Painkillers
12 |
drinkanddrugsnews
| July/August 2016
P
ainkillers are a growing market and
prescribing is on the increase. Drug
services are seeing a growing number of
people presenting with opioid painkillers
as their drug of addiction. But despite
local statistics and plenty of anecdotal evidence, there
is no national picture of how big the problem is – and
no coordinated strategy to deal with it.
‘It’s really impossible to try to assess the scale of
the problem,’ says Duncan Hill, specialist pharmacist
in substance misuse at NHS Lanarkshire. ‘There’s a
real gap in evidence, but it’s a massive problem in
America and prescribing here is on the increase.
‘It’s a really challenging issue and one of the
problems is trying to quantify it. There’s just no data.
You could be misusing over the counter (OTC) stuff, or
you could be getting it from friends and family, or you
could be going to the doctor and getting it prescribed.
It’s multi-access, multi-source – there’s a mass of
different methods of getting the medication.’
As a community pharmacist in north west London,
Stephanie Bancroft is well placed to take stock of the
situation, seeing patients who are picking up
prescriptions from their doctor; people who are
buying OTC painkillers – both ‘pharmacy only’ (P)
medicine at the chemist’s counter; and ‘general sales
list’ medicine (GSL) at the till.
‘Quite often patients are put on an opioid-
containing painkiller by their doctor and then it’s put
on repeat without being reviewed,’ she says. ‘The
patient continues to take it but might not need it – it
could be titrated down to a less potent medication.’
Then there’s the patient who actively seeks opioid
painkillers from the doctor or pharmacist when they
are no longer in pain. ‘They are the ones that are more
likely to be addicted, because they don’t understand
that they don’t need this pain relief anymore. Their
brain is telling them, “I want the opioid high”, which is
very difficult to address. They may also feel
uncomfortable or unwell when not taking painkillers
because of withdrawal effects.’
Recognising the problem is the first step, she
explains, which means being able to identify the
difference between someone deliberately misusing
the drugs and a person who has become addicted
from long-term use.
‘You do get people who will do anything to get
medicines, trailing round ten pharmacies to get a pack
of 16 or 32 painkillers maximum from each to feed
their habit,’ she says. ‘But if you refuse to sell them
the product, you know that they’re going to do down
the road to get it from somewhere else, or go further
afield so that they’re not recognised.
‘Then there’s the patient on a prescription who has
a two-month supply of painkillers, but comes back
after seven weeks, then six weeks, saying they’ve run
out. Quite often they come up with excuses – they’ve
lost them, they’ve given some to family members,
they’ve left them on holiday. I’ve heard it all.’
An experienced pharmacist can spot opportunities
to intervene, but even with years of experience
Bancroft acknowledges that this isn’t easy and needs
high-level consultation skills.
‘Often they don’t accept there’s a problem and
they don’t want to talk to you, so breaking into their
world is very difficult. How do you suggest that the
patient has a problem without appearing to be
interfering? Some people have the knack but others
dive in and alienate the patient,’ she says.
Pharmacists are supposed to ask the WWHAM
questions, she points out, which stands for who is the
patient, what are the symptoms, how long have you
had the symptoms, what action has been taken, and
are you taking any other medication. They also need
to counsel the person about side effects of the drug
and the fact they should not be taking it for more
than three days, but ‘there’s no guarantee that that’s
happening in every single case.’
The other crucial issue is referral. ‘If you do identify
a patient who you think has got a problem, there’s
nowhere really to refer them to,’ says Bancroft. ‘You
can’t do it as a pharmacist, you’d have to refer them
back to the GP.’ Of course there’s the drug and alcohol
team – ‘but quite frankly a patient who’s got this type
of addiction doesn’t want to be attending a drug and
alcohol service, because they don’t see themselves as
addicts or abusers,’ she says. ‘They regard themselves
as normal people who just need to take some tablets.’
Up in Lanarkshire, Duncan Hill’s team have been
trying to get heads together on the growing problem
of opioid painkiller dependence.
‘There are some discussions between primary care
GPs and pharmacy leads with addictions, and we’ve
also had some conversations with the chronic pain
services, but we’re not as far engaged as we’d like to
be,’ he says. ‘But we have been trying a couple of
small pilots with GPs, providing support, and have
started to develop tools.’ The aim of this, he explains,
is to help GPs to review and reassess the patient, and
to address their issues. The tools help to sit down with
the patient and look at what was originally prescribed,
what it was for, and find out if they still have the
same condition and the same pain – as well as
reviewing all the medication that they are currently
taking and finding out if there are other reasons for
taking it, such as to help them sleep better.
‘We need to provide support mechanisms,’ says
Hill. ‘We have to be aware that we need to treat the
pain as an everyday occurrence for most patients and
keep it at manageable levels. And we have to treat it
no matter what else is happening in the patient’s life.
‘What we need to do is bring all the people with an
interest in this around the table and try and work out
the best way.’
Painkiller addiction is a growing issue. In the first of
a three-part series, DDN asks, are we responding?
‘It’s a really
challenging issue
and one of the
problems is trying to
quantify it. There’s
just no data.’
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