Opioids – rational approaches to their use in acute and chronic pain

Articles in medical and pharmacy journals this month are asking us to adopt safer and more rational approaches to prescribing opioids. One comes from experts in chronic pain, notably Cathy Stannard, consultant in complex pain and Clinical Lead for the Pain Transformation Programme at NHS Gloucestershire CCG (1), and her colleague Professor Roger Knaggs, Associate Professor of Pharmacy at the University of Nottingham. Whilst they acknowledge the rates of opioid misuse and related deaths are lower in the UK than in the US, they stress the need to remain vigilant when caring for patients with chronic pain.

The good news is that opioid prescribing fell in England by around 2% between 2016 and 2018 (2). This suggests that caution and use of guidance such as ‘Opioids Aware’ – a resource for all prescribers (3) – and other local projects may be having an impact. It is not easy to estimate how many people are addicted to prescription opioids but there was a 30% increase in reported deaths to which prescription opioids contributed and in many, fentanyl and its analogues were identified post mortem. It’s impossible to know whether these were prescribed or acquired illegally and death rates in the UK are far from the scale seen in some other countries such as the US, but we should not be complacent.

Stannard clearly states that this class of drugs has a deserved and established place in the repertoire of cancer pain treatments towards the end of life and for severe short-term pain, such as post injury or surgery, but it has been estimated they are only effective for about one in ten people who have them prescribed for chronic pain. She goes on to say there is possibly no other class of drugs which is so widely prescribed and yet so ineffective and one of the biggest problems is the repeat prescribing and dose escalation when a patient is reviewed and describes continuing pain. Chronic pain is complex and so many other conditions go alongside it, such as depression, anxiety, poor sleep and mobility (4). We are increasingly looking at other, non-drug strategies to help people to live with their pain when it becomes chronic, but these options take time and require medical prescribers to have confidence and a willingness to think outside the box.

We need to ensure that communication between primary and secondary care is improved so that short-term, appropriate opioids supplied on discharge from hospital are given with explanations of the expected duration of pain and need for strong analgesia. ‘Opioids Aware’ gives helpful guidance on how long to continue and how to taper opioids and there is a general view that doses should be kept below 100 to 120mg morphine (or equivalent) per day and reviewed regularly to monitor adverse effects and efficacy. Projects such as one in Brighton and Hove (5) have shown success with targeted reviews by GP Pharmacists carrying out a pain medication review and helping patients reduce their opioid dose.

In the same week a report appeared on the abuse of over-the-counter opioids and questioned whether it is time to stop codeine-containing medicines being available without a prescription (5). This is a radical move already taken in 25 countries, most recently Australia where they had seen codeine-related deaths almost treble in nine years. Admittedly the numbers are small – from 3.5 to 8.7 per million population but it is a steep rise. Pharmacists are divided on whether this stringent change is unfair to those who want to use codeine products appropriately.

One of the biggest problems (with opioids) is the repeat prescribing and dose escalation when a patient is reviewed and describes continuing pain

Codeine is the most common OTC medicine of dependence seen in specialist substance abuse services (6) but concrete evidence is lacking as usage is not recorded nationally and those using the drugs inappropriately may be unaware that they are addicted. The MHRA has ensured warnings about potential addiction and guidance on the importance of short-term use only are on every pack, but as the drugs can be purchased readily it is easy for excess users to purchase from different outlets and slip under the radar. In Australia, a system was introduced which required customers to show identification when purchasing codeine-based products and these purchases were monitored, but this is not currently being considered in the UK.

To further complicate the debate, there is some uncertainty on whether the lower levels of analgesia provided by low doses, such as 8mg codeine, are therapeutically effective but the products containing this dose are commonly available and well used. Pain experts feel a ban on the products is not the answer at present but we should encourage community pharmacists to take small steps to improve interactions with patients who repeatedly buy codeine, simply by acknowledging the patient has been taking the medicine for some time and asking how it is helping them. It would be a good opportunity to talk about long-term effects and educate those who may not appreciate the addiction potential.