There was a suggestion at a Medical Council working group that Ireland could experience an opioid addiction crisis as has occurred in the US. Catherine Reilly reports on the group’s discussions and concerns, which includes the lack of private prescribing data
A Medical Council group developing strategies to address overprescribing has heard concerns that Ireland “could go down the same route as the US regarding opioid addiction”. The minutes of the virtual meeting in March 2021, obtained by the Medical Independent (MI) following a Freedom of Information request, did not specify the source of the comment or expand on the likelihood of such a crisis.
Attendees included the HSE’s National Clinical Lead for Addiction Services Dr Eamon Keenan; National Clinical Advisor and Group Lead for Primary Care Dr David Hanlon; the then President of the Medical Council Dr Rita Doyle; as well as officials from the Council, HSE, Department of Health, and Pharmaceutical Society of Ireland (PSI). The names of representatives from the ICGP and College of Psychiatrists of Ireland were redacted under the grounds of “disclosure of personal information”.
The stakeholder group has been discussing several types of drugs with the potential for dependence and addiction including benzodiazepines, z-drugs, gabapentinoids, and opioids. Its work has led to the development of new resources for prescribers to raise public awareness of the potential harm associated with benzodiazepines and z-drugs. These outputs followed a strongly worded press release from the Medical Council in September 2019 warning doctors to “reduce overprescribing of benzodiazepines, z-drugs and pregabalin or face potential investigation”.
According to data from the Health Research Board, prescribable drugs were implicated in two in every three poisoning (overdose) deaths in 2017, with benzodiazepines the most common prescription drug group. All benzodiazepine-related deaths involved other drugs, mainly opioids. There were 4,133 opioid (mainly heroin) treatment cases in 2019 and it remained the commonest main problem drug reported by people entering treatment. As a proportion of all cases treated, opioids decreased yearon-year from 51.4 per cent in 2013 to 38.8 per cent in 2019.
Unease
The Medical Council informed MI it was unable to provide data on complaints against doctors following alleged inappropriate prescribing of opioid medications. However, minutes of the stakeholder group reveal an unease about the level of prescription of potentially addictive medications, the lack of visibility of private prescriptions, and the “aggressive” promotion of some medications to prescribers.
In May 2021, the group’s then Chair Dr Doyle told MI that opioid guidance needed “to be more clarified, looking at what are the gold standards… and trying to encourage doctors to stick to the gold standards”.
“There is a lot of advertising among the producers of these drugs… the oxycodone/Oxycontin in the States was the big one, but there are other versions of that with things added to it… and not necessarily more efficacious medications appearing on the market all the time. So we are trying to get doctors to stick to the basic guidelines and follow gold standards.” She added there would be an education piece coming from the stakeholder group.
Dr Doyle has been succeeded as Chair by GP Dr Margaret O’Riordan, who was unavailable for interview last month due to the Covid-related demands on general practice.
An Irish Pharmaceutical Healthcare Association (IPHA) spokesperson said companies were required by legislation and the IPHA code of practice to ensure that “in making prescribers aware of prescription medicines, responsible prescribing practice is encouraged”. Adherence to the code was “very high”, they said.
Evidence
Opioid analgesics may be effectively used in the management of moderate-to-severe acute pain, cancer pain and pain during terminal illness, but there is a lack of evidence to support their long-term use in chronic non-cancer pain. Opioid analgesics are associated with harms, such as misuse, addiction, and fatal overdose.
The well-documented and ongoing US crisis has its origins in increased prescriptions of opioid analgesics following assurances from the pharmaceutical industry that patients would not become addicted. According to the US Centres for Disease Control and Prevention, the first wave of the crisis began with increased prescribing of opioids in the 1990s, with overdose deaths involving prescription opioids (natural and semi-synthetic opioids and methadone) increasing since at least 1999.
The second wave began in 2010 with rapid rises in overdose deaths involving heroin, and the third wave can be traced to 2013 with significant increases in overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl.
From 1999 to 2019, nearly 500,000 people in the US died from an overdose involving any opioid, including prescription and illicit opioids. The federal response was slow: A public health emergency was belatedly declared in 2017 by the US Department of Health and Human Services. Successful policies at state level have included prescription drug monitoring programmes and increased availability of naloxone.
In the Irish context, there is evidence of an increase in prevalence of strong opioid prescribing (see panel). But key issues emerging from the Medical Council’s stakeholder group include the incomplete picture on opioid prescribing and why certain opioids are being prescribed in favour of other opioids or non-opioid analgesics.
Hospital formularies
At the group’s meeting in January 2021, for example, apparent changes in hospital opioid prescribing practices were discussed. There was “a discussion around oxycodone and it was queried as to why this had superseded morphine – it was suggested that marketing may be a factor. There was a suggestion that the level of therapeutics taught to medical students could be better, with more of an emphasis on what is the ‘go to’ drug for different conditions, and a strong adherence to the formulary (a list of medicines approved for use in the healthcare system by authorised prescribers) available should be the norm, along with the requirement for any deviation from this to be justified. It was agreed that formularies are extremely useful, but they have to be adhered to.”
At the group’s following meeting in March, “Dr Doyle explained that she wrote to four Dublin hospitals and requested copies of their formularies. All hospitals responded, some with pdf and word versions, while others had the information only available via an app on a phone. Dr Doyle highlighted that there was no evidence of oxycodone being prioritised over morphine on these lists.
“There was a discussion then around why opioids may be in use more than other types of medication in pain management. Suggestions as to why this situation is occurring included the familiarity and convenience of using certain types of drugs, a lack of experience of some practitioners in prescribing MST (morphine slow-release tablets) and also aggressive promotion by drug companies of certain types of medication for the management of post-operative pain.”
This same meeting also heard a presentation from Ms Karen Finnigan, Pharmacist, HSE Medicines Management Programme, but the details were redacted from the minutes on the grounds of deliberative processes. On foot of Ms Finnigan’s presentation, “it was highlighted that the type of pain that is being managed is important when the type of pain medication is being decided upon as chronic pain, cancer-related pain or pain management as part of palliative care may require different solutions.”
“It was agreed that in certain situations opioids are given far too easily and that better access to pain clinics would be a positive development. There are occasions when prescribers issue opiate prescriptions when other therapeutic options might be preferable. However, it was acknowledged that access to these options (including counselling, pain clinics) may not be readily available.”
At this juncture the minutes noted “a discussion around the importance of educating patients regarding the risk of addiction to opioids, and concern that Ireland could go down the same route as the US regarding opioid addiction”.
The issue of lack of private prescribing data was also raised. “The point was made that it can be difficult to get a full view on the prescribing of controlled drugs as currently private prescribing is not captured centrally…. There was a discussion with the representative from the Dept of Health who said that she was aware that this topic had been discussed for some time and from the Dept’s perspective, if legislative change is being suggested then the Dept need to know that all of the different pros and cons of a proposal have been considered.”
According to minutes, it was emphasised “that the legislative changes are required as the current situation just doesn’t make sense, and that patient safety is at stake if this change doesn’t happen. It was acknowledged that the change does need to happen, but how it is done will need to be agreed.”
When contacted by MI, a Department of Health spokesperson did not comment on the mechanisms by which this data may be captured in future. They indicated that limits on prescriptions and more comprehensive tracking of prescriptions are currently under consideration. This newspaper asked the HSE for data on prescription of opioids including a review of opioid reimbursement from 2014 to 2019, which was prepared for the Council group by the Primary Care Reimbursement Service. MI also requested information on HSE actions to increase public awareness,
prevention and treatment. The HSE had not responded by press time.
OTC products
Misuse of over the counter (OTC) opioids has also been discussed at the Medical Council stakeholder group. However, as with private prescriptions, there is a lack of access to comprehensive sales data. “Sometimes it is not easy for a pharmacist to question an individual on their request for a particular type of OTC drug, however, it is much easier for them to do so if they feel protected in this,” according to minutes of its meeting in January. “There is a high demand for OTC opioids. A really extensive review has been carried out in the UK on this, and the resource ‘opioids aware’ in the UK (which outlines the risk/benefits of opioids to patients) was brought to the group’s attention; it was suggested that a similar resource for patients in Ireland may be necessary….
“The availability of an OTC opioid online was highlighted to the group and the representative from the PSI Dr [Cora] Nestor outlined that all non-prescription medications can be sold online in the EU. The members of the group agreed that there needs to be more psychological supports available to patients.”
Codeine dependency is one of two main types of opioid issues seen by Dr Garrett McGovern, a Dublin GP specialising in addiction medicine.
He told MI: “I treat a lot of heroin addiction, but new presentations are less than what we would have seen five or 10 years ago, although this is probably not the case in areas outside Dublin where heroin addiction has steadily climbed over the past 20 years.”
“The other opiate problem I see a lot of is codeine analgesic dependence, which is very much a hidden problem and unlike heroin addiction, which largely affects marginalised communities, codeine dependence tends to affect people from all sides of the social divide although possibly with a slight preponderance to females.” Dr McGovern reported that he was “not really seeing many cases in clinical practice due to inappropriate prescribing. It is mainly over the counter codeine analgesia (paracetamol-codeine or paracetamol-ibuprofen preparations).”
He also observed that ‘overprescribing’ was a “very inflammatory term”, which rarely took account of the nuances of patient presentations. “Occasionally you get doctors who are prescribing willy-nilly and getting loads of money for it. But a lot of the time, it is not as simple as that and it is very easy to look at it as simply an overprescribing [issue].”
In regard to patients who have developed an OTC codeine analgesic dependence, he said most began taking the medication for legitimate reasons, such as headaches and menstrual pain. “A lot of people still think there is an innocence to those tablets and really they are quite sinister when it gets hold of you. The irony of it is that the codeine is fairly weak… but in order to develop the tolerance and get something out of the codeine, they are absolutely exposed to, in some cases, colossal amounts of ibuprofen and paracetamol.”
Dr McGovern noted that since these products went behind the counter, patients with a dependency may engage in ‘pharmacy shopping’. However, he strongly cautioned against making such OTC products as prescription-only. These products were very helpful when used appropriately and making them prescription-only would be an undue barrier
in this regard, he outlined.
Rather, Dr McGovern emphasised the need for greater awareness efforts and ensuring people with a codeine dependence were informed that opioid substitution treatment was available and often successful. He suggested that more collaboration between pharmacies and treatment sites may be beneficial. “I think we need to put our heads together because there are people going in furtively buying this, and they are coming to real harm.
TCD study urged ‘continued surveillance’ of strong opioid prescribing
A paper in Pharmacoepidemiology and Drug Safety, published in 2021, aimed to determine the pattern
of strong opioid prescribing in Ireland over a 10-year period from 2010 to 2019 using a national administrative pharmacy claims database. It found that strong opioid prescribing prevalence increased from 14.43 per cent in 2010 to 16.28 per cent in 2019, with the greatest increase in the ≥65 years age group.
Non-combination oxycodone demonstrated a 2.1-fold increase in prescribing prevalence over the study period,
while oxycodone-naloxone (Targin) increased by 5.2-fold between 2011 and 2019. The prescribing prevalence and defined daily dose (DDD) per 1,000 population per day of tapentadol increased by 8.8-fold and 9.9-fold, respectively,
between 2012 and 2019.
Tramadol was the most frequently prescribed, accounting for 63.9 per cent of total strong opioid prescribing.
“Continued surveillance” of prescriptions of oxycodone, tapentadol, and in particular tramadol, was advised by the authors from the Department of Pharmacology and Therapeutics in Trinity College Dublin and St James’s Hospital.
A 2019 study by GPs in Cork, published in Forum, examined repeat prescribing of strong opioids for chronic non-cancer pain at four practices. Most prescriptions were initiated for lower back pain and joint pain. GPs had initiated the prescription in 65 per cent of cases and pain teams in 15 per cent. Only 2 per cent had been started in an emergency
department. Some 39 per cent of the identified patients had attended a pain clinic while 6 per cent had been referred, but were awaiting an appointment.
Some 43 per cent had their morphine equivalent dose (MED) increased since initiation, 37 per cent did not have
their MED changed over the course of their treatment and 18 per cent had their MED decreased. Weak opioids were
not included in the MED calculations. Most patients were being co-prescribed at least one other medication with
potential for sedation, overdose or dependence.
The authors acknowledged that providing safe, appropriate and effective management of chronic noncancer pain was “a dilemma facing modern medicine”. They advised of “an immediate need” for Irish guidelines regarding opioid use in primary care. “Collaborative management between GPs and pain specialists adopting a multimodal approach to the management of CNCP [chronic non-cancer pain] is the ultimate goal, with safe prescribing of opioids as part of a broader biopsychosocial approach,” they stated.
Dr Íde Delargy, Director of the Substance Misuse and Addiction Management Programme with the ICGP, told the Medical Independent the College is participating in “two high-level groups developing guidelines for GPs on best practice prescription of opioids in general practice”. The ICGP is represented on a working group led by the College of Anaestheologists preparing guidelines on “discharge recommendations relating to opioids in the post-surgery and post-admission environments”. The College is also represented on the Medical Council’s stakeholder group on overprescribing.
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