Podcast 36: Approaching difficult conversations with patients about opioid use

Dr. Caroline West:

Hello. I'm Dr. Caroline West. I'm a GP and I'm also a medical advisor for NPS MedicineWise. Thanks for joining us on this podcast. Now, it's been called an opioid crisis. Australia, like many other parts of the world, is experiencing record levels of opioid prescribing and, very tragically, overdoses. And at the heart of each of these is a personal story, a very personal cost. GPs are often at the front line of this complex area, and many health professionals are looking for additional skills, very practical ways to work with consumers and patients to forge a better path. Now, I'm joined with Dr. Richard O'Regan, who's an expert addiction medicine specialist, and he's with me today to help us all learn more about these complex areas and to help us have those very useful, but sometimes very difficult, conversations. There's also a recent companion article for this podcast, which is published on the NPS MedicineWise website, and its titled High-Risk Prescription Opioid Use: 10 Things You Need to Know. Welcome, Richard.

Dr. Richard O'Regan:

Thank you, Caroline. I do think this is an important topic for all practitioners to have a reasonable understanding with regard to the issues around opioid prescribing and the increasing recognition of harms associated with long-term opioid use in individuals with a persistent non-cancer pain.

Dr. Caroline West:

In the media, there's been a lot around this crisis that we're facing, about the terrible human toll that we're facing. What is actually the state of play out there?

Dr. Richard O'Regan:

Well, we have a report that comes out on an annual basis, the Pennington Report, which talks about substance related overdose deaths in Australia on a yearly basis. And for a number of years now, the number of individuals coming to harm, including overdose death, hospitalization, trauma, family discord, has been increasing over the last probably couple of decades, I would imagine. Looking at around about 1,700 to 1,800 individuals succumbing to overdose deaths on a yearly basis, and a significant proportion of those related to opioid use. Increasingly, we've found that opioid related overdose deaths are relating to pharmaceutical opioids. If we were to look at 15, 20 years ago, that would be a picture of predominantly heroin related overdose deaths. That picture has changed with the increasing use of opioids in our society and the availability of prescription opioids.

Dr. Caroline West:

That's pretty terrible to reflect upon, isn't it, to think that the crisis has gone to that point where we've got that number of people dying from overdoses, many through prescription access?

Dr. Richard O'Regan:

Look, it is, and it's an issue that a number of people are aware of. There are a number of projects occurring around Australia, for example, the national project for the provision of naloxone. It's a national project that began about 18 months ago and looking at the impact of providing naloxone to individuals who used opioids and also for people who might witness an opioid overdose. And the research will look at whether that has an impact on the incidence of opioid overdose in Australia and the impacts of the provision of the naloxone.

Dr. Caroline West:

Yeah, that's a really great point. And if I can, I'd love to come back to that point later in the podcast because I think it's really useful to explore further, especially in terms of offering practical suggestions to GPs and other health professionals. But if we can go back to the beginning, in a way, and really explore what it is around high-risk opioid use that's of concern and how we actually recognize signs that somebody's drifted into that lane.

Dr. Richard O'Regan:

Sure. Look, in terms of recognizing higher risk opioid use, there's a couple of things to remember here that prescription opioid use, of course, is always in relation to the practitioner who's prescribing it. And of course, I'm talking here about the prescribing of opioid medication. I would admit that there is an avenue for access to prescription opioids that aren't prescribed. But for now, we'll talk about the issue of the prescription opioid use and how to recognize that those that may be at higher risk, for example, a person who's prescribed a prescription opioid in conjunction with a benzodiazepine. In Australia, over half of the individuals who are prescribed a prescription opioid are also receiving a benzodiazepine. We know that the co-prescribing of these medications increases the risk of sedation and ultimately the increased risk of opioid overdose with the combination of medication. So, in a similar fashion, the individual who might be using or overusing alcohol, sometimes it's a little bit difficult to ascertain exactly how much overuse of alcohol is important in these circumstances. So, it's always an opportunity to raise the conversation, "How much do you drink? Do you drink every day? Do you have any alcohol-free days?" and try to explore the risks, I suppose, that the person's putting themself under. The person whose prescribed prescription opioid, who has a history of substance use disorder, perhaps they've been on a pharmacotherapy replacement, which is the treatment provided in Australia for those with opioid use disorder, and I'm talking about methadone syrup or the formulations of buprenorphine, suboxone subutex, and the depot preparations that came out a couple of years ago. These are individuals for whom the prescribing of opioid medications is much higher risk. But we can go to other issues as well. It's higher risk if a person is prescribed an opioid for a longer period of time. Some research from Australia from 2015 indicated that some of the higher risk prescribing are people who've been on opioids for a prolonged period of time. People who are on the higher doses, and I'm talking here beyond 90 milligrams equivalent of oral morphine, higher risk of overdose, higher risk of homelessness, higher risk of mental health disorders and suicide ideation. These are some of the risk factors that individuals need to be, I guess, screened for, in order to look at the overall risk of prescribing. Those individuals with mental health disorders, the use of opioids where you've got mental health disorders, substance use disorders, psychiatric or other mental health conditions, these are the areas where practitioners should be aware of flagging and considering the risk benefit profile of prescribing a prescription opioid in these circumstances.

Dr. Caroline West:

You made a really good point there about long-term prescription use, and I guess this can sometimes be a bit of a blind spot for doctors. So, they'll have a patient that presents to them and they may have a history of something like chronic pain where they've been on an opioid for years. And I guess the doctor may get comfortable with, "Oh, well, maybe this is no big deal because they seem to be tolerating it okay." But we do have increasing age, the issue with anticholinergic burden, which is the side effect profile from opioids which can cause drowsiness and falls and decreased cognition. We've just done an article and podcast, on anticholinergics and the burden there, also an educational program. So, I guess it's a little trap that you can fall into though, isn't it, if you've got somebody on it for the long-term? What have you observed?

Dr. Richard O'Regan:

Look, it is very difficult. And of course, there's the issue of taking over the management of a person who's been on long-term prescription opioids, sometimes referred to as the heritage patient, those people who've been on four, five years, seven years, 10 years, even longer. And it can be, I guess, easy to think, "The persons in front of me. They're telling me that the opioid use is non-problematic, that they're getting on with their life." But I would pose the question of, are they really? What does their partner have to say about what's going on at home? Have you asked about other substance use? Have there been admissions to hospital with falls, with overdose? What do you do with the person who has a prescription overdose who's on long-term opioid medication and you get the report from the ED department saying, "Polysubstance overdose requiring admission for several days"? The patient comes back to you and you're talking about it. Do you continue to prescribe? Do you then put in some of the safety requirements that we sometimes talk about, for example, staged supply at a pharmacy, reduce their dose, talk about deprescribing? These are difficult conversations to have with a patient. But I do think involving the family is important, I do think looking at the broader picture in terms of admissions to hospital, mental health conditions, how are they doing at work, these things. And again, GPs are looking at this as the bread and butter of GPs, the holistic engagement with a person. So, GPs are in a very good position to know this information. The question is, how do you then bring that into the conversation where the patient might say, "Look, I want to keep this. I want to continue. I don't want to reduce"? That's a difficult conversation where harms have been identified but that perhaps doesn't resonate with the patient as a reason to stop medication. Of course, we've also got to realize that in any discussion about deprescribing opioids, there's the issue of bringing in the topic of withdrawal and opioid dependence and being sensitive about talking about opioid dependence, because some people will listen to or hear the word opioid dependence or addiction and immediately throwback that, "You're saying I've got an addiction, that I'm a drug addict," when it's not that at all. Anybody who's on an opioid for more than a number of weeks on a regular basis will develop a degree of, A, tolerance and B, potentially symptoms of withdrawal when you start to reduce that medication. And that's physiology, that's not the difficult and challenging behaviours that sometimes get associated with opioid use disorder.

Dr. Caroline West:

I mean, I think it's an area where GPs have to manage this situation repeatedly in practice. But to be honest, I think that a lot of us have comfort zones and it might be something like discussing contraception, or blood pressure medications, or lifestyle interventions. And when it comes up to this area of high-risk opioid prescriptions and the idea of tapering or changing management, it can lead to a sense of anguish in the clinician, I think. They often feel that they're under-resourced, perhaps lacking in confidence to actually take it on. And as you say, they're difficult conversations and often there's quite a bit of blowback from the patient because it's something they may not have anticipated, or, as you say, they're very naturally sensitive to being stigmatized in any way. And so, the language that's used and the context that it's mentioned in the consultation can all be triggering. So, what do you do, going back to that legacy question? So as a GP, you've got somebody who you've inherited from another practice. They've arrived. They've run out of their script. They're out of their area because they've just moved there. They don't really have supporting documentation. But they need it now. It's late on a Friday afternoon and they've been on this medication for a long time. In those sorts of instances, what do you do? Because I've seen that repeatedly in practices. What do you recommend that a GP does in those instances where you're on the spot?

Dr. Richard O'Regan:

I think that's probably the most difficult scenario that you've painted there, particularly if it's after five o'clock in the afternoon, because essentially what is required is verification of the history that's being presented. So, verifying whether the person is actually receiving these medications, verifying whether there are contraindications, such as a pharmacotherapy replacement treatment program, would be a good start. But really, what you want is information from the previous prescriber. What was the reason? Is there a genuine... And when I say genuine, again, we're automatically moving into language which can be offensive to people. Is there a verified medical condition? Is this person in fact receiving opioid medication on a regular basis under authorization with another prescriber? I think when the scenario as you describe where it's after hours, the department perhaps may not be able to give that information, it is difficult. It might be that in some circumstances, the practitioner might think, "Well, okay, I'll provide enough until the next business day where I can actually find some more information. I'd like you to come back. Perhaps we really do need to talk about this. It'll need a longer consultation. I'll need information and access to your previous medical record. I need to do some background." That's not easy and it does actually take a little bit of time. The alternative, where you might decide to say... And some practices will have the approach of not prescribing Schedule 8 opioids until this information is available. Both options, I think, are reasonable. It can be difficult under those circumstances if the person is in genuine need. What's going to happen over the next day? Perhaps it's the weekend. Are you going to provide medication for that? And I think it's not unreasonable to do that. You might decide to provide the medication but have it on staged supply. So, "I'll prescribe this for you over the next couple of days. I'd like you to pick it up at the pharmacy on a regular basis. We'll get back together on Monday morning. I'll get some information, and we'll have this discussion." And get to know the person over a period of time. That is a very difficult situation, no doubt.

Dr. Caroline West:

In that situation, you're suggesting that you can contact your local pharmacist and arrange a sort of pick-up schedule for just a few days to just tide you over till you get more of a history and a sense of engagement with that person?

Dr. Richard O'Regan:

And that will be a difficult conversation too. My response to that would be that "Look, it's..." And I think it's helpful if GP practices have a policy that relates to new patients requiring high dose, which would be high dose because they've been on it for some time, opioid medication. I think it would be quite a reasonable and I think it's a good idea to have a practice policy of, "First up, we will provide this medication, if deemed appropriate, through staged supply." And I think GPs need to have the conversation response ready. "This is what I do with everybody. These are dangerous medications. They can lead to harm. They can lead to dependence. We don't know each other yet. What I'm going to do is prescribe in the safest way that I know, which is to have you attend the pharmacy on a regular basis until such time as we can get more information and get to know each other a little bit better."

Dr. Caroline West:

And how useful is it for practices to have, I guess, an overall policy around this so that everybody's agreed that we all follow the same standard? Because I've found in practices where you have an agreed agenda and that perhaps you don't prescribe any S8s on the first consult or you try to taper people if you detect a problem, whatever it is you decide is going to be on your policy, it's very hard when you go to a practice where everybody's acting like an individual and nobody collectively agrees on anything, because the patient just ups and walks to the front desk and goes, "Well, I didn't like that consult. Can I have an appointment with so and so?"So what happens with practices? What's important there?

Dr. Richard O'Regan:

Well, I believe that makes work much more difficult for the individuals and for the practices because where the practitioners are working perhaps in different ways from one another, it does lead to the issue of potentially patients being dissatisfied with one person's regulation or the self-regulation versus their colleague. What that will lead to, of course, is, if you like, a situation where a number of people will be drawn to or attracted to a particular practitioner. That'll make that practitioner's life more challenging, I think, as, I guess, more and more individuals who are seeking medications along these lines are attracted to that person. I essentially think that practices would be in a wiser position to have those approaches and to discuss those. And I think a lot of practices do actually do that more increasingly as time goes by. You mentioned before that some practice positions will be, "We don't prescribe psychoactive medications on the first visit, including benzodiazepines and some of the other medications that can cause problems, such as the gabapentinoids and some antipsychotics." I think a practice policy is worthwhile. The RACGP have produced guidelines along this issue, the prescribing of opioids and the prescribing of benzodiazepines. And they do talk about one of the features, which is a practice policy, which addresses some of these issues.

Dr. Caroline West:

Now, Richard, you're a specialist who works in hospitals and in the hospital setting. From a GP's perspective, a lot of the opioids that we see are actually initiated in a hospital setting, often a "just in case" prescription. So, "You've had some sort of routine surgery and just in case you need it over the next few days, here's a prescription for an S8 painkiller, and off you go." And the next thing you know, you've got an issue down the track. Is the culture of prescribing opioids in hospitals on discharge starting to change?

Dr. Richard O'Regan:

Indeed, it is. I think that the scenario that you've described was accurate previously. I think increasingly, hospitals are becoming aware of these sorts of issues. In the hospital I'm working at the moment, individuals will generally be tapered off and not prescribed an opioid on discharge. And to harken back to what we were talking before, that's a hospital-based policy of weaning and reducing the provision of opioids. Another way that we've addressed that is to reduce the number of opioids that can be prescribed, rather than provide large numbers, opioid provision is usually for, we're talking about, several days. But increasingly, the use of opioids under those circumstances of "just in case" are being wound back as people become more aware of this as an issue.

Dr. Caroline West:

So when you realize that there's a patient that you're managing that could do with a change in direction in terms of their management and their use of opioids, how do you actually start that conversation around tapering or a change in direction? Because that's a pretty tough conversation to start.

Dr. Richard O'Regan:

I think it begins with a conversation with the individual, and I think it's bringing in a non-confrontation, hopefully, a safe environment talking about, "Well, do you see yourself on these opioids, these medications in the next 12 months, in the next three years?" I think it's important to involve a patient in, "What do you want? What do you see as the benefits of this medication? And do you see that there are any downsides to this medication? Because it can be a friend and a foe. It can be both helpful, but there are some downsides to it." And I think in many conversations, you'll be able to actually ascertain those sorts of, I guess, differentiating the pros and the cons. But I think more than that, it's a matter of being able to highlight to the individual, "Look, we don't feel that chronic pain is best served by the long-term use of opioid medications."
That conversation is a difficult conversation. I think that conversation is difficult even for my pain specialist colleagues, particularly for the person who's been on that medication for a very long time. So, I think it's, number one, a conversation. It's not necessarily going to happen at one instance. And I think bringing into that conversation that we now know more than we did five years, 10 years, 15 years ago regarding the use of opioid medication, I think bringing in that information is one way that these conversations can commence and potentially go in a direction that one hopes the patient will join with you. When it gets to the scenario, the difficult scenario, of the patient who presents on a regular basis early for a prescription because they have self-escalated their medication dose, or when the GP finds out that the patient is potentially seeing a number of other practitioners, or the individual has developed use of the medication through means by which it wasn't prescribed, I'm talking here about potentially using the medication through intravenous methods or, indeed, using the medication for reasons that aren't related to pain, and I'm talking about mood regulation, I think then the conversation really needs to get serious about control over the medication and control over the use of opioids versus transfer over to a treatment alternative, such as the opioid replacement pharmacotherapies. But I don't shy away from the fact that it is a very difficult conversation and it doesn't always go in a way that the patient might be totally agreeable to.

Dr. Caroline West:

I think that's particularly the case in people who have had chronic pain and who have been on an opioid for some years, and they're so nervous about triggering the pain and they're also very sensitive to perhaps a sense that, "Well, you're not taking my problem seriously. Don't you realize I'm in pain? Don't you know how hard this is?" And so, as you say, it's not a quick conversation, by any means. But as you say, with chronic pain, the evidence around long-term use of opioids is pretty patchy. And a lot of people think that it's a natural fit to stay on them forever, and it's going to lead to very poor health outcomes.

Dr. Richard O'Regan:

Look, it is. And the issue associated with transfer to one of the pharmacotherapies, the opioid replacement pharmacotherapies, is definitely that issue of stigma. There's the issue of costs. Currently in Australia, pharmacotherapies generally have a cost associated with them unless you are able to access that through a government funded service that provides dispensing. So, there are some disincentives in Australia currently, and there is a look at or there's a study at the moment looking into the provision of these pharmacotherapies and the cost of these pharmacotherapies for consumers and looking at whether that's a particularly fair way to provide those medications. They've looked at this over many, many years, and it's never got to a situation where government has fully taken over the cost of these medications, but that's another barrier, I suppose, to getting onto these treatments for consumers.

Dr. Caroline West:

And you flagged earlier an area that I'd like to go back to and explore a little bit more, which was the take-home naloxone. So, if you've got somebody that you're really worried about and you're seriously concerned about overdose, what do you suggest GPs think about there?

Dr. Richard O'Regan:

I think that the provision of naloxone for individuals who use opioids and potentially for the families of people who use, who are prescribed opioids, I think it's a useful addition in terms of the safety aspects. I think it's a difficult conversation. I suspect very few, if any, GPs routinely talk about the provision of naloxone. We now look at it in terms of the conversation, if somebody who's on opioid medication, potentially they're also prescribed other psychoactive medications, talking about it in terms of, "Look, I'd like to prescribe this for you, naloxone." It's recently been provided in an intranasal formulation. So, it's no longer a situation where you have to give it in a intramuscular needle.

Dr. Caroline West:

And the intranasal one, you don't need the patient to be conscious. You give it can be used in that avenue and the person can be reassured, "Look, you don't need any skill set for this. This is pretty straightforward."

Dr. Richard O'Regan:

Absolutely. And I think the words that I would recommend for a GP is like, "I'm going to provide you this. It's like a fire extinguisher in your kitchen for a fire. I hope you never have a fire, but if you do have a fire, it would be really useful to have an extinguisher handy." This is a similar situation, and I think GPs should be looking at using the term accidental overdose, accidentally take too much medication, potentially shying away from opioid overdose. Because again, the connotation with some language for some people will be one of, "You think I'm the going to misuse this, or you don't trust me." I also think it's important if we can normalize the provision of something like naloxone, as I also feel that it could be normalized to seek a further investigation from patients. I'm often saying to my pain colleagues that it's useful to do a urine drug screen. But to normalize it, much like we would normalize taking blood pressure measurements from somebody who's got hypertension, I think for the person who's on long-term opioid medication, particularly higher levels, if we could get to a scenario where it was normalized to, for example, have a urine drug screen twice a year to provide naloxone to the person and/or their family, I think that would go some way to reducing the risks associated with the person who is on higher prescription opioids.

Dr. Caroline West:

Do you get quite a bit of feedback about that suggestion about the urine drug screenings in terms of patients just going, "No way. What do you think I am? This is not a prison. You're trying to put me under surveillance here"? I mean, there must be. You must have to hold onto your seat and stand your ground sometimes. Am I overstating it?

Dr. Richard O'Regan:

Well, yes. And look, I fully acknowledge that it's easy for me to talk about this. I've spent 25 years prescribing methadone and buprenorphine for opioid use disorder, and it is bread and butter. It is talked about on day one of the assessment, "Part of our procedure is to do urine drug screening." In pain medicine, it's not talked about, and I think we're actually a long way from it, because I think that moving from not doing it at all to one where it becomes potentially something that we do on a regular basis, I think we're actually a long way from that. And I do think that it's difficult because it's not regular, usual practice. I think a lot of these sorts of safety aspects of treatment will, with time, become more regular. For example, the provision of naloxone. It can be a tricky conversation. And at this stage, in 2021, I don't think a lot of people are provided or spoken to about the use of naloxone. I think we will come to a time, as has happened in America, where the provision of naloxone in association with opioids is closing in on almost ubiquitous. The issue of urine drug screen can be debated, actually, whether that's a useful or not useful tool in terms of you're talking about the therapeutic relationship. And there are aspects to the provision of urine drug screening which might actually be challenging to initiate. I hope one day it'll be something that'll be a little bit more available and routine.

Dr. Caroline West:

So I guess that just to sort of reflect, you're suggesting that we have quite a clear treatment agreement with a patient when you're navigating the journey and exploring some of these areas. And I'm hearing very much again and again that it's around using language without stigma and being very respectful. I think that that's very deserved in this area, that we have to be very mindful that all of our patients deserve our respect. And that's something that patients, I think, pick up on when they've felt that there's an element of judgment or an element of briskness where the doctor doesn't want to deal with this today, that's acutely felt. And I think that it's time that we see this as an area, a medical condition, just like anything else that needs appropriate management and-

Dr. Richard O'Regan:

Oh, look, I totally agree. Two things there that you mentioned, the treatment agreement. I think a treatment agreement, it clarifies where we're at and what we're going to do. I think the treatment agreement helps a practitioner in such cases as early presentation for script renewal. In cases where the patient perhaps is going to another practice or attends the emergency department for additional opioids, I think the treatment agreement makes it very clear, "These are the conditions. I'm your practitioner. We have a single pharmacy that we utilize for your prescriptions because these prescriptions and these medications are potentially dangerous. Sometimes they can get away from people and we need to make sure that it's as safe as it can be." I also agree with the notion of respect, honesty. I think the treatment agreement comes back to and supports our honesty and transparency. I've always felt that if my patient knows exactly how I'm going to respond in a certain situation because I've told them or that I've written it down, then they're not surprised or upset when I follow through on what I said I would do under certain circumstances. So, I really do think a treatment agreement. The question, of course, is when do you start the treatment agreement? Do you put everybody who you ever prescribe an S8 opioid onto a treatment agreement? That's probably not practical. But I do think people who are on longer term opioids and certainly for those scenarios where a patient is taken over, the introduction of a treatment agreement, "Look, I think we need to be on the same page here. I need you to know what I'm going to do, and I need you to understand what your responsibilities are so that we can both work together and understand each other," I think that's the conversation I would have when I take over somebody who's on long-term opioid medication. I think it's really important, all the while being respectful, polite, and affording the person dignity.

Dr. Caroline West:

Well, you've certainly given us all a lot to think about here. And I'll certainly be taking on board the take-home naloxone. I think from a practical point of view, that would be really useful for me to think about including in my practice. Obviously, there's so much we could talk about here, and I know that the article that's on the NPS MedicineWise website, the High-Risk Prescription Opioid Use article, has a lot more detail on many of the things we've talked about today. But I'd like to thank you, Dr. Richard O'Regan, for taking us through just why we need to tackle this area of high-risk prescription opioid use. It's a huge problem in Australia and it's just been getting worse over the last few years, as you've outlined. But with some strategies, some practical strategies, perhaps we can start to turn that curve around in the opposite direction.

Dr. Richard O'Regan:

I'd also finally point out that GPs can access support, advice, phone a friend, if you like, through contacting their local drug and alcohol services, and there are listings associated with the NPS article, or, indeed, accessing support and information through their local pain specialist clinics.

Dr. Caroline West:

Thanks so much, and thanks, Richard, for being with us today. For those of you who are listening who'd like more information, as Richard just said, you can go to the nps.org.au website for the article, for more consumer resources, and you can also check our website out for details for GPCPD associated with this podcast.

Dr. Caroline West:

So this is our last podcast for 2021. I'd like to wish you all the best for the festive season, and hopefully you can come and join us again when we kick off again early in 2022. It's been a very full-on couple of years with COVID, and I'm sure many of us are really looking forward to a break to recharge. This has been an NPS MedicineWise podcast. I'm Dr. Caroline West. Bye for now.