Dangerous Ideas: GPs should stop prescribing opioid medication except for palliative care

Most patients start taking opioid medicines prescribed by their GP, rather than being started by the hospital or specialist. GPs need to take responsibility and action to reduce opioid prescriptions, particularly as the large variation in prescribing is not explained by patient and practice characteristics but by individual GP prescribing habits.¹

WE ARE HEADING TOWARDS AN ‘OPIOID EPIDEMIC’

Prescriptions for opioids have increased greatly in the past 10 years. This rise is not explained by increasing numbers of patients with pain but by the changing prescribing patterns of GPs. The cost to the NHS of this rise runs into hundreds of millions, not only for the increased opioid costs, but also the costs associated with treating the well-known side effects (constipation and nausea), as well as the severe adverse effects (addiction to prescription medication, hospital admissions from falls).² Since the introduction of the World Health Organization (WHO) Pain Relief Ladder for cancer pain,³ GPs have been prescribing longer and stronger courses of opioids for chronic, non-cancer pain with little evidence that this is of benefit to patients and increasing evidence that this approach to pain management is causing harm. Although the UK has not reached the ‘opioid epidemic’ status of the US, we are heading towards an opioid problem.

To halt the projected rise in opioid prescriptions we need to refuse a prescription of opioids and suggest an alternative, non-pharmaceutical approach in just 1 in 20 patients who request analgesics. For every patient requesting analgesics, GPs need to think twice before starting the patient on opioids. For those already on long-term treatment we need reviews that ascertain whether they are controlling pain, and, if not, stop the medication rather than titrating upwards towards potentially toxic doses.

AVOIDING PRESCRIPTIONS FOR OPIOIDS

We need to address patients’ expectations that it is possible to live a life free of any pain and suffering. Pain is a normal part of life and it is unrealistic to expect complete freedom from pain. Instead, GPs should aim for functional improvement, addressing the idea that all pain has an answerable and treatable cause. Prescriptions are not always the best medicine and walking out of a consultation with one is often not good care. GPs need to base shared decision making and agreed care goals in the context of realistic expectations of what opioid medication can achieve and the harms it can cause. Furthermore, learning new consultation ‘scripts’ (for example, phrases to help discuss difficult issues) to manage patients’ expectations for a medicine as a ‘cure’ for pain could reduce unnecessary consultations and help take the pressure off overburdened GPs.

TAKING BACK RESPONSIBILITY AND CONTROL

GPs could just say no to all opioids where there is no palliative diagnosis. Those with major injuries or recovering from surgery could have the appropriate amount of opioid medication prescribed by secondary care, which is likely to have managed the patient, rather than expecting a GP to continue prescribing. GP training in managing chronic pain needs to be improved so the cancer-based WHO Pain Relief Ladder³ is not used to treat a very different type of pain and patient experience. Reducing and stopping prescriptions for opioids would help protect our patients from harm, save NHS resources, and reduce demand on busy GPs.

GPs need to take back responsibility for their prescribing.