ARE we facing an “opioid epidemic” in the UK? Are we already there? You cannot escape the press concerns about ‘”painkillers” and the comparisons being made with the United States.
The North American opioid crisis has been in full swing for around 10 years, but has gained pace and worldwide publicity particularly in the last five years. 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 this month, Jane Ballantyne, a world leading authority on opioid use in persistent pain, presented some startling figures. For every US death associated with a prescription opioid, it is estimated that 9 people enter misuse treatment services; 30 people attend A&E for overdose; 118 people develop abuse, or are dependent on prescription painkillers; and there are 795 non-medical opioid users.
Resolving the problem
Multiple agencies in the US have entered the fray in an attempt to resolve the problems, and both prescribers and patients have been targeted, with parties on both sides left feeling resentful, and questioning the motives of the decision makers.
Canada seems to have taken a slightly more collaborative approach in terms of developing strategy to address the over-prescription and misuse of opioids. However, simply shutting down supplies on prescription has led to many moving towards illicit drugs, with heroin, fentanyl and more recently carfentanil use on the rise.
In the minds of many professionals in North America, pharma played a major role in the development of the opioid epidemic. The use of opioids to ease distress and pain at the end of life was extrapolated to persistent non-cancer pain, with seemingly little thought to the millions of people affected and how that might pan out in practice beyond profit making.
Pharma companies allegedly suggested that people living with non-cancer pain were needlessly suffering as a result of clinicians’ opioid-phobia. Prescribers were assured that addiction to prescribed analgesics was rare, the drugs could be easily discontinued, and they were safe and effective when used long-term. The palliative model was also used to encourage steady titrations to effect with no upper limit on the dose that could be used.
Purdue Pharma, the promoters of Oxycontin® in North America, were fined $600 million as far back as 2007 for misleading patients and practitioners about the addiction potential of their drugs. However, well over $800 million had already been spent on promotion and lobbying to encourage opioid prescribing by that time.
US Healthcare is business orientated, leading to a production line where patient satisfaction can determine endorsement by insurance companies of practitioners. Diagnostic and medical treatment options are heavily reimbursed by insurers, unlike talking therapies and more multi-disciplinary, de-medicalised approaches to pain management. Add to this cultural factors such as a sense of entitlement: “I’m covered, therefore I should have it”; the fact that taking a drug is often easier than doing something else, and the general misunderstanding that painkillers do just that – it all starts to add up.
This side of the pond
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.
We have tighter control on the behaviour of the pharmaceutical industry, and we have 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. We have prescribing targets and increasing numbers of prescribing advisors whose role is to monitor prescriptions and compare practitioners to national averages and each other.
So what’s the problem? Why are we seeing articles in the national press talking about “deadly painkillers” and “GP 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.
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. A number of studies over the last four years have illustrated the rapid increase in UK opioid prescribing since the early 2000s.
Opioids only help perhaps 10 per cent of people prescribed them to achieve the desired outcome of reduced pain and increased function. For many more people, opioids are inhibitory: they live in a fog; their interaction with those around them is affected; they feel tired and depressed – all common symptoms of persistent pain. Knowing what is caused by the condition, and what is the drug becomes more difficult over time.
Prescribers, when faced with a person complaining of pain, debilitation, loss of employment, loss of relationships, depression, and who might lack the motivation or ability to engage with functional restoration or other self-management, are made to feel they have no other choice but to give drugs.
People taking opioids often feel better initially: the euphoria, relaxation, sedation or whatever it might be, can ease tension and make life seem a little more bearable in the early stages of use. However, over time, people need to take opioids simply to feel normal.
Jane Ballantyne states that the majority of people on long-term opioids are living in a permanent state of withdrawal – particularly those using modified release preparations. There are people with clear addiction behaviour and those who are maintained, normally on lower doses of opioids for significant periods without any signs of misuse. The majority are somewhere between the two.
Time for solutions
So, what to do? It would be easy to say don’t use opioids, and NICE have recently tried that with the latest low back pain guidelines – advising against using anything beyond co-codamol. The reality, however, is that other services such as physiotherapy, occupational therapy, supported self-management, psychology can be difficult to come by in a timely fashion and its challenging to encourage people to engage with these options.
Firstly, we need to build national awareness of the futility of opioids to provide long-term benefits and highlight the health risks of keeping on keeping on with them. We need to promote the internationally agreed upper limit of 120 mg morphine or equivalent per day in non-cancer pain conditions. We need to do this without making prescribers or people using the drugs feel guilty, inadequate, or like users or dealers.
Then, we need to work out what to do with all the people already taking these medicines.
In simple terms, we need to reduce peoples’ 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? Four words – go low, go slow.
There is advice available that suggests reducing by 10% of the total dose, each week. This is pretty fast and in primary care, where this will be happening, we can’t monitor people easily if things are difficult. Also – what’s the rush? We’ve been happy to leave people on these medicines for years already – they don’t all need to be off them by a week next Friday. The aim is to encourage people to use these medicines responsibly and safely. We want to promote a better way.
People in pain are scared. They might realise the drugs aren’t that helpful but they are frightened about how bad things will be without them. So, take away a small amount e.g. 5 mg of morphine MR, one co-codamol tablet or whatever it might be — the very smallest amount you can, using the strengths available. Ask them to try it for two weeks, and get them back and see how its gone – few will notice, especially people taking high doses (>120 mg/day). In two weeks, changes will settle and the lower dose is the new normal.
Go at the person’s pace, not yours. People with pain report feeling a loss of control – so give it back to them. Inform, agree, reduce, review, repeat.
The pharmacy workforce are ideally placed for this work, and practice pharmacists are already doing it, as often they have slightly more time for appointments and discussion. Polypharmacy reviews are an ideal place to discuss how pain is being managed and to suggest changes. Primary care presence allows regular reviews and helps form therapeutic relationships with people who can be used to encourage self-management.
Make MURs count by having the discussion about concerns around opioids. Community pharmacists are trusted by their customers and this trust can be used to positively influence patient behaviour. If we can improve working between sectors, then primary care prescribers could initiate reduction programmes and community pharmacists could monitor and make adjustments accordingly. People know they can seek help and advice from their community pharmacy teams, without appointments and 7 days a week in lots of cases. We must work hard not to lose this vital service.
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. Afterall, these medicines are being prescribed by professionals so if we have a population of ‘addicts’, then we need to also address the ‘dealer’ workforce.
We are comfortable with stopping medication that isn’t of clinical value, so lets 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, and pharmacy needs to lead this both in terms of educating the medical workforce and the public, but also in taking the lead clinically.
Got a problem with medicines? Call the medicines experts – call pharmacy.