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driving licence was revoked and I was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
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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