One cannot escape the media attention around concerns about painkillers and the comparisons being made with the USA. Deaths from prescription opioids have consistently risen but only tell part of the story.
Presenting at the British Pain Society Annual Scientific Meeting in Birmingham in May, Jane Balllantyne, a world leading authority on opioid use in persistent pain, gave some startling figures.
For every US death associated with a prescription opioid, it is estimated that nine people enter misuse treatment services, there are 30 A&E visits for overdose, 118 people develop abuse or dependence to prescription painkillers and there are 795 non-medical opioid users.
However, the UK is not America. The NHS, as it currently is, gives us a degree of protection, although that does not mean we should be complacent. It is also worth noting that currently, there is no evidence that addiction to prescribed opioids is greater than to illicit drugs in the UK.
The UK has tighter control on the behaviour of the pharmaceutical industry. It has instituted Accountable Officers within CCGs and Health Boards, who are responsible for monitoring controlled drugs and responding to anomalies in prescribing and other concerns over their use. The UK also has prescribing targets and increasing numbers of prescribing advisors whose role is to monitor prescriptions and compare practitioners to national averages and to each other.
So what is the problem? Why are we seeing articles in the national press about ‘deadly painkillers’ and ‘GPs handing them out like sweets’?
Headlines like that are not entirely helpful other than for getting people’s attention. We are risking chasing the wrong problem. Addiction is possible and it happens – let’s not pretend otherwise. But addiction is complex and it doesn’t happen just because someone has been given a strong opioid on prescription. For those people who develop genuine drug-seeking, harmful behaviours we must provide timely support and treatment.
If we have a population of ‘addicts’, then we also need to address the ‘dealer’ workforce.
What we have in the UK is almost certainly an overuse of analgesics. Not least as increasingly the literature suggests that drugs are of only limited benefit for managing persistent, non-cancer pain.
So, what to do? In simple terms, we need to reduce doses and come to terms with the fact that we might be doing it in less than ideal circumstances, without psychological input, without CBT, without group support and without having anything else to offer.
In this case, as pharmacy professionals, we can provide information on why reductions are needed; commonly, people are aware that despite taking quantities of opioids, their pain isn’t really any different. We can talk about the long-term health problems associated with opioids including depression and anxiety, falls and fractures, endocrine and sexual dysfunction, renal and hepatic failure and particularly with modified-release and higher doses – increased sensitivity to pain (pain gets worse with opioids).
How do we make reductions? Remember: “go low, go slow”. Take away a small amount, such as 5mg of morphine MR, one co-codamol tablet or whatever it might be. The very smallest amount you can using the strengths available. Ask the patient to try it for two weeks, then ask how it has gone. Few will notice, especially people taking high doses (more than 120mg/day). In two weeks, changes will settle and the lower dose is the ‘new’ normal.
There are lessons to learn from the North American experience, but sensational headlines are unlikely to provide the positive outcomes we need, driving use underground and making people reluctant to come forward for fear of being labelled as an addict. After all, these medicines are being prescribed by professionals so if we have a population of ‘addicts’, then we also need to address the ‘dealer’ workforce.
We are comfortable with stopping medication that isn’t of clinical value so let’s focus on the fact that opioids don’t work rather than the misuse issue.
So, do we have an ‘opioid epidemic’ in the UK? No, we do not.
Do we have a problem with opioids? Yes, we do.
Can we do something about it? Yes, we can.