Has our opiate prescribing gone too far?

MEDICAL MATTERS:Emergence of a 'prescription drug abuse epidemic'

BEFORE SETTLING into general practice, I spent a year working as the first medical director of the home care team at St Francis Hospice in Raheny. The beautiful building didn’t exist then; we worked from a Portakabin, providing palliative care in the community. There was an element of frontier medicine in what we did, breaking new ground on Dublin’s northside.

Apart from the many resource challenges we faced, I remember one significant clinical hurdle: a lingering reluctance to prescribe or consume opioid painkillers. Much of the team’s efforts went into educating patients, their families and, to some extent, health professionals not to be afraid to use morphine-like drugs in sufficient dosage.

Although aware of their effectiveness, people were genuinely afraid they would become addicted. For someone with a terminal illness, this really isn’t an issue. Most patients had good pain control on small doses of morphine, although we had one man with secondary growths on his spine who required hundreds of milligrams to control his pain. It enabled him to go out for a pint with his son a couple of times a week, which added to his quality of life in the weeks before he died.

Fast forward to 2011 and it’s as if the game keeper has turned poacher. There is no longer any questioning of the appropriateness of using opioids in cancer patients. But at times it seems as if the sustained education about morphine’s effectiveness was too good. An increasing number of people with chronic pain that is not due to cancer are being offered opiate drugs to help relieve the pain.

Personally, I’ve never been comfortable with the concept. But patients whose lives are blighted with chronic pain do benefit from the prescription of potentially addictive painkillers by specialists in the area.

However, some recent research suggests the pendulum may have swung too far. A Canadian study published in Archives of Internal Medicine has found the daily dose of opioids for non-malignant pain is strongly associated with opioid-related mortality; and doses of 200mg or more of morphine or its equivalent are associated with a particularly high risk. The study also found that doses in this range are common among people being treated for non-cancer pain. In 2008, some 27 per cent of Ontario social assistance recipients who were treated with long-acting opioids received daily doses exceeding the 200mg threshold.

In the US, officials in the White House have referred to the emergence of a “prescription drug abuse epidemic”. And a study in the current issue of Annals of Family Medicine has found that physicians are not conducting consistent risk reduction for patients taking long-term opioids. “We were surprised at the low rates of risk reduction,” lead author William Becker from Yale University medical school said of the relative lack of monitoring by family practitioners.

The FDA has introduced a Risk Evaluation and Mitigation Strategies programme for doctors in an attempt to reduce risks associated with the prescribing of long-acting opioids. Overuse may be associated with a small number of practitioners; in the Canadian study, the 20 per cent of family physicians who prescribed opioids most frequently issued opioid prescriptions 55 times more often than the 20 per cent who prescribed opioids least frequently.

One of the major reasons for prescribing opiates is the growing number of people with chronic musculoskeletal pain. Up to half the adult population has chronic pain at any one time. Physiotherapy, cognitive behavioural therapy and analgesic drugs are the mainstay of treatment. But there is little evidence to support the long-term use of opioids for chronic non-cancer pain; the evidence that does exist is of poor quality.

A modified form of the Hippocratic oath states that physicians “will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism”. Put another way, it appears the time may have come to rebalance the prescribing equation in people with chronic non-cancer pain.