News POST-IT FROM PRACTICE: “But I’ve been on them for years, Doc” Our Clinical Director, Dr Steve Brinksman, writes a Post It From Practice about managing a patient on long-term opioids: There has been a considerable increase in the focus on prescribed opioid pain killers lately and with good reason given the alarming statistics on overdose deaths from the USA alongside massive increases in the prescribing of these drugs in the UK. This has resulted in improved awareness of the risks associated with these drugs and hopefully means careful consideration will be given before using them for non-cancer chronic pain and that fewer patients will continue them where there is no substantial benefit. However we are still left with a large number of patients that have been prescribed these 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, many years of taking these drugs has blurred the line between benefit, tolerance and dependence. Auditing prescribing data can be a good start, 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 now and has been taking opioids for many years, originally for osteoarthritis that developed in his early 50’s. 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 30/500 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 as he got older, decreasing liver and kidney function could mean he was at greater risk of overdose. We also discussed the impact on his wife if he wasn’t around to care for her. Following on from our conversation we agreed that we would reduce his Fentanyl from 100mcg to 87mcg [1x75mcg + 1x12mcg] and in 6 months down to 75mcg and then 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. This article was first published in the September edition of Drink and Drugs News.