Drug poisoning deaths remain high, at 4939 in England and Wales in 2019, with two-thirds being accounted for by drug misuse. The rate increased to its highest level at 76.7 deaths per million people in 2019 compared with 46.6 deaths per million people in 2012, mainly attributed to heroin and cocaine (Office for National Statistics, 2020). Drug poisoning is an increasing cause of premature mortality in the population younger than 70 years. Similar trends have been noted in Scotland (National Records of Scotland (NRS), 2021) and Northern Ireland (Northern Ireland Statistics and Research Agency (NISRA), 2021). More deaths than previously have been caused by tramadol, codeine, dihydrocodeine and oxycodone, with concerns that the lockdown will have resulted in more stop-gap analgesia prescriptions from GPs with the COVID-19 pandemic service reconfigurations.
Jani et al's (2020) retrospective cohort study of adult patients (n=1 968 742 new opioid users) without cancer (2006–2017) found that morphine, buprenorphine and oxycodone prescribing rates continued to rise steadily during the study period, with codeine prescribing increasing five-fold (484 prescriptions per 10 000 in 2006 to 2456 per 10 000 in 2017). They also reported a 30-fold increase in oxycodone prescriptions, from 5 per 10 000 in 2006 to 169 per 10 000 in 2017, and a seven-fold increase in tramadol prescriptions from 101 per 10 000 in 2006 to 690 per 10 000 in 2017. About 15% of patients commencing opioids on very high morphine milligram equivalents/day (≥200/day) remained at the same prescribing level for a subsequent 2 years and became long-term opioid users. The multivariate analysis found that longer term opioid use was associated with: older age; social deprivation; fibromyalgia; substance abuse; suicide/self-harm; rheumatological conditions; gabapentinoid use; and morphine milligram equivalents/day at initiation. Three geographical areas (north-west (16%), Yorkshire and the Humber (15%) and south-west (15%)), 26% general practices and 540 (3.5%) prescribers had a higher proportion of patients with long term opioid use compared with the population average.
Long-term pain has major effects on an individual's life including daily activities, work and sleep, relationships, physical and mental health (National Institute for Health and Care Excellence (NICE), 2021). NICE recommends a full pain assessment to exclude possible causes of pain and to understand its effect on all aspects of life, so that a care and support plan can be developed. The new guidelines do not recommend the prescription of analgesia, including paracetamol and non-steroidal anti-inflammatories, but suggests consideration of exercise, acceptance, commitment therapy, cognitive behavioural therapy, acupuncture and an antidepressant for supporting people with chronic primary pain. Practitioners are also reminded to access the relevant NICE guidelines where people have underlying conditions, such as rheumatoid arthritis.
Ballantyne et al (2016) recognised that the World Health Organization's (1986) three-step analgesic ladder was useful for initiating opioid pain control for advanced cancer, but that its application to chronic pain management is inappropriate. The Faculty of Pain Medicine has a useful resource for practitioners about pain and medicines for pain (https://tinyurl.com/ckdvme9k). Community nurses can alert GPs to clients who require a pain re-assessment and a phased reduction in analgesics to improve their health and wellbeing.
‘More deaths than previously have been caused by tramadol, codeine, dihydrocodeine and oxycodone, with concerns that the lockdown will have resulted in more stop-gap analgesia prescriptions from GPs with the COVID-19 pandemic service reconfigurations.’