Opioid prescribing risks

OPIOID painkillers are highly effective and beneficial to millions of patients – but the risks of prescribing these drugs are well known. Used regularly, opioids can cause dependence and (with overuse) addiction, possible overdose and death.

The Mayo clinic reports that after as little as five days use the likelihood of dependence increases sharply. The sheer magnitude of the current scale of prescribing has now attracted attention because of the rise in adverse events.

Recent headlines from the USA mirror the increased interest and focus on problems here. The US Center for Disease Control and Prevention estimated that opioids caused the deaths of approximately 47,000 Americans in 2017. Only a few weeks ago an Oklahoma state judge ordered the drug maker Johnson & Johnson to pay $572m (£468m) for its part in the opioid addiction crisis.

Recent figures in England and Wales have shown an increase in prescriptions for opioid painkillers of over 60 per cent in the last decade. In 2008, 14 million prescriptions were dispensed in the community alone, a figure which rose to 23 million in 2018. It is also reported that from 2008 to 2018, the number of codeine-related deaths in England and Wales more than doubled to over 150. The National Records of Scotland showed that codeine-related deaths spiked at 43 in 2016, dropping to 27 in 2017. The Northern Ireland Statistics and Research Agency (NISRA) data shows that there were 16 codeine-related deaths in 2017.

In response to the growing problem, Secretary of State for Health and Social Care, Matt Hancock recently announced that all opioid medication will have to carry prominent addiction warnings.

At MDDUS we are frequently contacted for advice about difficult patients who exhibit drug-seeking behaviour. This can range from giving an inaccurate history in order to receive prescribed painkillers (or repeatedly reporting the loss of prescriptions) to clearly fraudulent actions such as altering prescriptions.

The continued prescribing of opioid medication also leads to complaints from both patients and their families. An adequate response to such complaints requires an explanation of why a prescription was continued and a clear rationale for doing so.

Inquests into deaths where a patient has received opiate mediation will also look closely at prescribing and whether this may have contributed to the death. If the prescribing is criticised by the coroner in their conclusion, the doctor in question must then self-report to the GMC.

There is helpful guidance about good practice in prescribing in these circumstances. The Faculty of Pain Medicine has published: Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain. This offers specific guidance on best practice in the use of opioid medication for pain.

Appropriate practice in prescribing opioids should also be based on the GMC guidance: Good practice in prescribing and managing medicines and devices. Certain paragraphs are worth highlighting here. At paragraph 3 the GMC states:

"You are responsible for the prescriptions you sign and for your decisions and actions when you supply and administer medicines and devices or authorise or instruct others to do so. You must be prepared to explain and justify your decisions and actions when prescribing, administering and managing medicines."

And at paragraphs 53 and 58:

• patients may be at risk, for example, patients who are frail or have multiple illnesses
• medicines have potentially serious or common side effects
• the patient is prescribed a controlled or other medicine that is commonly abused or misused
• the BNF or other authoritative clinical guidance recommends blood tests or other monitoring at regular intervals."

"At each review, you should confirm that the patient is taking their medicines as directed, and check that the medicines are still needed, effective and tolerated. This may be particularly important following a hospital stay, or changes to medicines following a hospital or home visit. You should also consider whether requests for repeat prescriptions received earlier or later than expected may indicate poor adherence, leading to inadequate therapy or adverse effects."

Any doctor who prescribes opioids should look carefully at their practice to ensure that they are complying with current guidance and exercising appropriate clinical judgement.

ACTION

• Keep up-to-date with guidance on prescribing opiates.
• Check carefully to ensure the continued need for prescribing at current levels.
• Provide clear advice to your patients about the risks associated with opiate use.

Dr Gail Gilmartin is a former medical and risk adviser at MDDUS.