The opioid problem in primary care

RESPONSIBILITY, AND LEGALITY, OF PRESCRIBING

There are few areas within the profession of clinical practice that evoke more controversy, and at times anxiety and risk, than the prescribing and control of opioids. To cause harm or to be exposed to criticism by prescribing inappropriately has to be balanced against the unique responsibility to help the patient and relieve pain and distress. Many drugs prescribed in clinical practice are potentially toxic or dangerous, but the use of opioids assumes a position of heightened importance crossing into areas of dependency and misuse, legal complexity, and governance and control issues, bringing prescribers into the largely unfamiliar areas of contact with General Medical Council and Home Office regulations.

Prescribing for non-cancer pain has become an area of clinical practice under critical scrutiny.¹ Scott et al ² draw attention to the complexity of the caseload and the multimorbid pathology driving consultations, as well as the range of interventions, investigations, and advice experienced over prolonged periods by this group who, by all standards, are dependent on opioids and other drugs. The range of drugs available and the history of repeated misuse of drugs such as barbiturates, benzodiazepines, antidepressants, gabapentin, pregabalin, and many others draws attention to the patterns of prescribing driven by concerns about overprescribing opioids and, quite understandably, attempts to search for alternative, less toxic (and less controlled) analgesics. The parallel increase in non-prescription interventions reflects the better understanding of the risks and limitation of the benefits of opioid analgesics, and the logical benefits of psychological and educational interventions. However, to many primary care practitioners, the enduring problems are of deprivation, adverse early life experience, and inequalities, which drive self-harm and self-medication in a population already at risk of health problems caused by smoking and heavy alcohol use.

A REASONABLE DEMAND FOR, OR EXCESSIVE USE OF, ANALGESICS

Scott et al ² draw attention to the value and importance …