Simon Holliday

An Evaluation of the Prescription of Opioids for Chronic Nonmalignant Pain by Australian General Practitioners

OBJECTIVE Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). DESIGN An anonymous, cross-sectional questionnaire-based survey. SETTING The setting was five Australian divisions of general practice (geographically based associations of GPs). METHODS A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. RESULTS We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (±8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. CONCLUSIONS In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions.

Does brief chronic pain management education change opioid prescribing rates? A pragmatic trial in Australian early-career general practitioners.

Abstract We aimed to evaluate the effect of pain education on opioid prescribing by early-career general practitioners. A brief training workshop was delivered to general practice registrars of a single regional training provider. The workshop significantly reduced “hypothetical” opioid prescribing (in response to paper-based vignettes) in an earlier evaluation. The effect of the training on “actual” prescribing was evaluated using a nonequivalent control group design nested within the Registrar Clinical Encounters in Training (ReCEnT) cohort study: 4 other regional training providers were controls. In ReCEnT, registrars record detailed data (including prescribing) during 60 consecutive consultations, on 3 occasions. Analysis was at the level of individual problem managed, with the primary outcome factor being prescription of an opioid analgesic and the secondary outcome being opioid initiation. Between 2010 and 2015, 168,528 problems were recorded by 849 registrars. Of these, 71% were recorded by registrars in the nontraining group. Eighty-two percentages were before training. Opioid analgesics were prescribed in 4382 (2.5%, 95% confidence interval [CI]: 2.40-2.63) problems, with 1665 of these (0.97%, 95% CI: 0.91-1.04) representing a new prescription. There was no relationship between the training and total prescribing after training (interaction odds ratio: 1.01; 95% CI: 0.75-1.35; P value 0.96). There was some evidence of a reduction in initial opioid prescriptions in the training group (interaction odds ratio: 0.74; 95% CI: 0.48-1.16; P value 0.19). This brief training package failed to increase overall opioid cessation. The inconsistency of these actual prescribing results with “hypothetical” prescribing behavior suggests that reducing opioid prescribing in chronic noncancer pain requires more than changing knowledge and attitudes.

Managing the continuum between pain and dependency in general practice

Advocacy for improved management of pain has contributed to the escalation of prescription opioid analgesic (POA) use in the West over the last two decades. In the USA, the most commonly prescribed class of medication is now the opioids [1]. While they are essential for acute or terminal pain, there is limited evidence for their safety or efficacy in chronic non-malignant pain (CNMP) [2], and population studies indicate that POAs do not seem to improve key outcomes such as: pain relief, quality of life or functional capacity [3]. POA safety and efficacy studies have excluded those with past opioid use disorders, yet half of those with this diagnosis will move onto chronic opioid therapy (COT) [4]. This commentary [5] calls for increased scrutiny for those with CNMP and follows similar calls by medical indemnity insurers and Departments of Health. The class of drug responsible for most medication-related notifications is now opioids, second only to vaccinations. Such medico-legal incidents may leave doctors exposed to civil, criminal and disciplinary proceedings, including punitive damages, such as removal of prescribing rights or deregistration [6]. Such calls for increased clinical diligence for general practitioners (GPs), to do with a major part (19.6%) of all their encounters [7], are likely to fall on deaf ears. GPs are already feeling over-burdened with workload, time and financial pressures. This is particularly so in rural Australia where workforce shortages have resulted in salaries being offered (Hamzeh N, 2010, personal communication) guaranteeing over double the average rural salary [8]. To help cover these labour costs requires an intense focus on time management. Public funding for general practice offers equal payment for consultations of between 5 and 19 min. Mindful of this, the chairman of the Australian Medical Association Council of General Practice, Brian Morton, has commented ‘Medicare rewards quick throughput’ [9]. A recent opinion piece in a free GP newspaper advised supervisors of GP registrars to teach that it is ‘entirely reasonable’ to simply provide a script if requested, and to leave any personal or preventative matters to the annual check-up. ‘Anything beyond that is a waste of time and money’ [10]. Currently COT surveillance is problematic, with a detection rate of only 13.9% of misusers in pain management centres [11]. Screening for dependency can be experienced by GPs as imposing judgment, threatening the therapeutic relationship and disruptive to the normal patterns of work and cooperation [12]. GPs may fear finding an addiction, which many are unprepared to treat [1]. Because of these time and financial pressures, the difficulty of detecting problematic opioid use and the lack of prescriber confidence in treating addiction GPs are left on the horns of a dilemma. So, what should GPs do? GPs need to explain COT is no panacea, with an improvement in pain and function levels found in only 26% and 16% of cases, respectively [13].These modest benefits of COT need to be balanced against the risks such as sleep apnoea [14], opioid-induced hyperalgesia, unintentional fatal or non-fatal overdoses [15], diversion and addiction.The prevalence of addiction in COT has been estimated in various studies as 0–7.7% in cancer patients and 0–50% in non-cancer patients [16]. General practitioners have been called to implement universal precautions (UPs) [2,17].The concept of UPs was developed after the advent of HIV/AIDS in order to reduce the risk of the transmission of infection. They described minimum standards of care for all patients, regardless of their perceived or confirmed infectious status. Introducing UPs for CNMP would systematise attention to the dimension of dependency in the use of COT. Rather than reserving harm minimisation strategies for those with confirmed POA abuse, doctors would systematically be assessing pain and addictive disorders along a continuum [17].They would prepare for an exit strategy at initiation of a POA trial. They would manage the nuances of any adverse drug-related behaviours (ADRBs) as routinely as they currently manage cardiac risk factors.This would normalise flexibility in the degree of supervision and structuring for all opioid treatments. Pain is frequently part of the presentation of opioid dependency and withdrawal. Deciding on a management approach becomes more challenging when a commonly agreed definition of pain notes, ‘if people regard their experience as pain and if they report it in the same ways as pain caused by tissue R E V I E W

Protecting Pain Patients. The Evaluation of a Chronic Pain Educational Intervention

Introduction Advocacy and commercially funded education successfully reduced barriers to the provision of long-term opioid analgesia. The subsequent escalation of opioid prescribing for chronic noncancer pain has seen increasing harms without improved pain outcomes. Methods This was a one-group pretest-posttest design study. A multidisciplinary team developed a chronic pain educational package for general practitioner trainees emphasizing limitations, risk-mitigation, and deprescribing of opioids with transition to active self-care. This educational intervention incorporated prereadings, a resource kit, and a 90-minute interactional video case-based workshop incorporated into an education day. Evaluation was via pre- and postintervention (two months) questionnaires. Differences in management of two clinical vignettes were tested using McNemars test. Results Of 58 eligible trainees, 47 (response rate = 81.0%) completed both questionnaires (36 of whom attended the workshop). In a primary analysis including these 47 trainees, therapeutic intentions of tapering opioid maintenance for pain (in a paper-based clinical vignette) increased from 37 (80.4%) pre-intervention to 44 (95.7%) postintervention (P = 0.039). In a sensitivity analysis including only trainees attending the workshop, 80.0% pre-intervention and 97.1% postintervention tapered opioids (P = 0.070). Anticipated initiation of any opioids for a chronic osteoarthritic knee pain clinical vignette reduced from 35 (74.5%) to 24 (51.1%; P = 0.012) in the primary analysis and from 80.0% to 41.7% in the sensitivity analysis (P = 0.001). Conclusions Necessary improvements in pain management and opioid harm avoidance are predicated on primary care education being of demonstrable efficacy. This brief educational intervention improved hypothetical management approaches two months subsequently. Further research measuring objective changes in physician behavior, especially opioid prescribing, is indicated.

Which, what and who: a description of opioid analgesic, anxiolytic and hypnotic prescribing by general practitioner registrars

Introduction and Aims: The aim of this study was to investigate patterns of supplement use among male university students, who have been identified as high consumers of these substances. Design and Methods: An online survey investigating supplement use was conducted over four weeks. Participants were sent a link to the survey via email and through posts on the online homepages of units from the School of Exercise and Nutrition Sciences at Deakin University. Results: Sixty-one males completed the survey (median age 21 years). All participants had used at least one supplement in their lifetime, with most having used legal supplements; the most commonly used supplement was sports drinks (80%), followed by protein (80%), and vitamins and minerals (80%). Although no participants reported use of anabolic-androgenic steroids, 18% would consider using them in the future. Motivations for use differed according to substance; for instance, vitamins and minerals were used for general health purposes while creatine was used to gain muscle. Friends were a common source of information about supplements (57%), followed by online (36%) and a supplement store staff member (22%). Participants reported few negative side effects from supplement use. Discussion and Conclusions: Supplement use is common among this group, and some indicate intentions to use more serious substances such as steroids. This study presents valuable findings about supplement use habits and patterns among male university students. However, more research is needed among this population to determine whether body image and exercise habits can influence supplement use.Abstract presented at the Australasian Professional Society on Alcohol and other Drugs Conference 2014, 9-12 November 2014, Adelaide, AustraliaAbstract presented at the Australasian Professional Society on Alcohol and other Drugs Conference 2014, 9-12 November 2014, Adelaide, AustraliaIntroduction and aims: contemporary research examining drinking behaviour highlights the importance of implicit processes in the initiation and maintenance of alcohol consumption. By definition, implicit attitudes are formed through experience with a target object. It is argued that implicit attitudes toward alcohol may be ambivalent because consuming alcohol can produce various negative (e.g. feeling nauseous) and positive consequences (e.g. feeling relaxed). Therefore the aim of the current study was to examine the ambivalent nature of implicit alcohol-related attitudes. Design and methods: participants (N= 343, M= 25.72 years) completed a Single-Category Implicit Association Test (SC-IAT) in which they were required to classify alcohol-related words with positively- and negatively-valenced words. The reaction times (RTs) for each pairing were then calculated and compared. Implicit ambivalence was operationalised as having similar RTs for classifying alcohol-related words with positive words and classifying alcohol-related words with negative words. Results: RTs for pairing alcohol with positive words (M= 752ms) were similar to those pairing alcohol with negative words (M= 716ms), suggesting implicit ambivalence toward alcohol consumption. ANOVAs revealed a pattern of results suggesting that drinking more standard drinks in a single drinking episode produced greater feelings of implicit ambivalence. Discussion and conclusions: these findings suggest that individuals hold both positive and negative implicit evaluations toward alcohol consumption. Furthermore, implicit attitudes toward alcohol may become more ambivalent as individuals consume more alcohol. This suggests that greater alcohol consumption may produce more experiences with both positive and negative consequences and lead to the development of implicitly ambivalent attitudes.