When the drugs don't work
As the evidence stacks up against the use of opioids for chronic pain, there’s a clear role for community pharmacists in helping people to follow suitable, alternative management approaches and reduce their opioid use
After reading this feature you should be able to:
• Recognise the role community pharmacists can play in ensuring safe opioid use
• Manage the treatment expectations of patients with chronic pain
• Understand the thinking behind the Painkillers Don't Exist campaign.
The latest data from Public Health England estimates that 5.6 million adults take prescription opioid medications. While opioids work well for acute pain and pain at the end of life, there is no evidence — or NICE guidance — that they are effective for chronic pain. Yet they remain widely prescribed for this use.
Shaheen Bhatia, pharmacist and owner of P&S Chemist in Ilford, who featured on Ross Kemp’s Living With Painkiller Addiction documentary in June 2020, says over-prescribing of opioids remains “a massive concern”.
“GPs are meant to be reviewing their prescribing guidelines but we see the prescriptions coming into the pharmacy and opioids are still being prescribed by the bucketload,” she says. “I fear if GPs continue seeing people at a distance, as they have been during the pandemic, it is only going to get worse.”
Part of the reason for this is that patients don’t always understand that these medicines are only meant to be used in the short term. “I saw a young woman who had been in a minor accident and whose GP had prescribed co-codamol for her muscle pain,” says Bhatia.
“She was given a repeat prescription and when she came in to collect it, I asked her why she was still taking the medication. She told me she wasn’t sure but thought she should continue – which is the problem when people are not seeing the GP and instead are left to their own devices.
“There is also the issue of patients asking for medicines to be delivered by the pharmacy because of Covid, which means they are not having contact with a pharmacist – so that is another missed intervention.”
One solution, she says, is for GPs and pharmacists to unite around patient care. “If GPs told patients when they initiated them on these medicines that they want them to follow up with their pharmacist, patients would be more likely to see us or call us with any queries they may have.”
• There is no evidence that opioids are effective in chronic pain
• A draft NICE guideline on chronic pain has recently gone through the consultation stage
• Sunderland and County Durham CCGs have launched a campaign to raise awareness of the dangers associated with the long-term use of opioids.
Draft NICE guidance
Another strategy for tackling the issue comes in the form of a draft NICE guideline on chronic pain, the consultation stage on which recently finished, and which is due to be published in April.
This guideline covers assessing and managing chronic pain in people aged 16 years and over and includes recommendations on managing chronic primary pain – for which there is no other NICE guidance. The aim is to reduce patients’ distress and improve quality of life by ensuring a care plan is informed by the person’s own “priorities, strengths, preferences, interests and abilities”.
While the guideline recommends that some antidepressants can be considered for people with chronic primary pain, it says that paracetamol, NSAIDs, benzodiazepines or opioids should not be offered because, while there is little or no evidence that they make any difference to people’s quality of life, pain or psychological distress, there is evidence that they can cause harm, including possible addiction.
The draft guideline also says that anti-epileptic drugs including gabapentinoids, local anaesthetics, ketamine, corticosteroids and antipsychotics should not be offered to people to manage chronic primary pain – again, because there is little or no evidence that these treatments work but can have possible harms.
Instead, acupuncture is recommended as an option for some people with chronic primary pain, along with supervised group exercise programmes, and some types of psychological therapy.
GPs are meant to be reviewing their prescribing guidelines but we see the prescriptions coming into the pharmacy and opioids are still being prescribed by the bucketload
New models of treating pain
“This guideline was always going to be very contentious because all recent NICE guidance on any pain has been contentious, as it moves away from the well established medical model,” says Emma Davies, advanced pharmacist practitioner in pain management at Cwm Taf Morgannwg University Health Board.
“As time goes on, evidence shows that for more and more people, for more and more conditions, medicines are only part of the answer rather than the only answer, and there are many benefits to be had from improving general health and wellbeing, particularly with the management of long-term conditions.”
However, Davies says, just because she frequently talks about how to reduce use of medicines is not to say she doesn’t initiate patients on them. “My reading of this guideline is that medicines are of really limited benefit when it comes to chronic pain. What I would promote – as I feel I have always done – is that we might need to try these medicines with some patients but we must be much more open about the likelihood of them being of benefit or not. We need to move towards only starting medicines as a trial rather than saying ‘here you go’ and not making any plans to see that patient again.”
The protocol for starting a patient on opioids should be like sitting through the safety briefing on a plane, she says. “Even if you’ve flown 100 times before, you are given a safety message and shown all the exits in case something goes wrong. We need to do that with analgesics.
“Before they are prescribed we need to have the exit routes planned with a review date, and tell the patient that if they are not improving their function – rather than aiming to be pain-free, because it is unlikely they will get there – then they need to be carefully and slowly stopped.”
Nonetheless, Davies doesn’t think this guideline will lead to a sudden cessation of medicines use in chronic pain. “It is not that straightforward. It doesn’t say that if anyone is on these medicines they should be stopped. It says prescribers should have conversations with patients about the risks and where it is agreed these medicines should be reduced, this should be done very carefully and slowly with conversations about withdrawal risks.
“If these medicines are allowing people who are already on them to maintain or improve function and are giving them a reduction in pain, provided the dose is safe and not causing any other problems, why would we stop them?”
Emma Davies is part of a vanguard of healthcare professionals who believe more should be done to manage the treatment expectations of patients with chronic pain.
“Pain is a perception formed from nervous system signals in the brain, which it uses to interpret where the pain is, how severe it seems to be, and if you have experienced that pain before,” she explains. “Also, the general perception of pain is that it is something going on right this minute that needs fixing – but long-term pain is not caused by something that can be fixed.
“We need to do more to help people come to terms with their pain and understand that it might reduce, but it might also be around for a long time, and that they can come and see us about pain but shouldn’t expect a prescription.”
The protocol for starting a patient on opioids should be like sitting through the safety briefing on a plane
With medicines use reviews coming to an end, community pharmacists are losing one tool in their interventionary arsenal for helping people manage their pain and their pain medications appropriately, but there are other ways to help with advice, signposting and support.
In its Best Professional Practice guidance for pharmacists on safe opioid prescribing, the Faculty of Pain Medicine of the Royal College of Anaesthetists recommends reminding customers that OTC analgesics containing codeine or dihydrocodeine in combination with other analgesics, such as paracetamol or ibuprofen, are intended for short-term use (no longer than three days) to minimise dependence and addiction.
Similarly, pharmacists noticing patients taking codeine or dihydrocodeine-containing analgesics regularly should encourage them to seek appropriate advice and support services.
Other interventions include lifestyle advice around sleep, diet and exercise, and supported self-management of pain, which could encompass signposting to psychological and mental health support services.
Pharmacists with a relevant independent prescribing (IP) specialism can also consider running a pain management clinic, which can work particularly well in collaboration with local GP surgeries and other community-based teams.
Pharmacist and IP Jon Smith has run a medicines withdrawal service at Mayberry Pharmacy in Newport for over a year, funded by the local health board. People access the service via GP referrals, and staff also keep an eye out for customers who are frequently buying painkillers or asking about their next prescription before it’s due.
“It is a patient-centred approach,” he says, “so our objective could be anything from complete removal of the drug, to dose reduction, and if the treatment is not effective for their pain, I can also do the switch for the GP. I see the person every two weeks and it takes as long as it takes. Some people get through it in four appointments; others can take eight months.”
Campaign to cut long-term opioid use shows promising results
In 2019, Sunderland and County Durham CCGs joined forces to launch the PainkillersDontExist.com campaign to raise awareness regionally of the dangers associated with long-term use of opioid pain medication, and help patients, their family and friends recognise if opioids were becoming a problem.
“The ethos is about trying to shift the conversation away from doctors and pharmacists trying to engage patients with pain on opioids by telling them that these medicines are not great for chronic pain, and then onto patients saying to their GP ‘I don’t think this is doing any good and I want to stop taking it’,” says Ewan Maule, head of medicines optimisation at Sunderland CCG.
The campaign features hard-hitting social media messages, posters and advice cards, roadside billboards, local stories and a website with information and support. All pharmacists in Sunderland – dubbed ‘the painkiller capital of the country’ – were sent a resource pack of posters and cards to go in prescription bags to help engage patients in conversations on the subject.
Controversial — but it’s working
“It has been slightly controversial in some ways as you would expect,” says Maule, “but that was deliberate because this is a difficult message to get across to people who don’t want to hear it. People don’t necessarily like our tagline of ‘painkillers don’t exist’ and are quite defensive about their situation.
“The expectation is that pain is a thing that can be removed but it is not. It can be managed but it is a trade-off between what you take for it and the pain itself. People think the residual pain they have is despite taking the medication, but the evidence says the medicine is unlikely to be working for that pain, so they will have pain plus side-effects. If you’ve been taking morphine for 30 years and can’t do without it, then you are exactly the kind of person we are trying to reach with this message,” says Maule.
However, he stresses that it is all about changing people’s thinking rather than telling them to suddenly stop taking the medicine. “In the first instance it is about opening up the conversation and signposting them to their GP – and indeed it is the PCN pharmacists in general practice who are taking on a lot of that opioid reduction workload now.”
For the CCGs this isn’t just a targeted intervention against specific individuals; it is about promoting the wider societal message around wanting to change – and it seems to be working. “We have seen a reduction in the people taking high dose opioids, although not a significant reduction yet in the number of people taking opioids overall or in healthcare professionals initiating them,” says Maule. “That’s our next piece of work and we are looking towards more pharmacists being involved in the future.”