30 October 2017

Guidelines offer clarity on opioids

Addiction Clinical

New RACGP guidelines cut through the fear and opioid-phobia to reassure doctors that these drugs can be appropriate even for chronic non-cancer pain, but also offer clarity on the red flags and the limits.

The focus on opioids comes amid increasing harms globally, and at home, with accidental opioid deaths among middle-aged Australians more than doubling between 2007 and 2013.

An estimated one in five presentations to general practice are for chronic pain, and Australia is the second highest opioid-prescribing country, per capita, after the US.

Dr Evan Ackermann, Chair of the College’s Expert Committee Quality Care, said it was vital to better protect patients from harm. However, he was critical of the demonisation of both patients needing opioids and the doctors who prescribed them, saying most GPs treated their patients appropriately and with commonsense.

Dr Ackermann supported the call from Victorian GP Paul Grinzi to stop using the term “drug-seeker”. Instead, recognising that substance-use disorder sometimes manifested in manipulative behaviour, and considering it a symptom that could trigger a discussion about treatment would be more helpful than taking it personally.

Presenting the guidelines at the RACGP’s 2017 conference, pain medicine expert and rheumatologist Professor Milton Cohen said the medical, biological, social and psychological context was vital to assessing patient pain, even though it was more time consuming.

“In this field, the social and the psychological [factors] turn out to be more important than the biomedical in assessment and management,” he said.

As part of the guideline launch, the College issued a 12-point challenge to GPs to assess whether the drug was necessary for either acute or chronic pain. This included prioritising non-opioid therapies, developing multidisciplinary care and regularly reassessing the appropriateness.

However, if the non-opioid options were insufficient then it might be appropriate to start an opioid trial. Explicit conversations about realistic expectations for success and reassessment were necessary, Professor Cohen said.

He drew a clear distinction between efficacy and effectiveness in explaining how the limited evidence supporting opioids for chronic non-cancer pain did not necessarily prevent them being helpful to certain individuals.

“I have no doubt that there are a significant number of patients in whom opioids are effective,” Professor Cohen said.

However, patients using opioids are a heterogenous group, with high rates of mental-health issues such as depression and anxiety, a history of abuse and concurrent medication use.

“It is very difficult to predict whether an individual person experiencing chronic non-cancer pain will respond to an opioid or not,” he said, which highlighted the need for an opioid trial instead of an open-ended approach.

“We now know that if a person is going to respond in a global way to an opioid, it’s highly likely they will do so when you reach an oral morphine equivalent of 50mg to 60mg per day.”

Understanding what the patient’s daily oral morphine equivalent was key to good management, with the guidelines stipulating a ceiling of 100mg.

Both Professor Cohen and Dr Ackermann enthusiastically recommended a calculator developed and found on the website of the Australian and New Zealand College of Anaesthetists.

Inherited patients could be a challenge, Milton Cohen said. But one tactic might be to consolidate all opioid medications into the same species and then taper down from that.

Clinicians could use the five “A”s to assess whether the drug was working: analgesia, activity, affect, adverse effects and aberrate behaviours.

If it became clear that the risk was outweighing the benefit, or the patient was breaking the “contract” then the clinician should always feel comfortable discontinuing treatment, Professor Cohen said.

In deciding whether to trial the drugs, doctors should be extra vigilant for high-risk patients, such as those with substance-use disorders, a history of overdose, who are psychologically unstable or who are taking benzodiazepines.

While opioid therapy might not be ideal, it could also help reduce the number of benzodiazepines and other medications the patient was on, and so reduce polypharmacy, Professor Cohen said.

As part of a broad effort to combat opioid harms, the College is also calling for opioid discharge summaries and tapering advice from hospital pharmacists, accreditation for pain clinics and better funding for pain management in general practice.

Dr Ackermann did reveal a surprisingly effective treatment for pain, placebo pills, which were the most consistently effective treatment at reducing pain, giving pain reductions of 20%.

When asked by an audience member which colour pills were the most effective, Professor Cohen responded with “red or yellow”.