Opioid safety in the news again

The MHRA has repeated its concerns about overuse of opioids based on a set of recommendations from its Opioid Expert Working Group of the Commission on Human Medicines. The first step taken was to put safety warnings on packs of medicines containing opioids. They now want to ensure people are supplied with consistent information on how to manage the risk of addiction. Patient information leaflets will ‘spell out’ the serious risk of addiction from opioid-containing medicines, particularly with long-term use. They will advise patients to seek advice from a doctor or pharmacist if pain becomes difficult to manage, as opioid tolerance could be an early warning sign of addiction.

Dr Farah Jameel is the GP committee policy lead for prescribing at the BMA and he feels that doctors are aware of the risks associated with opioids and says they will already be discussing the risks with patients and devising a treatment plan as part of safe clinical practice. He bemoans the lack of alternatives to medication that can help alleviate the suffering of patients living with painful conditions.(1)

A study at Nottingham University in conjunction with Boots UK(2) introduced an educational patient safety card to see if it ‘nudged’ customers into safe and appropriate use of over-the-counter (OTC) codeine products. They piloted it in twenty-four pharmacies and reported on 3993 interactions finding that staff felt the majority of conversations to be easy and they found regular customers known to be frequent purchasers of OTC codeine were deterred to an extent from buying more codeine products (5.5%), although it had little impact on unknown or new customers (1.1%). They conclude the results support the visual educational intervention and the principles behind better self-care.

These initiatives are based on accepted evidence that long term opioid use has a negative outcome for people with chronic pain. Clinicians working with such patients can clearly demonstrate that many people may be taking a number of analgesics and yet still remain in pain.

These initiatives are based on accepted evidence that long term opioid use has a negative outcome for people with chronic pain. Clinicians working with such patients can clearly demonstrate that many people may be taking a number of analgesics and yet still remain in pain. At present, other options for pain management are somewhat limited and require very specific, individualised tailoring to ensure people feel supported if they are to have some analgesics withdrawn but it is certainly valid that we encourage people not to start on opioids unless under expert advice. There is a NICE guideline for the assessment and management of chronic pain out for consultation at the moment. It says ‘do not offer opioids, non-steroidal anti-inflammatory drugs, benzodiazepines, gabapentinoids’…or other drugs including paracetamol. This is huge step change and one hopes that the other options such as physical therapy, exercise, psychological therapies and acupuncture will be available.

However, in all these recommendations, there seems to be no mention of the fact that there are situations where opioids ARE safe and effective. Although it is absolutely right that they should be limited and only used where the benefit outweighs the risk, it feels that these initiatives need to include some reference to the use of opioids in palliative care. It feels concerning that prescribers may feel overly reticent to prescribe and also that patients and families might see these warnings and feel less inclined to take the analgesia prescribed. We know that fear of addiction is a concern for people, but we also know that this is rarely a concern when pain is responsive to opioids. Another slightly controversial view may be whether we should take this as an opportunity to prompt a check on our own prescribing. We know that not all cancer pain is opioid responsive so should we be looking more often at adjunctive approaches too? It would be interesting to start a discussion.