The problem with opioids continued from Page 25 limited evidence of the treatments’ efficacy, something Dr O’Neil says will soon be established with the National Institute of Drug Abuse (NIDA), in the US, providing a $US6m grant to Go Medical, Columbia University and the New York State Psychiatric Institute to establish the effectiveness of the OLANI for detoxification of patients with OUD and measure the relapse rate as compared with treatments such as opioid receptor agonists. However, Dr O’Neil is keen to stress there are studies demonstrating the efficacy of naltrexone implants compared to oral naltrexone with regards to post-treatment mortality rates due to overdoses. Dr O’Neil first heard of naltrexone being used for opioid use disorder in the mid-1990s when he was speaking at a conference on pain management in China. When he returned to Perth, Dr O’Neil encountered a patient for which methadone was not effective. He approached the TGA for permission to trial oral naltrexone on the patient and after the successful intervention, more patients followed. “I realised there wasn't another doctor in Australia helping people to use medicines to get off opiates. And from then on, I was, accidentally, the only doctor in the country doing so,” Dr O’Neil told Medical Forum. Dr O’Neil, believes the issues faced by patients are as a result of a broken system of pain management and suggests the prescribers are the part of the problem. “Doctors around the world are starting to wake up and realise, gosh, we’re using opioids for treating pain. Now we have patients addicted to opioids and we're treating them with more opioids. There’s still a total reliance on treating people with opioids. It’s not good medicine,” he said.
Parlance of pain What once was the ideal treatment of CNCP is now being recognised as anything but. However, for the 26 | MARCH 2020
general public the association of opioids and chronic pain is synonymous, according to Associate Professor Suzanne Nielsen, Deputy Director of the Monash Addiction Research Centre, in Melbourne. “Patients might expect to receive something strong for pain, expecting that [opioids are the best outcome], and perhaps not aware of some of the downsides, particularly of using these drugs in the long-term. “And similarly, for medical professionals. I trained as a pharmacist about 20 years ago and at that time we were told that if people had genuine pain, it was almost impossible for them to develop addictions to opioids. We now know that that's absolutely not true. Many health professionals were trained with that understanding.”
overdose is often used. And you see information around naloxone and reducing opioid-related harm using the term overdose. And that just isn't salient for our patients who are prescribed opioids for chronic pain. “Often, patients interpret overdoses as something that applies to people who take too many opioids intentionally or associate that with illicit drug use, and it isn't necessarily something that patients prescribed opioids for chronic pain feel like might happen to them. “Obviously, our mortality data says otherwise, but we do need to have language to try and bridge that gap and let patients know that there are risks with opioids even when they are used as prescribed interventions such as naloxone, which might be appropriate for a really broad range of people. “For patients with chronic pain, it’s important not to use the word overdose because it is such a value-laden term and it's often stigmatised.”
According to A/Prof Nielsen, a lot of the harms from pharmaceutical opioids were being experienced by people being prescribed opioids for pain.
A/Prof Nielsen suggests that explaining symptoms explicitly is more effective, not only for the patient but also encourage them to discuss these symptoms with their families.
“When we're trying to reduce opioid-related harm, we need to be thinking about the many different populations. We need different strategies for those who might get pushed off opioids through prescription monitoring versus those that might be on opioids for chronic pain and might have other risk factors,” she said.
“Alerting them to the fact that opioids can affect respiration and when it’s severe, it can cause people to stop breathing altogether. And, in that case, why that person should have naloxone in their home. We need to educate not only patients and their family members around these signs and symptoms and what to look out for.
“For example, being prescribed multiple central nervous system depressant medicines, or also having some of those comorbidities such as COPD, which increase the risk of mortality with opioid use. There's a broad spectrum of patients with a range of issues we need to consider.”
“Tragically we hear in coroners’ reports of people who died in their sleep when there was someone in the home who heard them with laboured breathing and just didn't identify that as a sign of respiratory depression, and therefore they didn’t respond.
The specific language used in doctor-patient conversations is particularly important, A/Prof Nielsen told Medical Forum. “When having conversations with patients about opioids, the term
“Education for family members who may see these signs and symptoms is vital so they can intervene by either administering naloxone on the spot or calling an ambulance and thereby reducing those preventable deaths.”
MEDICAL FORUM | PAIN MANAGEMENT ISSUE
BACK TO CONTENTS
FEATURE
