The humane approach to opioids

This article was first published in the April 26, 2013 edition of Medical Observer. It was written by NDARC academic Professor Louisa Degenhardt.

Chronic, non-cancer pain will become an increasing health and social burden.

Around 20% of the population suffers from chronic pain. Among those 55 and older, it is one in four men and nearly one in three women.¹ Arthritis, rheumatism, back and neck problems are the most common conditions causing pain.

Pharmaceutical opioids such as oxycodone are effective in helping control pain. They are listed by WHO as “essential medicines” for the treatment of pain.² For the past decade in Australia, opioids have been available for treating acute and chronic pain. Oxycodone prescriptions rose by 152% between 2002 and 2008.³

Are opioids the treatment of choice for someone who may live the rest of their lives experiencing pain daily? We have few data to answer that question with confidence. Trials of opioids for people living with chronic pain have typically been short. Complex cases have typically been excluded, as is common in randomised controlled trials. There is the additional problem of opioid misuse. We have seen increases in deaths due to pharmaceutical opioids in Australia: in 2008, there were 551 accidental overdoses due to opioids, of which 70% were due to pharmaceutical opioids.⁴

These tragic consequences of misuse may be experienced by those for whom it was prescribed, or by people who are using another’s medication. The intention of those taking opioids differs, which matters because the responses to each must differ. For example, one quarter of oxycodone-related deaths in Australia were suicides. ³

Non-pharmacological interventions are recommended as a first and continuing line of response to chronic pain. ^5–7 Doctors and patients need information and assistance when making choices about using opioids. 

There are also other comorbid issues to be considered, especially mental health problems. In the course of our ongoing research with a cohort of people who have chronic pain,⁸ we have heard sad, sometimes tragic stories of debilitating, worsening illnesses, car accidents, work accidents, and varied other causes of pain among older people. It is important that doctors, family and the community do not forget the social and other problems people living with debilitating pain may experience.

A policy response attracting increasing attention is a “real time reporting” system, whereby treating physicians, including GPs, can see which opioids the patient has previously been prescribed, in what doses and quantities, and with which frequency, at the time of writing a prescription.⁹ Such a system seems far off given the need for state and territory approval and financial resourcing.

It seems reasonable to anticipate that we might see more people who have developed problems with pharmaceutical opioids, based on the US experience.¹⁰ Until more work is done with this patient population, we can benefit from what we know about responding to heroin dependence. Detoxification may be an attractive first option for dependent users, but it is rarely a long-term solution without ongoing therapy. People who stop using opioids face overdose risks if they return to use following abstinence.

Internationally, it is recognised that opioid substitution therapy — the provision of controlled doses of opioids with clinical supervision — is an effective way to assist heroin users regain control of their opioid use.^{11, 12}

The pharmaceutical opioid problem is causing concern, but it would not solve the problem by simply removing their availability, given that access to these medications is legitimate and humane. We need to develop evidence-based and compassionate responses to chronic pain, while doing the same to avoid pain medications used by those for whom it may not be therapeutic.

NDARC researchers led by Prof Degenhardt are running the Pain and Opioids IN Treatment (POINT) study, funded by the NHMRC. We hope to recruit over 1500 chronic non-cancer pain patients who have been prescribed opioids, and follow them over two years. Participants are reimbursed.