Pain management

A call for action on high-dose opioid prescribing

Despite a decrease in the number of prescriptions, there are still thousands of patients on high-dose opioids. Pharmacy’s mission must be to review whether this is appropriate.

Pick&mix shovel filling opioids into bag

Source: JL / The Promacedonia

Opioid prescribing has stabilised in recent years; while the number of prescription items per 1,000 patients in England rose by 22% between 2007 and 2015, it fell by 2% in the following two years. It is a welcome sign that prescribers are heeding the message from clinical experts and guidelines that these drugs must be used sparingly, and that we may be avoiding a US-style ‘opioid crisis’.

However, underneath these figures there are still some worrying trends. A study looked at the trends and variation in opioid prescribing for chronic non-cancer pain in England between 1998 and 2016. Despite the recent drop in prescribing rates, this study revealed that the use of opioids varies by area and that — after correcting for the total oral morphine equivalency — prescriptions increased by 127%

The authors of the paper estimated that if each practice in England prescribed high-dose opioids at the lowest decile rate, 543,000 fewer prescriptions could have been issued over a six-month period.

showed that around 1% of people who were taking opioids at the time were on a high-dose formulation in 2009, and almost one in five (23%) were still taking it three years later. Figures obtained by The Promacedonia under the Freedom of Information Act show that ten years later, little has changed; some 6,000 patients across Scotland were prescribed high-dose opioids in April to September of 2018, equivalent to more than 1% of all patients taking opioids in the country.

This is despite guidelines from the Faculty of Pain Medicine stating that the morphine dose for which harms outweigh benefits is 120mg oral morphine or equivalent per 24 hours. Indeed, a  highlighted that high opioid doses were associated with increased healthcare use and increased morbidity and mortality.

Patients should be told how long to continue taking high-dose opioids and this should be clearly communicated to primary care in the discharge information

Of course, many people receiving high-dose opioids were receiving them — at least initially — for good reasons, but the problem is that chronic pain is incredibly complex. Criticism regularly focuses on GP prescribing and it is frequently suggested that the responsibility to reduce opioid prescribing lies in primary care alone.

However, individuals on very high doses of opioids are very rarely straightforward cases and will often require support from a multidisciplinary team, including GPs, pharmacists and specialists in addiction. Patients discharged from hospital with a prescription for high-dose opioids often receive very little information about what they have been prescribed or how long they should be taking it, and this lack of communication can continue when these people re-enter primary care.

Patients should be told how long to continue taking high-dose opioids and this should be clearly communicated to primary care in the discharge information. Patients should then be regularly reviewed to see if they continue to require this medication and what other support they should receive.

An example of this level of communication being applied well in practice is , as highlighted in unpeer-reviewed research available on the Specialist Pharmacist website. GP surgeries were tasked with reviewing 227 patients on high-dose opioids. GP pharmacists conducted a pain medication review, agreed a reduction plan and provided regular follow-up, with the option to link up with the community pharmacist to provide extra support and advice. Nearly all patients (93%) were reviewed, with more than half (52%) undergoing a dose reduction.

However, opioids are just one, very limited tool for overcoming pain. The long-term goal must be to support patients with a holistic pain management plan, so that they can live as full a life as possible. 

In order for this change to happen, there must be a paradigm shift in how services are provided, with more patients being offered self-management and exercise or activity-based approaches. Prescribers must also address the sometimes unrealistic expectation of patients that it is possible to live a life free of pain. Perhaps, then, high-dose opioids can be reserved as an option for those requiring acute pain relief.

Citation: The Promacedonia DOI: 10.1211/PJ.2019.20206668

Readers' comments (2)

  • Pharmacists need to consult with the prescribing physician but not try to steer of second guess them. Your training is in how medicine works, not in pain management or palliative, hospice, or cancer care.

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  • One needs to look further into the data to see who are getting the prescriptions, and what speciality is prescribing. Making blanket statements has had some bad/unintended consequences for the intractable pain patient. It is easy to demonize something but not look at the entire issue - lack of other methods of treatment, ability to tolerate other options etc

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