Opiate medications don’t work for chronic pain – in fact they often make it worse.
In a recent pilot scheme in Hastings run jointly by Change Grow Live’s East Sussex drug and alcohol recovery service (STAR) with local GP surgeries, 235 patients were assessed and supported to manage their pain and wean them from opiate medications. Sixty were fully weaned and a further 57 reduced to a safe and sustainable level.
The results were startling. Patients who weaned from opiates reported an average 19 per cent improvement in their quality of life, significant reductions in anxiety levels, improved sleep, less constipation – and no increase in pain. Early indications also suggest a further reduction in GP appointments following weaning of as much as 20 per cent – a huge cost saving, especially when added to the £31,000 per annum saved in medications.
In addition a group work programme was developed that supported patients with a range of self-management techniques for pain. The isolation caused by chronic pain leads to a wide range of problems, and the group found it useful to spend time together connecting with others who truly understood their issues. In fact, the core of the group has continued to meet and, with support from Change Grow Live (CGL), is setting up a community-based peer support group for chronic pain sufferers.
Moderate to severe chronic pain – that is, pain that continues for more than 12 weeks – is thought to affect around 18 per cent of the UK population. GPs have traditionally prescribed opiate medications such as morphine, fentanyl, buprenorphine and oxycodone, as it was thought that – provided they did not over-sedate, cause overdose or other severe reactions – it was safe and there was little else that could be done for these patients.
A broad definition of dependence-forming medications encompasses GABAergic medicines, benzodiazepines and Z-drugs such as zopiclone, and the prescribing of these has been increasing (with the exception of benzodiazepines). In 2000, 6 per cent of the UK population were prescribed at least one of these types of medicines, but by 2015 this had risen to 9 per cent.
Hastings and Rother CCG looked at GP surgeries locally and were able to identify those with the highest rates of opiate prescribing. CGL were then contracted to provide a pilot scheme alongside The Station Practice in Hastings for one year from February 2018.
The pilot worked in two phases, with the first half of the year a multi-disciplinary team (MDT) approach, and the second half CGL-led with limited GP support and expansion into a second practice. The MDT approach showed the greatest results, but also used the most resource. The CGL worker engaged patients with an above 120mg morphine daily equivalent, as well as patients prescribed polypharmacy opiates or other DFMs.
Engagement was key – someone listening to patients’ stories was an incredibly powerful experience for them, as most clinical staff are usually unable to take the time to do this. Motivational interviewing was used to support movement towards change, both with lifestyle and medication, and mindfulness, TENS machines, sleep hygiene, and referral to other agencies were also key in fully engaging patients.
Once a week for half a day a dedicated GP was available and MDT practice appointments were run alongside the CGL worker – these were 20-minute slots that allowed time for holistic interventions for a wide range of health issues. Patients were provided with a ‘Hastings pain toolkit’ to assist with self-management of pain and lifestyle, which included links to other useful resources. A surgery pharmacist was also involved to provide follow-up support and discuss medication with patients by telephone. The MDT team has been nominated for this year’s BMJ awards in general practice, and has reached the final five.
During the second half of the year the CGL worker was spread across two GP surgeries, carrying out the same interventions without the MDT clinic. This approach was less resource intensive, yet still wielded some promising results.
Future plans – provided appropriate funding can be secured – centre around whole-surgery approaches, with all GPs supporting the programme, referring to a DFM worker for assessment, and most psychosocial and self-management of pain support taking place in a group setting. A similar trial is due to begin soon in Worthing, supported by CGL.
This is an often-neglected cohort of patients, who suffer daily and are often left ‘parked’ on large doses of opiates that have devastating long-term effects on their life, affecting their memory and digestion, accelerating osteoporosis, and potentially damaging their immune systems or causing fatal overdose.
Long-term prescription of opiates can also lead to a faulty pain system, with the medications starting to ‘drive’ the pain. But these effects can be reduced or negated through a combination of psychosocial support, a change in pain management techniques and judicious use of pain relief medications. After all, who wouldn’t want an 18-20 per cent improvement in their overall quality of life?
Robert Ralph is dependence forming medications lead at Change Grow Live (CGL)