No more opioids for chronic pain

doctor holding up a bottle of pills

Doctors at GP conference call for move away from “ineffective and unsafe” opioids to more active forms of pain treatment

As the RACGP conference kicks off this week, a pre-conference session has already generated some debate surrounding opioid prescribing and use among the population.

The session about managing chronic non-terminal pain explored how general practitioners can no longer rely on a quick fix for the complex problem.

“Opioids for chronic non-cancer pain are not an evidence-based treatment. Ineffective and unsafe,” said conference attendee Sydney GP Dr Carolyn Ee.

She called for a public health campaign against opioid use for chronic non-cancer pain, “especially with codeine restrictions in 2018”.

The GP17 session suggested that doctors choose active over passive management for chronic pain in their patients, encouraging activities such as walking, swimming, yoga and tai chi.

And the best way to prevent use of opiates for management of chronic non-cancer pain? “Stop starting them,” according to the presentation.

“Have you heard the phrase ‘genuine pain protects from opioid addiction’. It’s wrong. The two are not mutually exclusive,” said a Victorian GP and educator in the area of addiction medicine, in an adjunct GP17 session entitled “The drug seekers journey”.

The session on chronic pain also warned against use of benzodiazepines for sleep and sedation, with evidence showing they are ineffective for sleep and can cause dependency and withdrawal symptoms.

With evidence of GPs overprescribing S8s and S4Ds in some circumstances, GPs have been advised to create a structured approach to prescribing such drugs.

For example, in non-cancer pain, to have a policy not to provide the medicines: at the first appointment; with a phone request; without a proper assessment; and/or over the long-term.

According to RACGP guidelines, prescribing drugs of dependence should be seen as an adjunct to care, and not regarded as the primary treatment regimen.

“For many of the conditions which drugs of dependence are used, non-drug interventions are often more effective and have sustained results,” says the RACGP.

“Where there is good evidence for non-drug interventions, GPs should consider these as first-line therapy.

“GPs need to be aware of the evidence for allied health treatments and be able to offer these (in-house or through referral) to patients when they need them.”

Clinical pharmacist and pain educator Joyce McSwan agrees.

“The strong reliance on medication alone as therapy remains problematic as people are desperately looking for a ‘fix’,” Ms McSwan tells AJP.

“Pain management is about self-management. There may be no fix but life does not have to stop.  It’s about adopting a comprehensive plan and goal setting towards living life despite the pain rather than focusing on waiting for the pain to be relieved than living life again.

“Staged supply of opioids, or monitoring compliance with the appropriate use of adjuncts so opioids are reduced, are noticeable roles that pharmacists can play. Identifying possible dependency issues and navigating patients towards supportive options.”

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