Re-thinking opioids

Pharmacists can minimise opioid harm by helping patients step down.

While opioids play an important role in the management of acute pain, their widespread use to treat chronic pain and misuse in dependent individuals has resulted in multiple cases of harm. 

This has been highlighted as a public health issue in Australia’s Annual Overdose Report 2019.¹ The report revealed that opioids (pharmaceutical opioids and heroin) caused over 900 deaths in 2017, accounting for over half of all unintentional deaths. Although heroin deaths were found to be increasing, pharmaceutical opioids comprised the largest proportion of deaths involving opioids. The findings suggest we need improved management of persistent pain and less reliance on opioids long-term. Part of the harm minimisation strategy is to step down opioid doses with a view to stopping where possible. Pharmacists can support patients in the stepping down process in a safe, effective way.

Opioids present a challenge as they are addictive and can lead to significant harm. From 1992–2012 there was a 15-fold increase in opioids dispensed, and the Pennington report demonstrates that this is increasing.¹ Over the course of a year, 20% of Australians over 45 years of age will be prescribed at least one opioid, for either acute or chronic pain. Patients on longer-term therapy are more likely to be prescribed a higher dose opioid.² 

Opioids have a limited role in the management of chronic non-cancer pain (CNCP). Current evidence does not support long-term opioid therapy. Because of the lack of evidence of efficacy and risk of harm with long-term use, deprescribings should be considered for patients using them long-term, particularly when adverse effects have been reported.²

Adverse effects include opioid-induced hyperalgesia and tolerance which cause a perceived increase in pain and need for dose escalation. Recent studies indicate that opioids may contribute directly to chronic pain. This toxicity may commence after a brief exposure and leave a vulnerability to increased pain responses that may be of indefinite duration. Other long-term opioid toxicities include depression, sleep interference, hypogonadism, prolonged disability and delayed return to work.³

Deprescribing opioids

When deprescribing, the dose should be gradually reduced, and the patient monitored for withdrawal symptoms, level of pain and effect on quality of life.² Patients undergoing opioid tapering should be continually reviewed and assessed;  pharmacists are well placed to do this. 

Dr Marc Russo of Sydney Pain Specialists has reported minimal opioid withdrawal symptoms by stepping down sequentially each week over four to eight weeks. Typically, there’s a 10–20% reduction from the baseline dose each week or fortnight in order to achieve this outcome.⁴ Dr Russo stated: ‘If patients can feel that they are being empathically supported and that the deprescribing trial is exactly that, i.e. just a trial and that they are not going to be left with coping with increased pain, then they can be very open to the concept of reducing their conventional pure mu opioid medication.’

But for some patients, the deprescribing process may prove challenging and require months of gradual withdrawal to safely stop opioids. Gradual weaning may be derailed by an abstinence syndrome involving insomnia, emotional blunting, deficits in executive control and the exacerbation or reemergence of comorbid psychiatric disorders.1 If an attempt at deprescribing has been unsuccessful, it may be wise to plan a slower taper or consider opioid substitution therapy. Refer to the Australian Pharmaceutical Formulary (APF) for advice on opioid tapering and opioid substitution therapy, including equi-analgesic doses for opioid conversion.⁵ 

Ideally, multidisciplinary services including a pharmacist, should support patients living with CNCP and identify when to refer those at high risk of harm from opioids. Pharmacists could refer to PSA’s Medicine Safety: Take Care report for further information on the role of the pharmacist in reducing medication events in Australia.

Advise patients to speak to their pharmacist or general practitioner when having difficulty managing their pain or reducing their opioid doses. Pharmacists could refer patients to state and territory alcohol and other drugs telephone counselling and referral services, many of which operate 24 hours a day, seven days a week. 

To learn more about deprescribing, refer to the CPD articles:

• Deprescribing in the elderly: https://www.australianpharmacist.com.au/deprescribing-in-the-elderly/
• Overcoming barriers to deprescribing of medicines, the role of the pharmacist: https://my.psa.org.au/s/training-plan/a117F0000019uiTQAQ/overcoming-barriers-to-deprescribing-of-medicines-the-role-of-the-pharmacis

References

1. Australia’s Annual Overdose Report 2019. Penington Institute.
2. Chronic pain. Medicinewise News: NPS MedicineWise.1 June 2015. At: https://www.nps.org.au/news/chronic-pain
3. Holliday S, Hayes C, Jones L, et al. Prescribing wellness: comprehensive pain management outside specialist services.  Aust Prescr 2018;41:86-91. At: https://www.nps.org.au/australian-prescriber/articles/prescribing-wellness-comprehensive-pain-management-outside-specialist-services
4. Russo M. Deprescribing opioids. Sydney Pain Specialists. 19 July 2018. At: https://sydneypain.com.au/2018/07/19/deprescribing-opioids/ 
5. Sansom LN, ed. Australian pharmaceutical formulary and handbook, 24th edn. Canberra:2018. At: https://www.psa.org.au/media-publications/australian-pharmaceutical-formulary/