Pain not being managed with scattergun approach

Prescribers are handing out ‘Endone like lollies’ but pain management remains inadequate, says a pain expert—but pharmacy can help

Queensland pharmacist Karalyn Huxhagen, winner of the 2015 PSA Award for Quality Use of Medicines in pain management and group facilitator of the Mackay Pain Support Group, told the AJP that she agreed with doctors’ comments yesterday on a study examining increasing opioid use in Australia and its consequences.

The RACGP’s Dr Evan Ackermann told MJA InSight yesterday that “in hospitals, Endone has become the new Panadol”.

“I’m seeing people coming out of hospital with a suite of drugs – it’s an overall blanket approach to pain management rather than a targeted approach,” Huxhagen says.

“They come out on oxycodone, non-steroidals, paracetamol and codeine… it’s not unusual to get a script for four to six painkillers just to ensure you’ve hit every one you need.

“The patients is often needing to be counselled carefully as to where each of these medicines sits in their pain management scenario, so you’ve got to be able to spend time with them and make sure that they understand what each drug is for – you run the risk they’ll take all six of them when you don’t need to.”

Huxhagen says that particularly post-injury, a patient may develop a reliance on opioids if they are not weaned off them correctly.

“I agree with Evan wholeheartedly that inappropriate use of oxycodone is something we’re seeing. It’s being used very liberally.”

GPs are often in the dark about their patients’ subsequent opioid use, she says.

“I liken it to asthma. The GPs have a limited awareness as to how much codeine-seeking behaviour patients have,” Huxhagen says.

“It’s similar to what happens with salbutamol. The GP is often completely unaware of how many salbutamol inhalers patients use, because they just don’t tell them.

“One of the things I try to do, when talking with GPs, is say that when they make their pain management plan with their patient – because many go into a plan to help them get off opioids and get better – they need to ask for their patient’s permission to access how many OTC opioids they’re getting from their pharmacy.”

Unfortunately GPs are often reluctant to take that step, she says, while patients may go “far and wide” to access codeine.

Chronic pain may also be a growing problem to watch in future, she says, as “patients want relief and don’t want to pay the full price of Panadol Osteo, so they’re tipping over to use things that are really quite inappropriate”.

Victoria’s government has recently committed to funding a real-time prescription monitoring program for drugs including morphine and oxycodone, which Huxhagen welcomed.

In the meantime, she called for a collaborative approach to pain management and encouraged the use of non-drug solutions.

“The appropriate action would be discharging people from the hospital or health service with a pain management plan, including how to manage their pain and reduce inflammation rather than just a multi-bullet attack on something that can grow into a large problem,” she says.

“Simple things are often very good: warmth, rest, massage, high dose magnesium… there’s a lot of other therapies that can help.

“Use the physio for exercise plans and getting back to work plans; do something about the under-use of things like warm water exercises or tai chi.

“All of these have a place in pain management, and right now we’re giving Endone out like lollies and not managing the patient’s pain.”

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