Some ways to balance the benefits and harms of opioids
Tuesday, Nov 5, 2013, 01:48 AM | Source: The Conversation
The use of opioid medication in Australia has grown considerably in the past 20 years, and so have related harms. This increase in use is primarily for chronic pain conditions, now the most common reason for opioid prescription.
New South Wales hospital data suggests over half the opioid-related deaths in that state were among people who had chronic medical conditions and had been prescribed opioids by their doctor. Under a third (27%) of these deaths were intentional overdoses.
People who suffer the harms of opioid medications come from a wide range of the population; from the troubled and dependant, to the elderly, who are at greater risk of mistakenly overusing medication.
While it’s important that we address people getting opioids from doctor-shopping or illegal sources, we also need to reduce harms in those who are prescribed opioids; to prevent misuse, monitor them for signs of psychological distress, and minimise medication errors.
Opioids and chronic pain
Opioids come in variety of forms, and can be used for a large number of medical issues. The most common reasons for use are acute injuries and chronic non-cancer pain conditions, which is the main reason for long-term use.
There are a number of problems with opioid use for chronic pain, the foremost of which is that we have scant evidence to support their long-term use, even though we are well aware of their harms.
Chronic pain conditions are very complex; there’s no blood test or other kind of investigation to determine their existence.
Pain is a physical, psychological, and social illness, and other issues such as depression, substance dependence, and other chronic medical conditions are more likely in people who suffer from it. Chronic pain conditions often coexist with drug dependency, as a result of the constant physical and psychological suffering.
It would be inhumane to not give people with chronic pain an opportunity to trial medication that may help them feel and function better, but we need to be careful about managing harms. How then do we manage people with chronic pain effectively while limiting overuse?
Doctors need to ensure that patients benefit from opioid use. People at risk of forming a dependency or having an overdose shouldn’t be excluded from use but need to be monitored. A good way to do this is by providing a short-term trial while looking out for signs of risky behaviour.
There’s currently a permit system for opioids that places accountability solely on doctors for their supply.
Greater patient responsibility is important for providing people with a sense of control of their pain and the condition causing it. Having a contract between doctor and patient is important to establishing responsibility for the pain and treatment.
Continuity of care
The permit system also does little to enforce continuity of care, and is only required after eight weeks of use. Having a permit system that encompasses a trial phase and requires constant review by the same doctor can potentially foster this occurrence.
Continuity of care is vital. Right now, people are able to alternate between doctors, especially if they’re at the same clinic. Many people start off on what may initially be a trial of opioid medications, end up with an endless supply as they float between doctors.
Having a regular doctor allows insight into the story behind the pain, allows monitoring for signs of dependence or overuse, or to realise the treatment isn’t helping and cease its use.
Alcohol intake, use of other medications, and social problems may also not be known to a new doctor, even though these are significant factors in overdose.
Monitoring and education
Adverse events are not just the result of misuse, they can happen because of drug interactions and medication errors as well, especially in the elderly.
It’s vital that people getting a prescription for opioids have information about the drugs explained to them. And that doctors are aware of any difficulties with information uptake or other related issues, such as the inability to read dosing on the pack.
Education and continuity of care are strongly linked, and allow medication use to be monitored and reinforced.
It’s impossible to negate all the risks of opioid use, and misuse and addiction will continue to occur. But good management can both limit the need for these medications and prevent their misuse.
These are not just exercises in risk minimisation, but positive acts to treat chronic pain conditions more effectively.
Matthew Grant was previously was employed as a Pharmacovigillance Physician at MSD, but has no ongoing relationship.