Opioids are effective analgesics to treat acute pain and end of life care, but side effects are very common. According to NHS England, up to a quarter of patients taking opioids long-term become dependent on them.
So how can community pharmacists help deliver safe opioid prescribing?
Al Patel, owner of Lee Pharmacy in south east London, says that pharmacists have a large role to play in managing patients prescribed opioids. ‘Overdoses are high risk with opioids and pharmacists play a big part as they’re the last person a patient deals with before being handed over their medication,’ he explains.
He continues: ‘Pharmacists are called when converting from one opioid to another or changing routes of administration.
‘They’re also able to assist if a prescription is written out of the British National Formulary’s (BNF) range and call the GP to clarify.
‘Other ways they can help is through monitoring high-risk opioid therapies, developing policies, procedures and guidelines, participating in quality improvement programs to increase adherence to pain management guidelines and counseling patients on safe storage and disposal of prescriptions opioids.’
Since the case of Dr Harold Shipman – a GP who killed around 250 patients, mostly with a lethal dose of the opioid diamorphine – the Misuse of Drugs Regulations require pharmacists to check at the Point of Dispensing (PoD) ‘whether the person collecting the drug is the patient, the patient’s representative or a health care professional acting on behalf of the patient’.
Opioids fall under Controlled Drug (CD) prescriptions, which are only valid for 28 days.
Mr Patel says that ‘Clinical Commissioning Group (CCG) pharmacists often call the prescriber to request why more than 30 days were written’.
He adds: ‘There is a good practice requirement that the quantity of Schedule 2, 3 and 4 CDs be limited to a quantity for up to 30 days treatment.
‘In cases where the prescriber believes that a prescription should be issued for a longer period, he may do so but will need to be able to justify that there is a clinical need and that it would not cause an unacceptable risk to patient safety.’
The UK has the highest number of drug overdose deaths in Europe, according to the European Monitoring Centre for Drugs and Drug Addiction.
In 2015, there were around 8,500 overdose deaths – mainly related to heroin and other opioids – with the UK accounting for 31% of these.
In a study, the University College London (UCL) and University College London Hospitals (UCLH) found that there was an increase in opioid prescription by GPs between 2010 and 2014, with the highest prescribing areas found in the north of England.
Lead author Dr Luke Mordecai says that many GPs prescribed opioids such as codeine and dihydrocodeine because they thought it was ‘unethical to refuse their patients painkillers’.
But Emma Davies, an advanced pharmacist practitioner in pain management in Wales, argues that ‘to say that the reason for the large increases in prescribing we have seen is due to GPs entirely missing the complexity of prescribing’.
She continues: ‘In simple terms, the increases are likely due to an increase in prescribing across all sectors – potentiated by 20-year-old articles expressing the small risks of addiction to opioids when used in long-term, non-cancer pain.
‘The reasons for the increases are complex but certainly not due to any one profession or any one sector.’
Mr Patel says that ‘he has seen GP telling patients to put two patches of 12mcg/hr rather than one 25mcg/hr, which can often cause a risk’.
He adds: ‘The increase in prescribing of opioids by GPs is primarily due to patients not being seen in pain management clinics and seen by GPs who have only between a five and 10-minute consultation time.
‘With such chronic conditions, GPs prescribe medication for patients to alleviate their symptoms.’
Dr Mordecai argues that although opioid prescription is on the rise, the drug has ‘not been shown to be effective in most chronic pain beyond modest and short-term effects’.
Opioids are potentially dangerous, with complications and adverse effects such as addiction, abuse, hyperalgesia, gastrointestinal disturbance, immunological dysfunction, risk of fracture in older people and increased mortality.
NICE guidelines say that ‘the risk of harm increases substantially at doses above an oral morphine equivalent of 120 mg/day’, outweighing any potential benefit.
In 2013, a 32-year-old woman died following a respiratory arrest. After a back injury, the woman was prescribed increasing doses of oxycodone, against the advice of the pain clinic, alongside benzodiazepine medications, antibiotics and anti-inflammatory medicines.
Andy Burrells, pharmacist at a LloydsPharmacy believes that ‘it would be great if opiates fell into medicines use reviews (MURs) because of their extreme high risk’.