Supporting prescribers to respond to pharmaceutical opioid problems
From February 1 2018, medicines containing codeine are no longer available without a prescription in Australia. This is due to concerns about the inappropriate use of these medications and increases in related harms such as hospitalisations, iatrogenic dependence, adverse physical effects and deaths.
As a result of this regulatory change, many patients will need support to move to alternative non-pharmacological or non-opioid pain relief approaches. Others will find it difficult to stop their opioid use and may require alternative, more complex, treatment approaches. These approaches will require careful consideration, planning and dialogue with patients.
It is therefore timely to examine the inappropriate use of prescribed opioids in Australia, and how medical prescribers can be supported to identify and respond to problematic use in an evidence-based manner. Consequently, in 2017 NCETA was funded by Indivior to:
- Identify the key learning needs of Australian medical prescribers in relation to preventing pharmaceutical opioid-related harms and responding to patients experiencing such harms
- Collect and consolidate available evidence from relevant literature and expert opinion concerning best clinical practice in detecting, and responding to, pharmaceutical opioid problems
- Develop resources to inform best practice
- Identify the most effective approaches to distribute the resources and to encourage innovation dissemination.
Over the past fifteen years there has been a significant increase in the prescribing of Schedule 8 opioids in Australia. Use of over-the-counter codeine-containing medicines has also increased . However, harms associated with these trends have become increasingly apparent. These include iatrogenic dependence, overdose and inappropriate use for persistent non-cancer pain . In addition, there is growing awareness of the potential side effects of long-term opioid use including endocrine and sexual dysfunction, osteoporosis and hyperalgesia .
In Australia, more than twice as many people die from pharmaceutical opioid overdose than from heroin overdose. Rates of fentanyl, oxycodone, and methadone deaths all increased significantly between 2001 and 2012, by an average annual rate of approximately 40%, 16% and 3% respectively .
However, many prescribers are unfamiliar with contemporary evidence-based opioid prescribing guidelines and best practice responses to patients experiencing harmful use. Many lack sufficient knowledge, skills and confidence to address this issue and/or circumvent problems developing.
Preventing and responding to harmful patterns of pharmaceutical opioid use can therefore represent a significant challenge for many prescribers. Even when aware of appropriate prescribing practices, some prescribers may experience pressure from patients to receive scripts for, or increased dosages of, opioids. This can place prescribers in a difficult position when they do not believe that this is in a patient’s best interest .
Consequently, there is a pressing need to enhance the skills and knowledge of prescribers to prevent, identify and respond to patients experiencing pharmaceutical opioid use problems, and in particular iatrogenic dependence .
In order to address the above issues, NCETA has undertaken a comprehensive literature review of the trends, patterns, and prevalence of pharmaceutical opioid use in Australia, as well as an evidence-based resource for prescribers.
The literature review identifies current best international practice in preventing and responding to pharmaceutical opioid-related problems, and the extent and nature of these problems in Australia. It covers:
- The history of opioids
- Opioids’ uses and mechanisms of action
- Tolerance, dependence and withdrawal
- Measuring opioid use
- Patterns in opioid usage over time in Australia and globally
- Pharmaceutical opioid-related harms and adverse effects
- The role of opioids in the treatment of persistent non-cancer pain.
The resource, Responding to patients with pharmaceutical opioid-related problems focusses on assessing and responding to patients with pharmaceutical opioid-related problems. It also touches briefly on the issue of managing persistent non-cancer pain. It incorporates findings from the literature review as well as a comprehensive consultation process undertaken with key informants. Topics addressed include:
- Problems with longer-term opioids use
- Effective management of persistent non-cancer pain
- Opioids: Tolerance, physical dependence, withdrawal, substance dependence and pseudo-addiction
- Screening for codeine-related problems
- Non-opioid approaches to pharmaceutical opioid cessation or reduction
- Using opioids for pharmaceutical opioid cessation or reduction.
This project represents an important step in gathering the available international evidence on approaches to preventing and responding to pharmaceutical opioid use problems and applying it to the Australian context. It is the first nationally consistent approach taken to achieving practice change in detecting and responding to pharmaceutical opioid-related harms.
The resource will be made available to prescribers shortly and the literature review will be available for public download in coming months.
- Roxburgh, A, Bruno, R, Larance, B, & Burns, L. (2011).Prescription of opioid analgesics and related harms in Australia. Medical Journal of Australia, 195(5): p. 280-4.
- Nicholas, R., Lee, N., & Roche, A. (2011). Pharmaceutical drug misuse problems in Australia: Complex issues, balanced responses. National Centre for Education and Training on Addiction (NCETA), Flinders University, Adelaide.
- Roxburgh, A., Burns, L., Drummer, O., Pilgrim, J., Farrell, M., & Degenhardt, L. (2013). Trends in fentanyl prescriptions and fentanyl‐related mortality in Australia. Drug and Alcohol Review. 2013;32(3):269-75.
- Intergovernmental Committee on Drugs. (2014). National Pharmaceutical Drug Misuse Framework for Action (2012-2015). National Drug Strategy, Canberra.