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PRESCRIPTION opioid analgesics are an essential part of the management of acute and terminal pain.
However, with the growing use of opioids for chronic non-cancer pain such as acute low back pain — usually recurrent and often prolonged — we are seeing increasing rates of harmful use or diversion.
GPs often have to deal with the maintenance of an opioid regimen for acute cancer pain with little training, so may uncomfortably walk the tightrope of neither wishing to under-treat pain nor wishing to foster harms such as addiction. Now, with 20% of GP consultations involving chronic pain but few GPs receiving specific training, it becomes a frequent dilemma.
Several promising alternatives for chronic non-cancer pain such as fish oils, pregabalin and duloxetine currently lack Pharmaceutical Benefits Scheme subsidies, so the natural response to chronic pain is to re-prescribe subsidised opioids.
Opioids do reduce pain levels in the immediate post-dose period but significant improvement in levels of pain and function occur in less than 26% of long-term users.
In population epidemiological studies, opioids do not improve any of the key outcome treatment goals — pain relief, improved quality of life or improved functional capacity.
Almost half the patients who start opioids for chronic non-cancer pain stop them due to the classical side effects but many doctors and patients are unaware of the minefield of newly described toxicities. These include an exaggerated response to both physical and emotional pain, which seems to particularly be found in patients with past or present psychiatric or substance use problems.
Opioid-induced changes in “affective tone” leave patients without the usual emotional resources to cope with the pain and opioid toxicities. Opioids have been associated with endocrinopathies, suicides, inadvertent overdoses and sleep apnoea.
A major problem is the issue of hoarding or diversion, with 60% of those on opioids hoarding them. Among university students given opioids for acute pain, 27% reported diverting them. Some (18%) of those abusing opioids obtained them from just one doctor.
However, the majority of opioid abusers obtain their stock not from dealers but from family or friends. These are given freely (56%), purchased (9%) or stolen (5%). The person providing the opioids usually (82%) obtained them from just one doctor.
The widespread adoption of opioids in chronic non-cancer pain has been underpinned by pharmaceutical company research, marketing, funding of professional and consumer organisations and of professional education. From a low base rate, by 1999 86% of the opioid market was for chronic non-cancer pain treatment. The author more recently observed frequent prompting for opioids from nurse practitioners and from pharmacists conducting medication reviews, with both groups looking for a simple solution to an identified problem.
We are recruiting a population very different to that used in the trials of these drugs. In a prospective US study from 2001-2005, half of all past opioid abusers became long-term prescription opioid users.
The consequence of the experiment of extending prescription opioids to those with non-cancer pain is that now 29% of entrants to opioid substitution therapy units report their primary opioids are those introduced to them by doctors for pain management.
Most GPs have very strong aversions to opioid addicts or being associated with them professionally. This binary approach obscures the non-judgemental systematic approach of universal precautions.
GPs need proper support and resources so that initial screening, preventive monitoring, minimisation of hoarding and diversion, and advice about the safe disposal of unused opioids becomes a universal feature of the treatment of chronic non-cancer pain.
Dr Simon Holliday is a GP in Taree, NSW, specialising in addiction medicine.
Detailed references available on request to editor@mjainsight.com.au
Posted 31 October 2011
To Dr Hester Wilson
Dr Simon Holliday
Professor Richard Stark
Dear doctors
I am writing to you after your comments reported in the Adelaide Advertiser on 11/11/16, which were very hard to believe.
Dr Wilson is quoted as saying “codeine is a lousy painkiller”. “When combined with say paracetamol or ibuprofen in over the counter products, it offers little, if any, additional pain relief”. My husband and I were simply amazed at the comments.
Have you ever had much pain? Do you think morphine is a lousy painkiller? Do you know the similarities between morphine and codeine? Have you used either morphine or codeine yourself? Have you tried using paracetamol or ibuprofen for serious pain? Why do hospitals use morphine, if opioids are ‘a lousy painkiller?
My husband has had chronic migraine for forty years. His neurologist first prescribed 30mg codeine plus aspirin per day. Our GP says that he is coping well with a very difficult problem. Tony has tried every other migraine option, and has come off codeine several times for a month or two at a time, just in case codeine was part of the problem. Tony says he probably is addicted to codeine, but that is a lesser problem than one headache all day every two days, which makes life not worth living. As he says, he is a self supporting hard worker who doesn’t rob banks, addiction or no addiction. He varies his daily codeine intake according to how his head feels and his intake has not increased at all in the last 15 years. His kidney function is monitored because of the aspirin. Paracetamol doesn’t help. The doctor said that providing regular scripts would be a waste of time for himself, be more expensive for Tony than OTC, and that Tony is quite capable of monitoring levels himself.
I have had a 52 degree scoliosis thoracic curve, with a compensating lumbar curve, for fifty years. I now have recurrent bouts of pain, both nerve pain from the concave side and muscular pain from the convex side. When I have bad pain I manage it with panadeine forte, but when the pain is less I use OTC codeine / paracetamol tablets to stop it progressing. My digestion is not as ostrich-like as Tony’s, and I can’t take aspirin or ibuprofen. Paracetamol doesn’t help – in fact I read recently that research indicates that paracetamol is not a universal panacea and is particularly ineffective for back pain. I am now on a senior’s health care card, and my doctor will prescribe as much 30/500 codeine/paracetamol as I want, but I still minimise my intake. The risk level from codeine overdose is minimal compared with the risk level from the paracetamol overdose involved.
I was a welfare management consultant, and conducted a review of Supported Residential Facilities. I am well aware of how many SRF residents doctor-shop for prescription drugs as well as using any OTC and illicit drugs they can get hold of. Killing themselves is not a big disincentive. I understand that most of the emergency admissions to hospitals are from overdoses of paracetamol or ibuprofen, not in fact from the codeine component. I can’t quite see how you die from codeine overdose, without being already dead from paracetamol.
My experience is certainly not in line with Dr Hollidays’ statement that pharmacists are motivated by ‘a conflict of interest selling opioids’, Professor Stark’s support for ‘making codeine containing medicines prescription only’, or Dr Wilson’s statement that ‘pain medication is dangerous and offers little pain relief’. Pharmacists make more money from dispensing prescriptions than they do from generic OTC drugs. Our own town’s pharmacist checks high users, and says that his customers are overwhelmingly sensible people managing their own ailments. Our doctor also checks his patients and recognises people with sense and self control.
My belief is that the addiction ‘experts’ who want prescription-only low dose codeine medication are seeing mostly the small number of people who abuse it, not the much larger numbers of people who use it sensibly. Abusers will find some way to abuse some drug, and the rest of us should not be penalised because of their problems.
Yours sincerely, Margaret McKenzie LLB FCCA
I want to thank you for your very informative theses. I am currently on targin, but originally started on 20 mg night and 20 mg day about 18 months ago. I have cut it back to 1 x 5mg night dosage. It doesnt really seem to be doing much as my pain is still rather moderate once I am in bed. But I love the fact I have all my faculties back during the day and look forward to driving once again. I have osteoarthritis and bulging discs with a past injury to lower back. I am also on Lyrica 20mg which slows the sciatica pain and works quite well. I was booked into the Hunter Hospital for Pain Management late Jan 2015 but now find we are moving to your area. Is there a public Pain Management Clinic in your area? I am also on Oesteopanadol and find it works reasonably well during the day. I keep moving and balance sitting and standing during the day. I meditate, use hot packs and heat rubs. There are days when I suffer more at nights, especially after getting in and out of a car several times in one day…long walks, sits, shopping etc…. A major weight gain has done me no favours and increased my pain. I try to avoid inflamatory foods. Once again, as a patient originally prescribed oxycodin, I can honestly say, I am so glad to be weaning off it. Pearl.
Why use ineffective chemical analgesics when there are simple non-pharmaceutical processes which work consistantly and with no addictive issues?
Any acupuncturist who is worth half a sixpence will tell you that, acupuncture works. Empirical. Yes. But remember that lack of research is not lack of effectiveness.
I use an acupuncture analgesic method that is used by the USA military in the field to give reliable and effective analgesia to even the most damaged and injured soldiers. Why can’t we use methods that are shown to be effective, even though this be anectodoral, and then prove that it works afterwards.
It would be better than causing addiction.
Another factor to consider is the trend away from the use of NSAIDs in pain management, especially in the elderly.
Non-drug alternatives also need to be considered more often. Writing a prescription is an easy option for a medical practitioner under pressure. Involving physiotherapists, occupational therapists and other allied health professionals is time consuming and may incur increased expense for the patient.
Real time electronic monitoring at the pharmacy level would assist greatly in identifying inapporproate prescribing and detecting misuse. Pharmacists have a responsibility to contact prescribers if they are aware that a patient is having opioids prescribed by multiple doctors (Doctor shopping). However “pharmacy shopping” prevents this from being detected at present. Systems to link pharmacies need to be implemented.