An area of concern which has grown immensely over the last two decades is the overuse and abuse of prescription pain medication.
Studies in the United States of America and Canada reveal that there has been a 68% increase in unintended deaths associated with opioid use in the first 2 decades of this millennium.
Moreover, the correlation between unintended deaths and the steep increased prescription of opioids such as OxyContin and benzodiazepines such as Alprazolam is remarkably consistent. It is hard to know whether the increase in the prescription of these drugs relates to an increase in non-malignant pain disorders in society or an increased willingness by doctors to prescribe opioids for existing conditions.
GPs have an immense role in primary care of patients.
In the clinical setting, doctors do prescribe potentially abusable drugs for therapeutic effects for chronic pain related conditions. These drugs can be mood altering, analgesic and give euphoric effects, and are highly addictive. All patients on long term opioids become physically dependent and get withdrawal symptoms, but when the withdrawal symptoms include behavioural problems this is addiction.
Abusers of pain medication often target new, overseas trained and female doctors but are a challenge to all GPs with their persuasive stories, urgent requests and occasionally aggressive and threatening manner.
In a recent Medical Board of NSW decision where a practitioner was deregistered as the result of inappropriate prescribing matters, the Board said:
“Overall, the flavour of the respondent’s evidence was that he was a slave to the patient’s request for drugs, he could counsel and advise them to reduce but in the end submitted to their demands. The Tribunal finds this demonstrates both a lack of insight but also a failure to exercise his responsibilities as a medical practitioner.”
Unfortunately, there are inadequate prescription monitoring mechanisms in Australia such as to allow real-time prescription monitoring across the state and country. There is a concerted push in most states of Australia for such a system, but it does not yet exist. The Commonwealth Government has implemented a 24 hour service through the Medicare Prescription Shopping Information Service which allows GPs to search (without the need for patient consent) for their patient to see whether they are a known doctor shopper.
Extreme caution needs to be exercised by GPs in recognising and dealing with patients who have a chronic pain condition and may be overusing or abusing their pain medication.
GPs are guided by the Royal Australian College of Physicians publication, which is endorsed by RACGP – Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use.
GPs need to better recognise and deal with patients who have chronic pain conditions but who may be overusing or misusing their pain medication, identify risk factors such as past or present substance abuse and psychiatric illness, personality disorders that affect their response to pain, and those who exhibit behavioural difficulties. In some instances it may be best to manage a patient in a multidisciplinary way involving GP, pain specialist and psychiatrist.
Some strategies recommended under the policy are as follows:
- Develop standing clinical policies on the prescription of drugs of addiction and stick to them
- Engage the patient in a treatment programme
- Say ‘no’ to the requested prescription if there is reason to believe the drugs are being abused or misused
- See the patient more frequently so as to avoid the large one-off consumption
- Arrange for the pharmacy to dispense smaller quantities more frequently
- Request urine tests
- Adopt a multidisciplinary approach
- Switch to a methadone or buprenorphine programme if signs appear of ongoing drug abuse
The Law Office of Conrad Curry has had a number of cases involving GPs and the overdose and subsequent death of people from pain medication who have had chronic non-malignant pain conditions. The area is complex and challenging but the GPs duty is high. If you would like to discuss this article or a potential case in this field please feel free to contact our office to make an obligation free appointment.