Everyone who was approached consented to take part in the study. In total, there were 17 individual interviews and one focus group, consisting of five participants. The sample included newly qualified GPs and those with wider experience of prescribing opioids, both in general practice and in specialist situations, such as hospices. Practices ranged from city centre to rural and semi-rural settings also incorporating areas of high deprivation and areas with large retired populations. The GPs’ experience in general practice ranged from 9 months to 30 years; 15 were male and seven female. All were currently practising in Exeter and East Devon: 12 in the city centre, two in areas of high deprivation and two with a high elderly and retired population; nine semi-rural; and one locum covering urban and rural areas.
Training
Of the 22 GPs, 10 had no training in pain management or palliative care, five recalled some training during initial GP training, four reported that they had attended occasional day courses, and five declared a particular interest in the area and had attended courses or spent time in a palliative care setting:
‘Umm, not really I’ve been to occasional courses that I have chosen to go to, but nothing specific and certainly nothing before I started as a GP.’
A p1
‘I’ve probably got a bit of an interest in palliative care and have done more than the average number of courses. But in terms of specific, specialised training, no.’
D p1
‘I had no training at all as an undergraduate or as a GP trainee in pain management.’
F p1
Emergent themes
Chronic non-cancer pain is seen as different from cancer pain
All participants had prescribed opioids for CNCP, although one had stopped doing this. All GPs described the use of a stepwise or ladder method for prescribing opioid medication24 for cancer pain, starting with low doses and gradually working through stronger medications with an aim of keeping the patient pain free:
‘I suppose the sort of pathway really is to start off with simple analgesia then you progress down through the stronger, what I would call simple analgesics, through, you know, like paracetamol, down through perhaps tramadol and I think probably then my next line if it’s more severe pain would be to drift into the morphine-based drugs.’
B p2
For CNCP, deciding to initiate opioid treatment was less straightforward, with many considerations.
GPs would often say that, in theory, prescribing for CNCP is the equivalent of prescribing for cancer pain, but this would then be qualified by reluctance to move onto stronger opioids for chronic pain. Other avenues, such as the pain clinic or antidepressants may be explored first and there was recognition that total pain relief may not be achieved for the CNCP patient:
‘I don’t regard them as the same, whereas with one of them your aim always in progressive malignant disease is to get complete relief of pain as best you can, umm, and for that you will need increasing amounts of morphine over a finite period of time. For chronic pain in someone with a non-terminal type of illness you’ve got to weigh up what you are giving them in the long term, what are the potential side effects, is there an issue with addiction and you’re not going to just be increasing … For chronic pain, non-malignant pain, I think there has to be an acceptance that you are not necessarily going to get them pain free because they’ve got the rest of their lives to live as well … so your two end points are different.’
D p2
‘If I know that someone is terminally ill I am probably less inhibited about the scale of opiate use ... but when you know that someone is going to go on and on suffering from the pain of whatever cause it is that they’ve got, that can make it very difficult.’
A p2
‘There is always a worry at the back of my mind that I may over prescribe the opiate but I’m having to be careful to titrate the dose of the opiate with the pain that the patient has got. If I’m not careful about that the patient may end up having too much opiate and you know I do feel that is probably a problem, something I wouldn’t want to have myself so I wouldn’t want to do for somebody under my care.’
A p3
One GP explained that, although in theory prescribing is reasonable, in practice he was a little reluctant to prescribe:
‘I think my brain tells me that there is no problem, although you know, life in general makes you think that you must be a bit careful but I don’t think there is a reason why we shouldn’t put somebody on long-term opiates if the need is there.’
B p3
Another commonly stated concern was the potential length of time patients could theoretically spend taking opioids if started at a younger age:
‘The aims are different, you can be dealing with these patients for 30, 40 years still … .’
D p4.
‘I mean when you’ve got somebody who has actually got some progressive cancer you’d probably go down the steps or up the steps quicker than you do with Mrs Bloggs who is going to have arthritic pain for 30 years, and you know she will so you do your best to try and muddle along with something of a lesser strength.’
B p2
Difficulties in assessing pain
GPs expressed having difficulty assessing the level of CNCP (and therefore titrating the dose correctly). They also expressed concern about the possible secondary gains of obtaining opioids or accessing financial benefits:
C p2:‘The concern would be is this pain real, or is it just put on to obtain opioid?’
Interviewer:‘How do you deal with that?’
C p2:‘On an individual basis, I mean, an assessment of the pain and whether I think it’s genuine or not. I think it’s very difficult; it’s something I’m currently dealing with at the moment, and not very successfully.’
‘The pain is what the patient says hurts, … But how do we judge that, and that’s when it gets very difficult so I think the hardest group that I have is drug addicts and malingerers, people who are faking pain … I can think of one very clear malingerer I’ve got at the moment with chronic back pain. His agenda is not about getting strong pain killers his agenda is about persuading the DLA to give him full disability living allowance … .’
G p4/5
Some felt that they should be exploring other ways of managing pain, including psychological treatments and alternative medication approaches and delivery pathways:
‘Well people without a specific diagnosis or younger people who hadn’t worked for a long time without any definite diagnosis so you feel there may be other things going on, I might be a bit concerned about putting them on a long-term opioid, because I wouldn’t necessarily know what I was treating, I might send them to pain clinic for psychological assessment.’
L p3
‘I suppose the concern is are you adequately addressing their pain needs, have you looked at alternatives to managing their pain with ever and ever increasing doses of opiate use.’
H p3
‘I still have this general rule that has increased over the years that I’ve been in general practice that I will only take the opioid route when I absolutely have to.’
D p5
Concerns around tolerance and addiction
The most common concern cited was the potential for addiction. This was sometimes combined with concern for tolerance (habituation), causing a worry that the dose might increase over time and the possibility that the patient may require that medication over many years:
‘There’s always the feeling that it’s going to be more difficult for somebody to stop taking opioids or needing to take more, but it would depend on the personality. Because chronic pain is related to having other problems, mainly psychological problems, one wouldn’t want to hand it out willy nilly to people who might have psychological problems as well and would be more likely to become dependent.’
L p3
‘Yes I do worry about addiction and if someone has a pain, umm, I understand that addiction is not supposed to happen if you use the opiate for pain and that if the opiate relieves the pain the patient is not supposed to get addicted to it. It’s very hard for me to believe that is true. I am probably more inhibited where the patient is not terminal because I have that sort of nebulous fear in the back of my mind that I am going to a) cause opiate habituation and b) cause addiction.’
A p3
Where there was a strong interest in palliative care or pain management this appeared to facilitate prescribing in four participants, who reported less concern about prescribing strong opioid medication for CNCP:
‘I think there’s a lot of unreasonable fears, the biggest one being addiction and I think it’s a grossly, grossly overstated concern, addiction. In my practice I’ve yet to see the patient who was put on opiates for benign pain who is addicted.’
F p3
‘No I really don’t have a problem with that [addiction]. I think that one has to consider that you have got to put yourself in the patient’s position. Would you want to go through life being denied something because there was a theoretical risk of addiction, and the answer would be no, if it improves your quality of life, that’s what you want.’
M p2/3
GPs demonstrated awareness about prescribing to patients with a history of substance misuse or what was termed an addictive personality. However, this did not necessarily prevent the prescribing of opioids:
‘I’m always more concerned about people who have an abusive or abusing personality, or been abusive of other drugs in the past, particularly concurrent abuse of alcohol or other drugs.’
F p8
‘I think if someone’s history shows that they have an addictive personality, whether it be street drugs, alcohol, smoking pot, whatever that theoretical concern is, but the patients I’ve used opiates for in non-cancer are nearly always the elderly with joint pain and I don’t have any concerns about them, no.’
N p3
Effect of experience and events
For many, experience facilitated prescribing, giving confidence over time:
‘I suppose, the way I behave now prescribing for everything is a sort of rather woolly, nebulous product of everything I’ve done, particular experiences of dealing with pain.’
A p7
‘You just pick it up over the years, so I’m sure I’ve been moulded by the successes and the failures which have come my way in 27 years of general practice, yeah sure we all learn on the hoof, don’t we?’
B p7
‘I’m not as slow to treat with opiates now as I was 30 years ago, and I’m sufficiently big-headed that even if another doctor with the title consultant thought it was inappropriate I’d still go ahead and do it. If there was no other way of controlling someone’s pain, and having discussed it with the patient, I’m prepared to do it.’
N p4
However, not all events were positive, and these could have a negative effect on prescribing:
‘Well, I guess that the previous experience of it being quite a taboo thing.’
I p3
‘I think everybody’s fingers get burnt with people who you give the opioids to with a more trusting attitude than maybe you should have and the problem has quickly come back to you with needing more and more opioids.’
R p6
For one GP in particular, a bad experience has resulted in his never prescribing opioids for chronic pain:
‘One of the doctors used to use quite a lot of low dose MST in older people with arthritis, umm, and I certainly hadn’t considered doing this and I thought well it might be worth a try and there’s one lady in particular that I tried it on in whom it was a complete disaster and it just made her so ill and from reasons that I couldn’t, we just couldn’t get her off it and she was ill on it and was worse when we tried to get her off it and you don’t need many of those.’
D p8
Participants were asked whether the Shipman case had had any effect on their prescribing of strong opioids. All the participants indicated that Shipman had not affected their prescribing:
‘No, because from my point of view Shipman was a very clear aberration of care and it doesn’t really influence.’
H p6
Cost
There were mixed responses to the issue of cost. Some participants did not consider it at all, simply prescribing what was needed, regardless of how much it cost. Others felt it was important to bear in mind how much some of the preparations cost, particularly patches, which can be expensive:
‘Well I have to say I’m hopeless on cost because I never know, patches are more expensive than anything else. It personally wouldn’t make a hap’oth of difference to me, if somebody needed something then I would use it and I don’t think I’m really aware of the relative costs, so no, I don’t think actually cost is very high on my priority.’
B p8
‘These are not cheap treatments at all, and you could potentially be doing it for 10, 20 years and you know, there may be a rise in patient numbers doing this type of treatment in a few years’ time, I think it’s really important.’
C p4
