THE inappropriate use of opioids for chronic pain is a system-wide problem which can only be addressed by providing guidance to all health professionals across each stage of care, say experts.
Dr Evan Ackermann, GP and chair of the Royal Australian College of General Practitioners Expert Committee — Quality Care, said that while opioid prescribing was a key issue for general practice, “we need to reappraise prescribing in the acute setting, because opioids are being prescribed here when there are alternatives”.
“Patients are also given a box instead of two to three pills. In hospitals, Endone has become the new Panadol so there is a cultural shift that we need to address. There has to be better discipline”, he told MJA InSight.
Dr Ackermann was commenting on an MJA article published today which summarised the evidence on opioid prescriptions in general practice for chronic non-cancer pain.
The authors wrote that Australia continues to experience rising rates of opioid prescription and an increase in the number of opioid preparations available.
They said that part of the treatment for acute non-cancer pain would inevitably include opioid analgesics for days to weeks.
However, as a patient’s pain becomes chronic, there is no evidence to support the ongoing prescription of opioids.
The authors said there had also been documented clinical consequences of using opioids to treat chronic pain, including acceleration of bone density loss, hypogonadism and increased risk of acute myocardial infarction.
In Australia, the National Prescribing Service recently released a series of documents providing clinical advice for health professionals caring for people with chronic pain, including recommendations for the prescription of analgesic opioids.
The authors wrote that “only carefully selected patients should be considered for long term opioids for chronic non-cancer pain that is moderate to severe, has led to substantial negative impacts on daily living and has failed all other analgesic modalities and adequate allied health assessments”.
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Dr Scott Masters, chair of the RACGP Musculoskeletal Medicine Special Interest Group and senior lecturer at the University of Queensland, said that “there is a worry that we’re heading in the same direction as the US and that our rates are going up”.
He told MJA InSight that for chronic pain, opioids were seen as a quick solution and “for whatever reason, once people are prescribed opioids they tend to stay on them”.
Dr Masters said that while there was nothing wrong with current guidelines on opioid prescription, “it is not easy to put guidelines into practice”.
“People can move to different GPs and shop around. It’s easier to keep track of pseudoephedrine than opioids.”
Melbourne GP Dr Karyn Alexander told MJA InSight that the main driver of the rise in prescriptions was the tension between the need to effectively alleviate pain, and managing the hopes of the patient.
“When a patient has gone up that pain ladder, and other medications are not working for them, it is a problem.”
She said it was important for GPs to follow up with patients using opioids every month; however, there could be potential financial barriers in some practices that would discourage patients from regular reviews.
“We have to get the patients to buy into this and encourage them to keep coming in so we can look at all aspects of their care,” Dr Alexander said.
Despite their efforts, GPs were bearing the brunt of a growing health burden in Australia, she said.
“We offer a listening ear [for our patients], but our lists are full of patients with multiple morbidities who have chronic pain.”
Dr Masters added that there were simple measures that could support GPs in following up with patients using opioids.
“There could be more prompts put into clinical programs — prompts to regularly review and ask does the patient still need to take opioids”
Dr Ackermann said that the RACGP is developing opioid prescription guidelines for GPs; however, there are many areas within pain management and prescriptions that are inconsistent.
“Even when it comes to pain trials, almost all of them are flawed. We’re not getting good evidence about chronic pain.”
Dr Masters said the evidence base supporting the limited use of opioids for non-cancer pain was clear.
Opioid prescriptions should be given to a small selection of patients “only when it is just to get them over a flare of not responding to other measures”.
Dr Masters highlighted the role of multidisciplinary approaches to managing non-cancer pain, which would “generally involve GPs, physiotherapists, and psychological interventions to control mood and sort sleeping patterns out”.
“Training the brain to optimally manage pain is vital.”
However, Dr Masters said “this approach does require more effort than taking a pill. For this reason, it is essential that all health professionals across the spectrum give the same, consistent message to patients around chronic pain and the need for multidisciplinary management”.