A snapshot of opioid use

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New PBS data shows that opioid prevalence in Australia has increased since 2013, but incidence has decreased

And in response, pain stakeholders have called for better access to multi-disciplinary treatments, as well as compassion for those in pain.

The study, published in the British Journal of Clinical Pharmacology, aimed to determine both prevalence and incidence of prescription opioid analgesic use in Australia, and also to compare the characteristics of people with and without cancer initiating prescription opioid analgesics.

The researchers, from the Centre for Medicine Use and Safety (CMUS) at the Monash University Faculty of Pharmacy and Pharmaceutical Sciences, analysed opioid dispensing through the PBS from 2013 to 2017.

The retrospective population‐based study used a random 10% sample of adults receiving such scripts.

“Opioid prevalence increased {RR = 1.006 [95% confidence interval (CI) 1.004, 1.008]}, while incidence decreased [RR = 0.977 (95% CI 0.975,0.979)] from 2013/2014 to 2016/2017,” the authors write.

“There were between 287,677 and 307,772 prevalent users each year. In total, 769,334 adults initiated opioids between 2013/2014 and 2016/2017, and half of these initiations were by general practitioners.

“Initiation with a strong opioid occurred in 55.8% of those with cancer and 28.2% of those without cancer.”

The study concluded that rates of opioid use remain high, with around three million adults using the medicines, and more than 1.9 million adults initiating opioids each year.

“Between 2013 and 2017, opioid prevalence has slightly increased but incidence has decreased,” the authors write.

“People without cancer account for the majority of opioid use and are more likely to be initiated on short‐acting and weak opioids. Initiation of strong opioids has increased over time, reinforcing concerns about increased use and the harms associated with strong opioids in the community.”

Concerning findings

Lead author Samanta Lalic, who is an Austin Health pharmacist and CMUS PhD candidate, said that of particular concern was the finding that 2.6% of Australians (around 50,000 people per year) become long-term users over a year.

Also of concern was that an increasing proportion of patients are being started on stronger opioids, she said.

According to Ms Lalic, this a significant worry because both long-term use and the use of strong opioids are associated with a range of adverse health outcomes: overdose deaths, falls, fractures, hospitalisations and motor vehicle accidents.

“Opioids do have an important role in managing cancer pain and acute non-cancer pain. However, their use remains less well established for chronic – i.e. long-term – non-cancer pain,” Ms Lalic said.

“For the treatment of chronic pain, we need to change prescribing culture and raise the level of awareness of other treatment options among patients. The goal of care, treatment expectations and intended duration should be agreed upon by patients and prescribers prior to opioid initiation.

“In many cases the safest and most effective way to treat chronic pain will involve a combination of therapies, including exercise, physiotherapy and non-opioid painkillers.”

Ms Lalic said the next step is to determine how prescribers and patients escalate doses over time.

Approaching pain with compassion

Commenting on the study, Chronic Pain Australia said that it believes the most effective way to manage chronic pain is through a multi-disciplinary approach, which may include medication where appropriate.

“While we all might want every person living with chronic pain to regularly see their GP, pharmacist, pain specialist, physiotherapist, counsellor and other health practitioners, the reality is that this is not affordable for most people living with chronic pain,” said Chronic Pain Australia National President Dr Coralie Wales.

“If we want to see all Australians living with chronic pain take a multi-disciplinary approach to managing their pain, then we need to ensure that it is affordable for them. How do we realistically expect people to be able to change the way they manage their pain?”

Dr Wales also encouraged people reading the report to consider the daily struggles confronting someone living with chronic pain.

“I think it is important that we bring back compassion for people living with chronic pain when we discuss issues like opioids in their treatment. It is very important for people to try and view the situation from the perspective of someone living with chronic pain,” said Dr Wales.

Dr Wales also said that while opioids need to be used appropriately for the treatment of chronic pain, this does not meant they should be withheld if prescribed opioids is the best option to treat and manage a person’s chronic pain.

Pharmacist Jarrod McMaugh, who is on Chronic Pain Australia’s board, told the AJP that “Opioids have a place in treatment of pain, and that a decision to NOT use them should be based solely of therapeutic appropriateness at the discretion of the clinician.”

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