Getting a grip on opioid usage

New guidance

Chronic non-cancer pain is estimated to affect around 43 per cent of UK adults. It is defined as pain lasting for three months or more and may be localised (e.g. lower back pain or knee osteoarthritis) or be widespread throughout the body (e.g. fibromyalgia). 

In April 2021, the National Institute for Health and Care Excellence (NICE) issued guidance which said that patients with chronic pain shouldn’t be started on commonly used analgesic medicines, including opioids. Instead, supported self-management is recommended with first-line non-pharmacological approaches including exercise, physiotherapy, acupuncture, and behavioural and relaxation therapies.

Opioid usage has reduced in recent years but according to research published in July 2021 by the Drug Safety Research Unit in Southampton looking at 'Opioids in the United Kingdom: safety and surveillance during Covid-19', the safety of opioids remains an important issue to be monitored, especially following the emergence of Covid. 

Opioid medicine use is also strongly related to socio-economic conditions. Ian Hamilton, senior lecturer in addiction and mental health at the University of York, says that opiates have often been used to help people with pain management without tackling underlying health, social or psychological problems. 

"A number of people taking opioid medicines have underlying problems, mental health or social, including inadequate housing, job losses and financial problems. There needs to be a change in culture – among both prescribers and patients. Many people are started on opiates inappropriately and then continued on them inappropriately, and people who are already being prescribed opiates get very anxious that they will be taken off their medicines."

Reducing prescribing

In October 2021, a study led by researchers from the University of Leeds and published in the journal PLOS Medicine showed that a campaign urging GPs to "think twice" before putting a patient on opioid medicines can be effective in reducing opioid prescribing in primary care. The Campaign to Reduce Opioid Prescribing study involved a 'feedback' intervention that continued for a year, where 316 GP practices in West Yorkshire were given two-monthly updates on the number of people at their practice being prescribed opioids (but not for cancer or drug dependency). 

The doctors were reminded of the need to "initiate opioids with caution" and to review whether patients should continue to receive opioids when there was no benefit.

"In a previous related study, one GP practice wrote a protocol including what constitutes an opioid not working, encouraging doctors to think twice about prescribing them," says Dr Sarah Alderson, clinical associate professor at the University of Leeds and a GP in Holmfirth, West Yorkshire, who led the study. 

"One practice took patients off repeat prescriptions [for opioids] so they had to go back to the GPs to ask for them again. Another practice wrote to all patients informing them about DVLA requirements if they were a driver and took high doses of opioids regularly."

Over 12 months, the Campaign to Reduce Opioid Prescribing resulted in 15,000 fewer patients being given opioids – and a net saving to the NHS of £700,000. According to the researchers, if the campaign was replicated across the UK, it could lead to 406,000 fewer patients taking opioid medications and generate a potential saving estimated to be around £18.5m. 

"Our analysis shows that the intervention was particularly effective at getting GPs to stop or reduce their prescribing for those groups at high risk, such as older patients or those who also had a mental health condition," says Dr Alderson. "The study shows that GPs can be highly effective in identifying other ways of supporting patients who experience chronic pain. The feedback intervention could easily be adapted and delivered elsewhere at relatively low cost."

The West Yorkshire research followed a public-facing campaign that was launched in October 2019 by Sunderland CCG and in March 2020 by County Durham CCG. Every GP practice in these areas received a range of materials to support the campaign as well as committing to limit new opiate prescriptions to three months and reviewing existing opioid usage. GPs and pharmacists worked together with patients to identify sustainable, alternative pain management techniques for chronic pain. 

As a result of the campaign, NHS Sunderland CCG cut opioid medicine prescribing by 34 per cent and NHS County Durham CCG’s opioid prescribing was down by 17 per cent. The CCGs then stepped up the campaign to raise awareness of the dangers associated with the long-term use of opioid medicines to help patients, their family and friends recognise if opioid painkillers such as codeine and tramadol are a problem. 

"Side-effects like dependence and addiction, personality change, drowsiness and mood swings are all indicators that individuals need to be aware of," says Ewan Maule, head of medicines optimisation in Sunderland. "We would urge people to discuss their approach to long-term pain management with [a healthcare professional]. We understand that pain management is not a one-size-fits-all approach. Simply prescribing opioid painkillers to mask the symptom of pain is no longer the sole method used to treat long-term, persistent pain."

Increasing awareness

In September 2020, the Medicines and Healthcare products Regulatory Agency (MHRA) announced that people prescribed or taking OTC medicines containing opioids for non-cancer pain were to be given stronger warnings about the risk of dependence and addiction. 

Additional warnings were added to the patient information leaflet, making it clear that the medicine is an opioid, which can cause addiction, and that there can be withdrawal symptoms if people stop taking it suddenly. 

If community pharmacists notice worrying behaviour in patients taking opioids they should feed any concerns back to their GPs, says Dr Alderson. "This is something pharmacists may be more aware of than GPs, when they speak to the patients on repeat prescriptions," she says. "It is important to make sure the patients realise opioids are a potentially addictive medication and have had a pain management review with their doctor. Most worrying are the people on repeat prescriptions who are being prescribed increasingly high doses."

Dr Barry Miller, chair of the medicines advisory group of the Faculty of Pain Medicine, says community pharmacists are well-placed to raise awareness of patients on high or prolonged doses. "They can suggest the patient goes back to their GP to discuss whether the high doses are doing any good, and about other options," he says. 

"However, this relies on the patient taking their advice. There’s often an assumption that if the dose isn’t doing any good, people need more opioid medicines, when they actually need less."

Dr Michael Dixon, GP and chairman of the newly formed Integrated Medicine Alliance (IMA), says that the IMA would like pharmacists to be better informed about social prescribing, as this can have a profound effect on mental and physical health, and therefore on pain management. "There are a wide number of interventions that are safe, cheap and readily available, such as hypnosis, mindfulness, acupuncture and thought field therapy, which have minimal side-effects and are extremely effective in many conditions," he says. "Social prescribing is a sustainable solution to isolation, loneliness and pain management, and has been shown to reduce opioid intake."

OTC Sales

In 2018, Australia joined 25 other countries including Germany, Japan and America in restricting codeine-containing analgesics to prescription-only. However, codeine-containing analgesics remain on sale from pharmacies in the UK. This is a controversial topic. 

"OTC codeine-containing analgesics do have a future, but codeine as a painkiller has its limitations and side-effects," says Dr Miller. "Doses in OTC codeine are small, although there is no evidence that they don’t work, and anecdotally people do get benefit. 

"There are risks of overusing OTC products, but the biggest issue is still the overprescribing of opioids. If codeine-containing products are removed from OTC sale – and some countries have done this – this leaves patients with only paracetamol and NSAIDs. It puts more pressure on pharmacy, GPs and other prescribers to provide alternatives for non-serious but significant pain problems."

In May 2021, Boots devised a Codeine Patient Safety Card to be used by its pharmacy team members to support appropriate sales of codeine-containing medicines. This followed research which looked at the role of community pharmacy staff in encouraging the safe use of OTC codeine products. According to the researchers, total sales of all codeine-containing OTC products in the UK in 2020 were 26 million units, or 7.8 per cent of the total adult oral pain relief market.

The A6-sized opioid medicines safety card was distributed to 36 Boots pharmacies between June and July 2020. Staff reported that they found the card to be a useful prompt to support discussions with customers on the appropriate and safe use of codeine-containing medicines, and most patients accepted the card when offered one. 

The results of the study suggest that community pharmacists can be involved in behavioural change regarding purchasing codeine products, which could assist in decreasing misuse.

Janice Perkins, chair of the RPS community pharmacy expert working group, suggests that all pharmacies produce a codeine awareness card both for the pharmacy counter and for customers to take away if they are taking OTC or prescribed opioid medicines. "The card should remind people of key issues associated with codeine and how to take the medicines safely," she says. 

"Every time a repeat prescription for an opioid medicine is dispensed, have a conversation about pain and pain relief. Talk about dependence and tolerance rather than addiction. There is nothing for patients to worry about when taking opioid-containing analgesics for short-term use, but they need to be used appropriately. 

"It is easy to move on to a higher dose without noticing this, so medication reviews are important. Pharmacies should have a good relationship with local GPs, as having conversations about what is best for the patient is a three-way decision."