We need a more rational approach to opioid prescribing

There has been no shortage of unflattering coverage of opioids in the written and broadcast media in recent years. Over the past two decades, opioid-related deaths have become a public health catastrophe in the United States and Canada. In the United States alone, 130 people die of an opioid overdose every day^[1]
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In the early 1990s and early 2000s, the liberal prescribing of medicines such as oxycodone, marketed as OxyContin by Purdue Pharma — which some media outlets have described as the ‘jet fuel’ of the United States’ opioid crisis — contributed to rising addiction to prescription opioids and have taken a ghastly toll on those who took them. The opioid crisis has since evolved into an epidemic of misuse of heroin and, more recently, of potent fentanyl-related compounds^[2]
. This crisis has thrown the appropriate use of opioids as pain relief into sharp focus.

We must stay alert in the UK

In the UK and elsewhere in Europe, opioid prescriptions have been on the rise since the mid-2000s but on a smaller scale. Opioid consumption per capita in the United States is around four times higher than in the UK, and within Europe the UK is ranked eighth in the table of opioid prescribing^[3]
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In fact, opioid prescribing in England fell by around 2% between 2016 and 2018, suggesting that initiatives focusing on cautious prescribing — including nationally agreed guidance such as ‘Opioids Aware’, a resource for all prescribers, and other similar projects led by clinical commissioning groups (CCGs) — may be having an impact^[4]
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Opioids are probably effective for only one in ten people for whom they’re prescribed for chronic pain

It is difficult to estimate the number of people who are addicted to prescription opioids in the UK — mainly because there is little agreement about how addiction is defined and coded — but as far as we know, addiction to prescription opioids is less prevalent in Europe than in the United States^[5]
. However, between 2012 and 2017 in England and Wales, there was a 30% rise in recorded deaths, to 824 deaths, to which prescription opioids contributed (including those in which fentanyl and its analogues were identified at post mortem). Whether these medicines were legitimately prescribed or acquired illicitly is unknown, but opioid-related death rates are far from the scale seen across the United States^[6]
. However, healthcare professionals must remain vigilant.

Opioids for chronic pain

What is undoubtedly a cause for concern is that opioid painkillers are being prescribed more liberally for some types of pain than can be justified by their known efficacy^[7]
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For example, while this class of drugs has a deserved and established place in the repertoire of cancer pain treatments at the end of life and severe short-term pain (such as after an operation or injury), opioids are probably effective for only one in ten people for whom they’re prescribed for chronic pain^[8]
,[9]
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There is possibly no other class of medicine so widely prescribed but so ineffective for such a prevalent condition. Prescribers are well aware of the short- and long-term adverse effects of opioids, as well as the risks of addiction and overdose. Yet still, when a patient returns for review and describes continuing pain, we often do not see that opioid treatment is not doing what it says on the tin. Instead, we escalate the dose in hope, but not really in expectation, that we will make a difference to the patient’s condition for the better.

As clinicians, we know that pain management is not always as easy in practice as it is in theory. Chronic pain is very complex and patients live with not only pain, but also its many consequences — poor sleep, poor mobility, inability to work and social isolation.

Importantly, there are often numerous existing conditions that can directly influence the pain experience, including depression and anxiety, concerns around previous experiences of pain and its treatment, worries about the causes of pain, and other emotional past or current burdens^[10]
. No medicine alone can make an impact in these very challenging situations — even for psychological and exercise-based therapies, success is not the norm and pain reduction is rare^[11]
. This can be frustrating for patients and so we tend to respond to this distress by sticking with opioids, even if the treatment does not seem to be working.

Opioids’ place in healthcare

This does not mean that opioids should never be prescribed. When opioids are prescribed for acute pain in hospital, prescribers must be meticulous in the information that they give patients about tapering in the days after discharge from hospital. Communication between secondary care and prescribers in primary care must improve, and this needs to be resourced properly. They should share information about the expected pain trajectory for the patient, the likely duration of opioid treatment, followed by the scheme for tapering within the early post-discharge days.

Opioid treatment should be reviewed regularly to monitor adverse effects and efficacy

For longer-term pain, it would be irrational to avoid prescribing altogether; a small proportion of people do well with opioid treatment, and pain reduction is accompanied by other improvements in quality of life. However, it is important that prescribed opioid treatment does not continue if it is ineffective.

What pharmacists can do

‘Opioids Aware’, launched by the Faculty of Pain Medicine in December 2015, is a useful resource for all prescribers managing patients who take opioids. Pharmacists and GPs must work together to ensure that trials of opioid therapy are short (no more than two weeks) and involve immediate-release preparations so that patients can use them for episodes of worse pain; prescribers should recommend prompt tapering if the treatment does not work^{[12]
,[13]
,[14]}
. If opioids seem effective in the short term, they may be trialled for a longer period but doses should be kept low (below the morphine equivalent daily 100–120mg) and treatment should be reviewed regularly to monitor adverse effects and efficacy^[13]
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Perhaps a greater challenge is providing care for patients who have been taking high-dose opioids for a long time. There are resources available — from the Faculty of Pain Medicine, for example — for tapering schemes that aim to support prescribers to reduce a patient’s opioid doses to a safe level with few withdrawal symptoms^[13]
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In Gloucestershire CCG, clinical pharmacists and prescribing support pharmacists have been reviewing the prescriptions of all users of high-dose opioids within their practices. Although there have been many success stories of lowering doses, there are many barriers to dose reduction, including lack of time and resources, little available help from hard-pressed and cash-starved addiction services, and poor provision of mental health support.

First do no harm

The central role of primary care in prescribing, the excellence of our GPs and the enthusiasm of pharmacists in engaging with the opioid debate mean that we are unlikely to end up in an opioid epidemic of US proportions, but we must not take our eyes off the ball in the UK^[15]
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We should prescribe with full knowledge of the efficacy and harms of the medicines we use, and with an insight into the many influences on the experience of chronic pain. Most of all, we must be empathic with our patients and reach a shared understanding of chronic pain and its treatments to avoid the damaging cycle of patients’ raised expectations and dashed hopes. Living with chronic pain is tough enough without healthcare professionals adding to the burden by prescribing medicines that impair quality of life even further and offer little in the way of symptomatic relief.