Painkillers 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.’
In 2004 I was literally hit overnight with acute pancreatitis, and over the next four years I was in hospital about 40 times. As an inpatient I was treated with IV morphine and tramadol and then as an outpatient I was given oxycontin.
I was moved up to a London hospital at the end of 2007, where they switched me onto IV fentanyl, because the morphine had exacerbated my condition, making me even more ill. I’d had lots of surgery, lots of procedures, and was eventually discharged in 2008 with a repeat prescription for fentanyl lozenges [opioid analgesics], being told I could have eight a day as a maximum.
It took me about three months before I took an extra one – and I don’t know why I did. I’d had years of being operated on, diagnosed, misdiagnosed, and I had no control whatsoever over my journey. So for some weird twisted reason I felt I had taken back control of my life by taking an extra lozenge for the pain. But actually it was the start of a terrifying descent into drug addiction.
This was in 2008 and by the time I got to rehab in 2010 I was on 60 lozenges a day, all on prescription from my GP. He’d told me that he wouldn’t sign any more prescriptions and I hit desperation.
I was refused NHS detox because I wasn’t homeless and I wasn’t offending. There’s a massive loophole in the system and I fell right through it. My parents had to lend me lots of money, and I had to sell my house.
I was lucky I had a house to sell, or I would be dead. But how many people are there out there suffering in silence, with GPs not taking the fact they’re dependent seriously? GPs who feel that taboo about having patients who are on long-term opiates and having no other way of treating them, but knowing they are dependent on them.
It’s a really complex issue – you get pain and you get the denial of addiction, and when those two are working together it’s incredibly difficult for anybody to make any headway. That’s one reason we set up a charity, the Pain Addiction Information Network (PAIN), to say ‘if I can get off these, then almost everybody else can’. It’s to raise awareness of OPD, recognised by the World Health Organization and is as much about stigma busting as saying ‘this is something that can happen, so what are we going to do about it?’
We’re campaigning to have specialised services to help people who find themselves dependent on their prescribed or over-the-counter medication, and we want NHS England to provide specialised treatment services for patients who come in via pain, rather than via illicit drugs.
Opioid Painkiller Addiction Awareness Day (OPAAD) is on 22 September
This article has been produced with support from Indivior, which has not influenced the content in any way.