30 August 2018: Dr Simone Yule: To avoid opioid abuse we need to re-think our relationship with pain By Dr Simone Yule, Clinical Lead at Action on Addiction We need to re-think our relationship with pain. That is, if we want to better manage substance abuse and avoid the opioid pandemic that is fast approaching the shores of the UK. It is sadly becoming a well-told and oft-repeated story: a patient that either had an accident or injury or a major illness is started on high dose opioids for pain relief in hospital, they are then discharged with a prescription of something like the highly addictive liquid oramorph with little explanation of how to treat this drug and then have an expectation that they need it and will be prescribed it until the pain stops. Because of how opioids work the body builds up a tolerance and if the prescription does not facilitate that pain relief then patients will take more and more to reach the same level of relief, this can then result in patients seeking the medication through alternative sources such as buying illicitly or online. Wherever there is demand, there is supply. We know this story, we have been told this story, but unless we re-think how we tackle pain management and pain relief we will hear this story more and more. With my work at Action on Addiction it is sadly a regular story with patients at our treatment centre seeking help from prescription medication addiction which is now matching those seeking help from illicit drugs. This is not one person’s fault, not the surgeon, the GP, the patient, the outpatient care or the treatment centres, but every part of this chain needs to come together to create a healthy and holistic solution to pain management that quickly gets patients off drugs and back to living a realistic pain managed life. Drug education We have seen at our treatment centre many more patients, particularly orthopaedic patients, prescribed high dose opioids such as the fast-acting liquid oramorph with no clear guidance of how long they should be on this medication and no clear understanding of what this medication does and how powerful it is. In my experience, patients are often discharged with a significant amount of medication and no direction given to the primary care team as to what the ongoing treatment plan is. We need better education for the patient and better planning and communication between hospitals and the primary care team regarding the patient’s discharge so the whole team including the patient are part of the process and understand the required outcome. Prescribing GPs could improve methods for policing repeat prescriptions. In our surgery group we have strict monitoring of opioid prescriptions and we now have a warning on our computer, if anybody has been on a long-term prescription, for them to be reviewed. I actually saw a patient recently who had previously suffered a major road traffic accident and was quite debilitated and on high dose opioids. It was highlighted that he was requesting more than he should be so I brought him in and in reality, it turned out, that he was desperate to get off medication but because he had not had the support from physiotherapy and the rehab service following his accident he had nowhere else to go other than to continue taking pain killers. Without a warning system it could have been many more months of repeat prescriptions before his desperate situation was clinically managed. Access to physical rehabilitation I fully believe in the holistic approach to pain management. The drugs are a quick fix and should only be used in the immediate aftermath of an accident or illness. I think true rehab, where you are looking at the psychological aspects and physical rehabilitation to manage and help alleviate the pain, is not nearly accessible enough. I have one patient, in significant pain, who has to travel 25 miles to their nearest rehab centre. Taking the time and considerable effort to make that journey once a week for him was not possible and so his recovery time extended, meaning his time on high dose pain killers also extended. In some parts of Britain, the distance is much further than 25 miles. De-stigmatising treatment centres There is still a public perception that drug treatment centres are for illicit drug addiction and somehow patients should be able to come off prescribed drugs without help. We need an awful lot more publicity about prescribed medication treatment and how you can access it and the long-term benefits of seeking this treatment. At Clouds House, the treatment centre run by Action on Addiction, we are seeing considerably more people coming in addicted to not only opioids, but drugs like pregabalin, a prescribed non-opiate medication. The fortunate ones who seek help, or are guided to that help by a GP or family member, come to realise that this addiction is serious and with the right treatment it can be overcome. Obviously, to create healthier planning around pain management, and make it accessible for all patients, of course, requires funding. The pressure to discharge patients quickly, to reduce waiting times in GP clinics and to cut outpatient services, all means we reach for the quick fix and we will all pay the price somewhere else down the line. The only winner is the drug company. This article appeared in GPonline.com. These comments also featured in an opinion piece about an opioid pandemic by senior reporter at GPonline.com Jenny Cook: Workload pressures are driving the UK towards an 'opioid pandemic', with growing numbers of patients becoming addicted to pain relief, a leading GP has said.