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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”.
- Related: MJA InSight — GPs prescribing opioids “in the dark”
- Related: MJA InSight — Opioid problem “displaced”
- Related: MJA — Five reasons to not prescribe opioids
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”.
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There is a moralistic undercurrent pervading this topic that angers me. While it’s true that opiates have side effects (as all medications do, including paracetamol) chronic pain is a serious and debilitating condition that inflicts great suffering. Are we seriously expecting that treating it should have zero negative consequences? Would we say that of chemotherapy for a malignancy? Mortality and morbidity in chronic pain are also highly elevated. There is no doubt that education, close monitoring, rotation and alternatives all play a part however, unless you have, (or live with someone who has) severe chronic pain you probably need to ask yourself, ‘do I have a right to restrict an individuals access to something that relieves their suffering, even if there are some consequences they are willing to bear responsibility for’?
Enthusiasts for newer ‘neuroplasticity’ approaches are premature in claiming they are superior to more conventional treatments. Certainly anything like an NNT of 3 is fanciful. I refer interested commenters to this link http://search.pedro.org.au/search-results/record-detail/44043 which is hardly cause for celebration.
I think rational use of opioids means they should be restricted to cases with clear evidence of opioid responsiveness over time, in patients who do not dose escalate and are attempting to self-manage as best they can given their circumstances. This needs to be an interim strategy until better evidenced, more comprehensive pain services are more widely available. This will be expensive and take time, not to mention political will.
There is a very strong cross current of thinking in the above posts.
To say that opioids are rarely indicated for persistent non-cancer related pain IS in fact to say that rarely, opioids ARE indicated for this situation, as evidenced by the sufferers who have commented.
To say that the NNT for neuro-plasticity treatments is 3, means that it appears to work better than opioids. If this were born out in practice, the word-of-mouth effect would be wild-fire, and we would not need to talk it up! However, I must agree that pain IS only present in the brain, and MAY be amenable to these treatments. However, for the OTHER 2/3 for whom brain-training is ineffective …… and those who have NO access to this form of management …. Scott, what would you recommend???
see bodyinmind.org for many links and other information on overcoming pain through brain training.
What needs saying in all of these matters is that we must recognise where the information at hand is limited by various vested interests – as pointed out re drug companies being the primary source of investigation funding. There is often LACK OF EVIDENCE which is different to EVIDENCE OF LACK – opioids do appear to be effective and safe for many patients for long treatment times. This was well attested by the references from strayan, above.
Most studies get extrapolated beyond their findings – eminence based medicine. We see lots of “experts” making wide-ranging pronunciations which are NOT evidence based at all. I do it. Others do it. The evidence is absent for most social/age/gender/genetic groups, excluded by studies (eg, reproductive aged women, children, aged, 2/3 world nations).
The use of multi-modal therapy for chronic pain is a bit like multi-modal therapy for depression – talking therapy is effective but is long, slow and expensive. The over-use of narcotics is the flip side of the under-treatment of pain. We now know that a significant proportion of people are non-metabolisers of codeine, so panadeine forte – a great medication for many – doesn;t work for these people. And the active metabolite of codeine is morphine anyway – so the beneficial effect of panadeine forte – for those who can metabolise codeine – occurs via conversion to morphine. We now have oral preparations of morphine that do not rely on metabolism for effect.
So, in acute care, we have addressed the previous under-treatment of pain by better awareness, assessment and treatment. How this translates to chronic care in the community is more difficult. The majority of people with an acute issue will receive relief from acute pain with morphine, which will enable them to get more mobile until the episode resolves.
We do need to accept, as a community, that some pain in life is inevitable. We should not expect to keep people in ED, or in hospital, until they are fully pain-free. But nor should we abandon people with chronic disabling pain. There is no perfect solution, and every decision will be a compromise. All effective therapies have side-effects. We should not have a drug/non-drug dichotomy, though, but multi-modal approaches with analgesia, physical therapy, exercise and social/psychological support – where it can be accessed.
The cold hard facts, as clearly stated in the most recent Cochrane review Long-term opioid management for chronic noncancer pain is that: “serious adverse events, including iatrogenic opioid addiction, were rare.”
Another systematic review published in 2012 concluded that: “The available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence.”
The NSW Department of Forensic Medicine reviewed all cases of fatal oxycodone toxicity from 1999-2008 and concluded that “In all cases, psychoactive substances other than oxycodone were also detected, most frequently hypnosedatives (68.6%), other opioids (54.3%), antidepressants (41.4%), and alcohol (32.9%).”
A study of 9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005 identified only 6 fatal overdoses
How long are we going to ignore the actual facts?
The amount of opiophobia here is staggering. The natural endpoint of this are cases like these: http://www.smh.com.au/nsw/doctor-rejected-dying-man-as-an-addict-2011071…
Thank you Scott. Your suggestion is welcome – in fact, I saw a new physio yesterday who recommended the Explain Pain book and uses the techniques in her practice, so I am looking forward to learning new skills in managing my pain. All the best.
There are various people trained in neuroplasticity- the Explain Pain group ( NOI ) run regular courses largely attended by allied health such as physios and psychologists. If you have any pain rehab or musculoakeletal physicians in your area, they should be able to direct you or contact your local physio or psycholog rep. Or even better, do an explain pain or such course, if you are interested in learning more.
The missing link is the problem when pain is only viewed through ‘structural’ causes eg: “degenerative disks”.
This indicates suboptimal pain literacy and sets up the whole ensuing pathway via adverses neuroplasticity processes ie: a large component of chronic, resistant pain is iatrogenic (the elephant in the room).
The science of placebo and nocebo responses is crucial to understanding what this is all about.
Has anyone stopped to ask how come such massive doses of opiates are perceived to be required by anyone?
Paradoxically these are far in excess of what is prescribed usually in post-operative or post acute injury phases ie: the high nociceptive input phase of pain experiences.
Most times when I ask patients who are stuck in pain about their pain response to such absurd doses they say it takes the pain from approx 8/10 to 4/10. Is that a concordant analgesic response? Or just setting someone up for side effects and dependency issues.
High time to reconceptualise things completely right from the first time the injured patient walks in to the room and a scan is ordered. The science is there to do it; just not the financial incentives …
Thank you everyone for your comments. I would love to try ‘neuroplasticity’ for my chronic pain, and reading about it is fascinating, but I don’t know who to see about it, and neither do my GP and rheumatologist. Can anyone (Scott perhaps) tell me where to obtain any advice/treatment along these lines?
The comments above are well expressed and echo very common sentiments. If I can try and clarify. Persistent pain has been successfully fully treated with neuroplasticity techniques i.e. cured. Thats why “brain training” to eliminate or at least minimise pain should always be considered in management. For neuropathic pain it has a NNT of three – the only side-effects are time and money. It is by no means implying that the pain is in some way not real – its just a fact of neuroscience. Pain is an output of the brain that has multiple complex inputs of which nociception is only one. And pain is possible without nociception.
Counselling on the other hand is for the common co-morbidities of persistent pain which are depression, anxiety and insomnia. Again, counselling is by no means denying the reality of the suffering of pain or saying people are imagining pain – it is used to decarese the suffering associated with pain.
Opioids have a role in pain management – no doubt about it. But in persistent pain they have poor outcomes for many with the very real possibility of harms. Health practitoners need to continue to be vigilant in minimising harms – the US experience should serve as a warning and make us all pay attention to this.
I absolutely agree with Dean and Ruth. I have been sparingly using panadeine forte most nights to sleep due to chronic pain and have not escalated this use in ten years. I am now taking lyrica in addition to p. forte for sciatic nerve damage. There is absolutely no way counselling, paracetamol and physio can fix my problem and I am not a surgical candidate. I have a gp to prescribe for me.
It is insulting and ignorant to say that individuals with documented causes of chronic pain should have counselling instead of pain relief. The approach of my colleagues has made me feel embarrassed to be honest with anyone and has affected the potential for trust. I have had little sympathy for my condition, I don’t usie sedating pain relief at work and despite obvious limping and varying incapacity. I do not take time off work because of pain, I keep going despite it full time. I do not drink alcohol and I do not need antidepressants. It has been a horrifying experience to observe the opinions of many “experts” who assume that all pain patients are addicts, that we are all incapable of understanding our problem with pain and that we should suffer rather than ask for help. Some of the opinions here reflect this clearly.
I believe that chronic pain has to be put up with to a certain extent otherwise opioid tolerance occurs. I disagree that short-acting opioids leads to addiction and is inappropriate in all cases, but rather, if used once daily to sleep, my experience is tolerance does not occur with very short-acting or immediate release substances. Long-acting and increased amounts should be reserved for exacerbations.
Surely post-operative opiate prescription is for short term use, and entirely necessary if we expect patients to go home earlier, mobilise to prevent DVTs, look after their babies immediately following C-section, then return to work early. Inpatient stays were much longer in hte days quoted when people only required panadol.
I will continue to prescribe opiates for a few days, with tapering doses to my post operative patients
Having worked many years in the WorkCover “Network Pain Management Program” at La Trobe Uni and St Albans, I have found the most common “INTRODUCTION” to opiates are the Surgeons, in particular with spinal surgery, where I note spinal surgeons call it “Failed Spinal Surgery SYNDROME!!!.
The other maor contributr are what I term the “Pain Proceedurlists”, where failure of their “Diagnostic Algorythm or Spinal Cord/ nerve trials or in perimnt Stimulatrs, they resort to opiates.
In my opinion THERE begins the problem.
Thank you Dean for sharing your experience. I agree with you and find myself in a similar situation, having been suicidal due to pain. I find that I manage better when the pain is helped somwhat with pain medication and antidepressants, though of course I would rather not need to use them. I have tried and learnt to use physical and psychological strategies from many therapists of various disciplines, and tried other modalities that were not helpful, spending lots of time and money in the process.
Those without chronic pain cannot understand the issues we face, though a GP, specialist or therapist who tries to do so without judgment is a real blessing. To say that Panadol is effective for most aches and pains suggests a lack of experience in talking with real people about the effect pain can have on their lives and those of their families.
As a crhonic pain sufferer for the last 20 years with degenerative disk disease at three levels of spine following injury I can say with great conviction that opioids have a place as a becon of light for unresolvable severe pain. To simply say people in pain must take less and use panadol is OUTRAGEOUSLY insulting and belittleing our conditions. Ongoing permanant use is not a good idea given the physcological depression it can cause long term bit often there is no other option. With the disolution of unions and many unsafe workplaces we can expect to see demand and use of opiates increase accordingly as funding cuts remove alternate therapies the only option left is suicide or opiate use to dull the continual severe pain. PLEASE do not think for a second removing access to opiates will solve the problem it will simply result in the needless suicide of those of us in chronic severe pain as no option to escape the daily oppresive and severe pain. Controlled use and supervised use YES totally agree but removal and reduction and stigmatising chronic severe pain sufferers can only be the result of a bean counter sighting a “saving”. Lets fund more research into promising alternatives like the coming generation of conotoxin based pain relief. WE LIVE WITH OUR CONDITIONS others need to learn to live with us whilst we live with pain irrespective if that results in a cost. Denying pain relief is not only illegal but morally and socially irisponsible.
A recent article in medscape described how the opioid epidemic in the US had been driven by a few “Experts” that out in the late 1990’s in favor of opioids for chronic pain. These statements saw the sales of oxycontin go up from a few tens of millions every year to approximately 2 billion per year in the US alone. After more than ten years and tens of billions in sales, the manufacturers were taken to court and fined 600 million dollars for misleading practitioners and the public. Very small penalty for what has become one of the biggest killers in that country (drug overdoses with prescription medications both intentional and unintentional). Reminds me of the big push, not so long ago, by pharmaceuticals in Australia promoting medications like oxycontin and norspan and more recently for Targin….
The issue of managing chronic pain in general practice is very complex. Putting the onus for reducing opioid prescribing for non-cancer pain on GPs denies the dearth of access to the allied health services needed to deal with associated psychological and social issues complicating the patient experience of chronic pain. I suggest more sociological research of the determinants of chronic pain in the primary care setting may help determine what extra resources are necessary to support more regional prescribing.
One factor not mentioned has been the relentless promotion of opiods by the pharmaceutical companies for non-cancer pain; in what they see as an extremely profitable market.
They are funders of most of the studies of opoid treatment for non-cancer pain, and have exponentially increased their sales for this indication as they promote it a long term treatment. Their market was previous limited to short-term and cancer pain.
Reducing inappropriate use of opioids AND broadening our practice to include a spectrum of non-drug pain management strategies – physio, psychology, group therapy and so on. How many multi-disciplinary pain services do we have in Australia? Answer – Not many and certainly none in rural and remote areas.
I have been doing medicolegal work for 40 years.
I have seen the trend of panedine forte been sparingly prescribed to narcotics now being the drug of choice first up. Panadol was effective in the past for most aches and pains and still is if doctors took the time to talk with their patients.