One in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids

One in five^[1] Australians live with chronic pain lasting three months or more. Common causes include^[2] back and neck pain, headache, and joint pain.

Opioid medicines – such as oxycodone, morphine, fentanyl and codeine – are essential medicines and provide relief^[3] to many people with this type of pain.

However, opioids can also cause side effects^[4] and harms^[5] including dependence and overdose^[6], which may be^[7] fatal^[8].

Over the past decade, measures have been introduced in Australia^[9] to curb growing rates of opioid use and harms. But this has come at the expense of access for some people who genuinely need them.

In our new study^[10], one-third of participants prescribed opioids long-term for chronic, non-cancer pain had difficulties getting ongoing prescriptions.

Read more: 1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering^[11]

Tightening access

In 2018, codeine^[12] was made a “prescription-only^[13]” medicine. In the same year, Australia’s Chief Medical Officer wrote to doctors^[14] prescribing a lot of opioids to encourage them to consider reducing their prescribing.

States have also introduced^[15] prescription monitoring programs^[16], allowing providers to see whether their patients are getting opioids from other doctors or pharmacies.

We’re underaking a long-term study^[18] of just over 1,500 Australians prescribed opioids for chronic non-cancer pain. We started asking questions about accessing opioid prescriptions in our 2018 interviews with participants.

These weren’t prescriptions for new pain conditions, but ongoing prescriptions for people who had been using these medicines for four years^[19], on average, and living with pain for ten years, before the study.

Opioids can cause significant harm

Over the past 30 years, the amount of opioids (doses per Australian per day) dispensed on the Pharmaceutical Benefits Scheme (PBS) has increased four-fold^[20].

There has also been a 15-fold increase^[21] in opioid prescriptions dispensed on the PBS between 1995 and 2015. Australia currently ranks eighth^[22] among countries using the most opioids^[23].

Read more: 2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year^[24]

As opioid use has risen, so have harms^[25]. Opioids are the main drug involved^[26] in drug-induced deaths.

Pharmaceutical opioids are now involved in more deaths than heroin^[27]. Pharmaceutical opioids also contribute more to poisoning-related hospital visits^[28] than heroin, with hospitalisations doubling since 1999.

So what did our research find?

In our study^[29], one in five people reported problems relating to accessing doctors.

As opioids become more restricted, people may need to visit their doctor more frequently because they’re given smaller pack sizes and fewer repeats. They may be put in a position where they’re unable to get prescriptions if doctors aren’t available.

Opioids can cause dependence^[30] and tolerance^[31] with continuous and long-term use. However, sudden interruptions to opioid medicine supply may place people at risk of experiencing unpleasant withdrawal symptoms^[32] such as nausea and vomiting, flu symptoms, and muscle cramping.

One in ten people in our study reported their doctor wanted to reduce or stop opioid medicines against their wishes.

Patients and doctors need to work together

More doctors are practising^[34] “opioid tapering” (reducing opioid doses over time), especially in the United States, following^[35] the release in 2016 of Centers for Disease Control and Prevention (CDC) guidelines^[36] for chronic pain.

However, there were soon reports of opioids being ceased without^[37] reducing the dose first^[38], which risks withdrawal. This prompted the CDC to warn^[39] that applying guidelines without adequate care could harm patients.

Worryingly, studies have linked stopping or reducing opioids with death by suicide^[40] and^[41] overdose^[42], even for people prescribed opioids at low doses^[43] to begin with.

These studies also found people who stopped opioids were more likely to visit the emergency department or be admitted to hospital for mental health crises^[44], illicit drug use^[45] and overdoses^[46].

Read more: Opioid script changes mean well, but have left some people in chronic pain^[47]

For some people, reducing or stopping opioids will be the right thing for them, clinically. Some studies suggest stopping opioids can be done^[48] without increasing pain^[49].

Some studies suggest pain may even improve^[50] when opioids are stopped^[51]. However, participants in these studies are usually enrolled in special pain programs. These programs are notoriously difficult to access in Australia and it is common to wait months to years^[52] for services. Increased investment^[53] in pain services and programs is needed.

There is also a need for opioid tapering to be undertaken in a collaborative way^[54], with patients and doctors working as a team to achieve agreed upon goals^[55].

Balancing benefits and harms

Since we conducted our study, new restrictions introduced^[56] in 2020 reduced the quantities of opioids that can be prescribed on the PBS. For most opioids, doctors can only supply quantities and repeats for up to three months at a time.

So it’s likely to have become harder for people with pain to access pain medicines. In a survey released last month by Painaustralia, half of the respondents said their pain management was worse^[57], and their pain was more severe, because of the changes.

When it comes to using opioids for chronic non-cancer pain, it’s important to balance both benefits and harms. Potential opioid-related harms need to be recognised and addressed. At the same time, adequate treatment of pain is essential, and we need to make sure people don’t suffer harms due to changes to opioid access.

The needs of people who live with pain and the impact of restrictions on them need to remain at the centre of all decisions and discussions about opioids.

Read more: Patients leaving hospital sometimes need opioids. Doctors can reduce risks of long-term use and dependence^[59]

References

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2. ^{^} Common causes include (www.painaustralia.org.au)
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5. ^{^} harms (pubmed.ncbi.nlm.nih.gov)
6. ^{^} overdose (pubmed.ncbi.nlm.nih.gov)
7. ^{^} may be (www.ncbi.nlm.nih.gov)
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17. ^{^} Shutterstock (www.shutterstock.com)
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21. ^{^} 15-fold increase (www.publish.csiro.au)
22. ^{^} currently ranks eighth (link.springer.com)
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26. ^{^} main drug involved (ndarc.med.unsw.edu.au)
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29. ^{^} our study (www.sciencedirect.com)
30. ^{^} dependence (pubmed.ncbi.nlm.nih.gov)
31. ^{^} tolerance (www.ncbi.nlm.nih.gov)
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40. ^{^} suicide (pubmed.ncbi.nlm.nih.gov)
41. ^{^} and (pubmed.ncbi.nlm.nih.gov)
42. ^{^} overdose (pubmed.ncbi.nlm.nih.gov)
43. ^{^} people prescribed opioids at low doses (www.annfammed.org)
44. ^{^} mental health crises (pubmed.ncbi.nlm.nih.gov)
45. ^{^} illicit drug use (pubmed.ncbi.nlm.nih.gov)
46. ^{^} overdoses (pubmed.ncbi.nlm.nih.gov)
47. ^{^} Opioid script changes mean well, but have left some people in chronic pain (theconversation.com)
48. ^{^} stopping opioids can be done (link.springer.com)
49. ^{^} increasing pain (www.ncbi.nlm.nih.gov)
50. ^{^} pain may even improve (www.mja.com.au)
51. ^{^} opioids are stopped (pubmed.ncbi.nlm.nih.gov)
52. ^{^} common to wait months to years (pubmed.ncbi.nlm.nih.gov)
53. ^{^} Increased investment (www.painaustralia.org.au)
54. ^{^} collaborative way (pubmed.ncbi.nlm.nih.gov)
55. ^{^} agreed upon goals (pubmed.ncbi.nlm.nih.gov)
56. ^{^} restrictions introduced (www.nps.org.au)
57. ^{^} their pain management was worse (www.painaustralia.org.au)
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