on people who can often least afford it.
But he said many GPs will have support in place to help low-income Kiwis cope, adding having a community services card will reduce the cost significantly.
It's not just patients who are struggling with the changes either. Dr Bradford said it is putting even more pressure on already overwhelmed GPs.
"It is more work into general practice at a time when we're trying to work out how to cope with the demands and the fact that a lot of patients can't even register with a GP and those who can have longer wait to see one and it is because of increased work like this."
He said staffing and resourcing issues for New Zealand's doctors must be addressed so patients have access to safe and reliable healthcare whenever they need it.
Karen Joseph is a specialist pain medicine physician who works in private practice in Christchurch. Dr Joseph is aware of New Zealand's over-reliance on opioids and lack of appropriate specialists.
She said the recent changes were introduced to fix this but it wasn't accompanied by increased funding or resourcing for GPs to provide effective and safe community pain care, or for specialist pain clinics for those who need more intensive treatment.
This means many people are still struggling to access the appropriate care and now may be struggling to access their medicine as well.
She said medication should only be one small part of chronic pain management but lack of resources means for thousands of people it's the only treatment - and, as mentioned earlier, it doesn't work.
"Unfortunately, many New Zealanders lack access to such comprehensive care. Many regions do not have a public hospital pain clinic at all; and areas that do have limited capacity and long wait times.
"This often leaves people with chronic pain relying solely on their GPs.
"While specialist general practitioners try their best to provide good care for people with pain, they are very limited in the time and resources available to them (e.g. physiotherapy, pain clinics). Often all that is available to them is to write a prescription for a medication," Dr Joseph said.
Along with worsening the pain long term, she added opioids also carry other risks such as increased rate of motor vehicle accidents, constipation and nausea, hormone imbalances, depression, immune problems and accidental death.
"I am fortunate to mostly work in settings with multidisciplinary teams, allowing me to offer various treatments and support, minimising the need for opioid use by my patients. If such care were available to all New Zealanders, it could significantly reduce pain-related suffering for many across the country. "
But for Heather, the changes mean more pain - both physical and financial - and still no specialist care.
