Drink and Drugs News DDN September 2019 | Page 11

IPTION But doc… I’ve Been on them for years Addressing long-term prescribed opioid use requires an individualised approach, says Dr Steve Brinksman ‘I was then referred to my first drug clinic, where the drug worker said they couldn’t help me as it wasn’t heroin. Another clinic told me the same thing.’ However, this is where my journey to hell began, going around in circles from doctor referrals to drug clinics and pain clinics, being told the same old story and referred back to my GP. I was suicidal at this point. I’d done so well to reduce my dose, but could no longer see any way forward. Eventually I contacted Release who got one of the drug clinics to agree to treat me, and after an agonising few months, starting on a minimum dose of 30ml of methadone that didn’t even hold me for two hours, they eventually got me to a dose of 105ml where I was stable and no longer going through horrendous withdrawals. I reduced the methadone over many months until I finally became drug-free. However in 2016 I was diagnosed with severe ‘central’ sleep apnoea. My driving licence was revoked and I was told after blood tests that my testosterone level was zero. I also have peripheral neuropathy from pernicious anaemia, where it is painful to walk www.drinkanddrugsnews.com due to nerve damage in my feet, and I still have the degenerative disc disease in my back. However, I’m looking at alternative relief rather than the legal heroin I was given that almost took my life. My main passion and purpose now is to educate everyone about how long-term opiate use destroys lives and actually makes pain so much worse in the long term. Opiates do have a very important role to play in pain relief, but only in certain situations and only for the short term, prescribed and monitored very closely. Even though I was lucky enough to beat my addiction, I am now having to deal with the long-term health effects. Not only did my addiction take everything I had, it also greatly affected the people who I love most. If by telling my story and raising awareness of what I experienced I can save even one person from suffering what I went through, it will have been worth it. THERE HAS BEEN A CONSIDERABLE INCREASE in the focus on prescribed opioid painkillers lately, and with good reason given the alarming statistics on overdose deaths from the US alongside massive increases in prescribing in the UK. This has resulted in improved awareness of the risks associated with these drugs, and hopefully means that careful consideration will be given before using them for non-cancer chronic pain and fewer patients will continue them where there is no substantial benefit. However we are still left with a large number of patients who have been prescribed these drugs for many years, and that brings us to the potentially thorny issue of de-prescribing. How do we best approach this? Some may advocate reducing and eventually stopping these drugs for all in whom there is no sizeable reduction in pain, but how to assess that? For some patients, years of taking them have blurred the line between benefit, tolerance and dependence. Auditing prescribing data can be a good start, and writing to patients and flagging notes to discuss at medication reviews are useful tools as well. Richard is a case in point. He is 70 and has been taking opioids for many years, originally for osteoarthritis that developed in his early 50s. He has a history of depression and anxiety, was alcohol dependent for many years, and cares for his wife who is slowly dying from severe COPD. As well as his opioids he also takes regular diazepam, although over the years the dose of this has come down. He is currently on a 100mcg fentanyl patch, co- codamol and Oramorph. He freely admits that he is dependent on these but as they were started by a doctor, he doesn’t feel he should have to stop them. I suspect this is a common scenario. We had a lengthy consultation and I was able to explain that medical opinion was changing, that these drugs were now felt to be less effective than we used to believe, and that decreasing liver and kidney function could mean he was at greater risk of overdose as he got older. We also discussed the impact on his wife if he wasn’t around to care for her. Following our conversation we agreed that we would reduce his fentanyl from 100 to 87mcg and in six months to 75mcg, when we would discuss the situation again. This probably wouldn’t be enough for the aggressive de-prescribers, but as a GP I can hopefully take a pragmatic long-term approach. It would be better if the situation had never arisen. However it has, and an individualised approach agreed between the prescriber and the patient seems to my mind the best compromise. Steve Brinksman is a GP in Birmingham, clinical lead for SMMGP and RCGP regional lead in substance misuse for the West Midlands ‘An individualised approach agreed between the prescriber and the patient seems... the best compromise’ September 2019 | drinkanddrugsnews | 11