Opioid prescribing still climbing

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