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GPs advised not to prescribe opiates

NICE (National Institute of Clinical Excellence) has produced it’s draft report on the use of opiates and other medication for chronic pain which will apply to general practice. The previous link is a summary from a GP magazine but the full draft report from NICE with evidence can be found here.

The summary of the draft report is that treatment with opiates (codeine, tramadol, morphine, fentanyl, oxycodone) and gabapentoids (gabapentin and pregabalin) does more harm than good. Also the evidence for them making a difference in chronic pain is poor. That is also my experience as a GP who sees many people with chronic pain.

Is this approach a good thing? I think that it it because;

  • It will move attention in the GP consultation away from medication to what else might make a difference. Why doctors prescribe is complex with patient, doctor, societal and social factors. Part of the problem of opiates has been overprescribing by doctors; doctors will be less likely to reach for a prescription and will manage the consultation in a much more holistic way.  GPs will ‘play by the NICE rules’ to support not prescribing opiates and other medications in chronic pain.
  • We need better services for physiotherapy, acupuncture, pain programmes, mental health interventions  (Acceptance and Commitment Therapy and Cognitive Behavioural Treatments) which the report says have evidence of effectiveness behind them. Maybe this change will stimulate health commissioners to ‘beef up’ or start these services, Services for people with chronic pain are poor and until recently hospital led pain clinics have been focused on prescribing medication rather than a holistic package of interventions. That ‘medical only’ approach to chronic pain cannot be supported anymore because it is a bio-psycho-social problem.
  • It is clear from this report and the accompanying research papers that pain research is in its infancy. For example, few studies examine the impact of pain on sleep which is a major issue for people with chronic pain. We need more community research looking at what pain interventions work and what can be left behind.
  • The report does highlight medications like amitrytpyline, duloxetine and antidepressants, like fluoxetine, that can help pain. Often I think that they ‘work’ by sedation to improve sleep but can help nerve pain. I think that we will see more prescribing of these because, like Old Mother Hubbard, the cupboard is bare of medicines that can be used in chronic pain.
  • Many patients who have been on opiates for many years will be worried about their tramadol or other opiate or pregabalin prescriptions because the latest evidence is that their medications are no longer indicated for their conditions. Clinical Commissioning Groups and local GP practices will want to target patients where these medications can be stopped. I think that this is a good thing but it need to be managed with care, and it would be helpful to have more of the services that work in place as alternatives too medication. It is often that I and a patient decide to stop a medication that they have been on for years; their pain is no different off the medication, but they have more energy because they are not sleepy due to medication.
  • I don’t think that the new guidance will affect prescribing for cancer patients and those with neurological syndromes. But it will impact on a huge group of patients  with chronic back pain. The emphasis will be even more so on promoting activity, pain programmes and mental health interventions and not prescribing which will become severely limited.
  • I think that the NICE chronic pain guidelines will also impact on ‘acute’ prescribing for pain of any cause, apart from cancer,  because GPs will be even more cautious about prescribing opiates and keen to promote non drug treatments.