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LACK of treatment options has been cited as a major reason why a new analysis shows GPs are much more likely to prescribe opioids than they were a decade ago, mostly for patients with non-malignant conditions.
The analysis, based on Bettering the Evaluation and Care of Health (BEACH) program data and published in the latest MJA, suggested that opioid prescriptions rose from 3.83 million in 2000-01 to 6.65 million in 2010-11, and now accounted for 5.8% of all medications prescribed or supplied. (1)
The same analysis found that the rate of oxycodone prescribing had increased almost sevenfold over the same period.
A significant proportion of prescribed opioids were for conditions classed as non-chronic. Malignant neoplasms accounted for only 3.5% of opioids prescribed and chronic non-cancer conditions for 43.9%.
Almost 60% of prescriptions were for musculoskeletal problems, with “back problems” accounting for more than a quarter of all opioids prescribed.
However, the authors noted that the classification of a problem as non-chronic did not preclude it from being chronic for some patients, or preclude severe pain over an extended period.
The article adds weight to growing concerns about the high rates of opioid prescribing. Pain experts say part of the problem is the lack of treatment alternatives available to GPs to help patients manage chronic pain.
“We believe this issue is intrinsically linked to the deficiencies in providing optimal pain management at a primary care level and impaired access to specialist support services”, an editorial in the same issue of the MJA said. (2)
Australian Pain Society president, Dr Tim Semple, who coauthored the editorial, told MJA InSight that GPs had minimal access to training in pain management and the Medicare funding model discouraged longer consultations required to manage complex, chronic pain conditions.
Proven therapies like cognitive behaviour therapy-based pain management programs were very hard to access in primary care.
“The conundrum in primary care settings is that you’ve got a time-pressed GP with limited options available, and the one therapy that is readily available is strong opioid pain medication. In some situations this option is overutilised”, Dr Semple said.
“We need to increase capacity in the specialised pain management sector, but we also need to support good pain management in the primary care sector to by removing the obstacles that are preventing GPs from doing what they could do very well”, he said.
Sydney GP Dr Tim Shortus agreed. GPs were often portrayed as prescribing opioids too willingly, yet other good options for certain types of chronic non-malignant pain, such as pregabalin, were not listed on the Pharmaceutical Benefits Scheme for this purpose, and so become expensive for patients, he said.
“We are left with patients in genuine distress and few therapeutic options”, he said.
Dr Shortus said opioids were important and useful for acute pain, so their use in non-chronic pain as described in the MJA research seemed appropriate. He said the bigger problem was that it was not well understood why one patient with acute pain would go on to develop chronic pain and another wouldn’t.
“It can be very difficult to convince someone in chronic pain that ceasing their pain medication is a reasonable step”, he said.
That task often falls to specialist pain clinics, but another research article in the MJA found that patients were waiting on average 150 days for publicly funded adult outpatient pain management services. (3)
The authors of this study noted a consequence of these long waiting times was GP reluctance to refer patients to specialist services.
– Amanda Bryan
1. MJA 2012; 196: 380-381
2. MJA 2012; 196: 372-373
3. MJA 2012; 196: 386-390
Posted 2 April 2012
Perhaps the problem is as simple as the shortage of primary care and emergency department staff including doctors and security staff. Did the study quoted differentiate between opioid dependent and non-dependent patients, and drug dealers? It is quite quick to give a patient what they demand. If the patient is opioid dependent, or selling the medication, they may harass staff and or other patients to let them go ahead of their appointment. To take a full history and examination, make a diagnosis, investigate, refer, and refuse to prescribe takes much longer. To refuse an opiate dependent patient or a drug dealer places staff including the doctor at risk. Unless the study differentiated between the different types of patients demanding opioid medication, studied the patients for doctor-shopping, and asked whether the prescriber felt that they/staff were at risk, then I think it is of little value. While the PBS subsidises Oxycodone, (for non-malignant conditions,) while Oxycodone is known to be sold on the street, then surely the PBS is responsible. Have the authors of the BEACH analysis been confronted with criminals convicted of armed robbery, diagnosed in prison with paranoid schizophrenia, demanding Oxycodone? I doubt this. How hard would it be to restrict Oxycodone for acute pain, for short-term use, malignant pain patients, and pain specialists? Too hard? Then do not waste taxpayers’ money studying this cheap drug, nor blame overworked understaffed primary care doctors with no security for prescribing it.
The use of long term opiates for chronic non-malignant pain is not evidence based. If you look at the literature, the number of studies looking at opiates in chronic pain are low, and the bulk of these studies have time frames of 16 weeks or less.
As a profession, we should be concerned that there is this increasing use of a treatment option where the efficacy over the long term in unknown, and significant potential risks are known (eg dependence, hormonal imbalances, QT prolongation, narcotic bowel syndrome).
Panadeine Forte is used so extensively already that most pharmacies order it in multiples of a gross. Even the smallest pharmacies order large qty of it. Then there is Nurofen Plus & Mersyndol problems. These are significant issues that don’t seem to be addressed. The number of people who are in effect addicted to these meds is enourmous.
Proven therapies like pain management clinics? 50 % success rate is often quoted. And the definition of success is a pretty low bar.
Advice from some pain experts about the merits of long acting (slow release) opiates has clearly proven wrong; tachyphylaxis is real, addiction is very real, and “uncommon” SE such as osteoporosis are are being seen more often. The use of Endone seems to be increasing massively in our Vic hospitals too. And I agree with the post above it is often prescribed for trivia.
Could it be possible that we would be better off going back to prn panadeine forte?!
I think it is very easy to prescribe opiates but there are many barriers to GPs prescribing opiate replacement therapy. So we seem happy to generate the problem but not very organised to fix it. About 25% of people on ORT got there via poorly managed pain problems.
I have wondered for some time how much this has to do with hospital “standing orders” allowing nursing staff to initiate opiates.
In one hospital on the coast of NSW oxycodone was frequently handed to waiting room patients who were waiting to be seen with things like sprained ankle. The ED was certainly too small for the number of patients although had admissions been expeditiously accepted there would be no problem. But a lot of the “unrelieved pain” after paracetamol and ibuprofen seemed to be with young patients with no visible (and subsequently, no detectable) injury. Sprained ankles can hurt as much as some fractures – but no swelling or bruising after an hour? And once having received the oxycodone, they would demand a script from the doctor; if refused the nursing staff would come back and demand it on their behalf, and it was very difficult for some doctors to refuse, given that “we can’t do that” had been disproved by the nurses’s actions and a pretty strong suspicion that the hospital would be unsupportive of the doctor in the event of a complaint.
A smaller but real problem is ambulance initiated i/v morphine to chronic pain patients, particularly those who are already on authority prescriptions which are supposed to limit their use.