INTRODUCTION
There have been increasing concerns about the potential harms of prescribed opioid drugs, their ability to cause inadvertent dependence, and worries about their lack of effectiveness for managing chronic pain.1–5 Prescription opioid medication has been found to be a significant and increasing cause of death from accidental and intentional drug poisoning.6
This article discusses five important questions: the extent to which opioid analgesics are prescribed, their costs and consequences, what benefits they give for chronic pain, what treatment is effective in helping patients with dependent use, and whether this can be provided in a primary care setting.
THE EXTENT OF PRESCRIBED OPIOIDS
Bolton, a district in Greater Manchester with a population of 280 400, spent just under £2 million on 148 000 prescriptions of opioid drugs during the financial year 2016/2017 (Bhaiyat H, health information analyst, Bolton CCG PACT data 2018). On average this is a prescription for every two people per year. For many this was repeated prescribing. There is considerable variation in opioid prescribing.
A study of the duration and potency of opioid analgesic prescribing in general practices in Leeds and Bradford to patients without cancer found an association between higher potency of drugs and longer duration of prescribing, with greater number of medications prescribed, increasing number of practice appointments, and referrals to pain clinics.7 The authors describe marked variations in stepping up and stepping down prescribing of opioid drugs between different practices. They were not able to explain this variation in prescribing practice but it could relate to training, culture within the practice, and patient expectations.
In 2016 there were 3744 registered deaths in England from legal and illegal drug poisoning, a rate of 66.9 per million.6 This was an increase from previous years, containing a significant increase in deaths from prescribed opioid drugs, particularly fentanyl, oxycodone, and tramadol. Other countries, such as the US and New Zealand, report significant numbers of deaths from prescription drugs and illicit use.1,2
DOES LONG-TERM PRESCRIBING OF OPIOID DRUGS RELIEVE CHRONIC PAIN?
Clinical reviews have not found opioids to be effective for the management of chronic non-cancer pain, have significant side effects, and cause dependence.3,8
Why then do patients continue to take opioid analgesics for long periods when their benefits are at best marginal and they suffer side effects? The reasons are likely to be complex, with personal and contextual factors, but I believe there are two important ones: a fear of increasing pain or disability upon stopping or reducing the medication. Inadvertent long-term use of opioids at higher dose is associated with withdrawal and worsening of pain and disability symptoms reinforcing continued use; and habitual behaviour and drug dependence. This is driven by a complex interaction of personal, drug, situational, and social factors.9
Drug use is positively reinforced by its euphoric effects and negatively reinforced by unpleasant withdrawal symptoms.
IS TREATMENT EFFECTIVE IN HELPING PATIENTS REDUCE AND STOP THEIR PRESCRIBED OPIOID USE?
The Royal College of General Practitioners10 and Faculty of Pain Medicine11 advised that prescribed opioid addiction can be identified and treated. Certainly if illegal opioid use such as heroin can be successfully treated there is good reason to believe that prescribed opioids can be as well.
Effective treatment is based on a structured programme with medication management, psychological support, social and physical activities, and alternative non-medication approaches to managing chronic pain and mental health problems.2,10,11
IS PRIMARY CARE A GOOD PLACE FOR MANAGING PATIENT ADDICTION?
General practice with its wealth of information about the patient and their background, and frequent contact with patients, is potentially a good place for identifying prolonged, excessive, and dependent use of opioid analgesics, particularly among patients with associated mental disorders, distress, and chronic pain. Patients can be identified when they come in for medication reviews or by a drug search.
It is reasonable to assume a patient who has been on the maximum or exceeded the maximum recommended dose of an opioid analgesic continuously for 6 months or more should be assessed further. Opioid dependence is suggested by the following factors:
a long duration of uninterrupted use;
increasing dosing over time with no clear evidence of increasing disease severity;
the underlying condition has resolved or improved;
the symptoms are not consistent with clinical findings and what is known about the disease;
overt drug-seeking behaviour — lost or misplaced prescriptions, frequent requests for additional medication, use of additional over-the-counter medication, requests for medication for out-of-hours medical services, walk-in centres, or other surgeries; and
a previous history of drug or alcohol dependence.
A patient assessment can be carried out by any of the practice clinical staff: GPs, advanced nurse practitioners, mental health practitioners, clinical pharmacists, and practice nurses with relatively little additional training. The skills needed to treat opioid drug addiction are:
an understanding of the pharmacology of opioids;
a knowledge of the underlying conditions and their effect on health;
an understanding of dependence;
knowledge of alternative ways of relieving pain and distress; and
ability to help patients change their attitudes and behaviour.
Many GPs do not feel confident, trained, or experienced in managing drug dependence. Though GPs could be trained in these key skills, other health professionals may already have or could develop the necessary knowledge and skills, and work with GPs to manage these patients.
There is currently a national initiative to extend the number and range of health professionals working in primary care. As part of this initiative our practice recently appointed a part-time mental health practitioner with a background including mental health, counselling, and working in substance misuse services.
One of her key roles is to identify, assess, and treat patients addicted to prescribed opioid drugs, working with a practice GP. We seek to help and support patients to reduce and stop their use of opioid drugs, and find alternative ways to cope with chronic pain and distress. So far we have not found this as difficult as we expected, and those patients who have reduced their opioid drug use have not had a worsening of their pain and distress in the process.
- © British Journal of General Practice 2018