When the soon-to-be-abolished Public Health England warned last autumn that one in four patients had been given a prescription for a potentially addictive medication, it was unclear how the problem would be tackled in primary care.
Almost a year later, the regulators are turning their attention to opioids, with significant ramifications for GPs, who are recommended not to prescribe them for certain types of chronic pain.
Pulse has also discovered the Medicines and Healthcare products Regulatory Agency (MHRA) is considering a ban on all over-the-counter (OTC) opioid-based painkillers and reclassifying them as prescription only.
PHE’s major report last year found that opioid prescribing has been decreasing year on year. But even then, more than 10% of patients in England had been prescribed opioids in 2017/18.
And long-term dependency was a worry – three-quarters of those on opioids had been taking them for three months or longer, while a quarter had been on them continuously for three years or more.
But GPs are concerned about NICE’s new recommendations, which have been put forward in its draft guideline on chronic pain.
Professor Tony Avery, professor of primary care at the University of Nottingham and a GP in the city, says: ‘We do have to take account of the lack of evidence for prescribing opioids in chronic primary pain but the issue of what we do with the patients already on opioids is really difficult.’
He adds: ‘If you look at the list of what NICE says we should be doing, it doesn’t fit in any way with the time we have in a standard consultation and a lot of the suggestions are completely theoretical because we don’t have access to those services.’
The guidance recommends for the first time how to manage ‘chronic primary pain’ – defined as ‘chronic pain in one or more anatomical regions that is characterised by significant emotional distress (anxiety, anger/frustration or depressed mood)’ or ‘functional disability (interference in daily life activities and reduced participation in social roles)’.
What NICE says we should be doing, it doesn’t fit with the time in a standard consultation
Professor Tony Avery
The NICE panel found there was a ‘lack of evidence for effectiveness of opioids’ alongside ‘evidence of long-term harm’. It issues similar warnings about NSAIDs, steroids and paracetamol, as well as gabapentinoids, which are now not recommended unless given within a clinical trial.
Instead, the panel recommends considering antidepressants. Other options for patients are a ‘supervised group exercise programme’, acceptance and commitment therapy or cognitive behavioural therapy (CBT), or a course of acupuncture or dry needling.
On patients who are already taking opioids, the guidance says: ‘If a person with chronic primary pain is already taking any of the medicines… explain the risks of continuing.’ NICE says it is developing a guideline on medicines associated with dependence or withdrawal symptoms, on safe prescribing and withdrawal management.
‘No easy answers’
Dr Alun George, a locum GP in Bradford with an interest in substance misuse, says NICE is essentially pointing out that a great deal of chronic pain is actually a mental health problem. That’s not to say it isn’t real, he adds, but means a great deal of resources are needed to manage it.
There are no ‘easy answers’, says Dr George. ‘Six years ago we did a pilot with persistent pain in drug services and we started off with half-hour appointments and that wasn’t quite enough. It’s a lot of work.’
In his experience, managing these patients is too much for one person to handle and requires substantial extra funding. ‘You do get lots of anger directed at you. GPs are the right people to do this but you do need a lot of extra resources.’
The sheer number of patients involved makes this a huge problem. It is estimated that between a third and a half of the population may suffer from chronic pain. Within that group it is not clear how many people have chronic primary pain – but NICE considers this to cover everything from chronic headache or musculoskeletal pain to complex regional pain syndrome.
Alternative therapies are time consuming and hard work – who wouldn’t want a pill?
Dr Alun George
And GPs who have in the past moved patients with chronic primary pain off opioids or similar drugs and onto some of NICE’s suggested alternatives say it is far from an easy process. Dr George says: ‘In practice, these therapies can be hard to come by. Alternative therapies are time consuming and hard work – who wouldn’t want a pill that makes them briefly feel better?’
There is another aspect to the opioid prescribing problem. The pain clinics to which GPs can refer patients for specialist help often end up initiating opioid treatment.
It will take time to ‘revolutionise’ these clinics and develop other services that are so lacking – but commissioners must be given the extra funds to do so, says Professor Avery. ‘So many of us avoid sending patients to pain services because that’s where they end up on more stuff. It almost feels like we need a revolution in pain services.’
Sutton Coldfield GP Dr Samuel Finnikin agrees there is little or no support for GPs trying to tackle opioid prescribing for patients with chronic primary pain. Dr Finnikin says pain clinics have tended to be unhelpful and generally mean the patient waits several months only to be given a prescription for a gabapentinoid and discharged. He has now stopped referring patients to the clinics but says alternatives are lacking. He adds: ‘Acupuncture is not available in my area and the way that the guideline is phrased suggests it’s not very effective.’
We need more psychologists and not more doctors working in chronic pain
Dr Samuel Finnikin
A proper specialist CBT pain service is what is needed, he says. ‘This, in my opinion, would be the biggest step forward in managing chronic pain.
‘We need more psychologists and not more doctors working in chronic pain. Along with good specialist physiotherapy and rehab services, this would be the solution,’ he says.
According to some GPs, NICE has also missed the glaringly obvious contributing factor of social deprivation.
East London GP Dr Jonathan Tomlinson stresses complex trauma is ‘almost always a factor’. He says: ‘Chronic pain is almost overwhelmingly a problem of deprivation and despair.’
The RCGP is currently drawing up its official response to the draft NICE guidance, but its clinical representative on chronic pain, Dr Martin Johnson, says he has concerns about GPs being overburdened with the regular patient check-ups that would be required. He says: ‘General practice doesn’t have the resources to do all of that. They wish they did but they don’t.’
Similarly, Dr Johnson says a wholesale ban on OTC prescriptions would not be workable. An MHRA spokesperson told Pulse last month: ‘The MHRA is keeping the safety of OTC products containing codeine under review and will consider other interventions, including the possibility of reclassifying all opioidbased painkillers as prescription only, as necessary.’
But Dr Johnson says steps such as reducing pack size may be more realistic. ‘If you have toothache the medication works and we don’t want to deprive people of that. Putting it on prescription only? General practice doesn’t have the resources to cope with that.’
But there is some room for optimism that the tide can be turned in the UK – as the decreasing proportion of the population on opioids suggests.
There is a recognition that we need an overarching pain council in England
Dr Martin Johnson
Dr Johnson says he wants to see a connected pain service across the country – similar to those developing in the devolved nations. He says: ‘There is a recognition that we need an overarching pain council in England that has seamless oversight of pain services. That happens in Scotland and is starting to happen in Wales, but England doesn’t have any system. We have got guidance but it’s the whole approach that needs to be sorted out.’
But unless and until that happens, if NICE’s draft guidance is adopted, GPs will find themselves having yet more conversations with patients in which their hands are tied. Dr Finnikin adds: ‘I am constantly telling people the medications don’t work and they then ask me, quite reasonably, what does work? I currently have little to offer them. I wish I had more.’
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