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Sighs filled the room as the nurse described the case. The patient’s fentanyl patch had been increased because he was in pain but he couldn’t swallow.
Two days later he was confused and hallucinating…and still in pain. A few weeks ago I too would have sighed, but today is different. Instead of shaming the person who prescribed the offending patch (which should only be done when pain is stable) I reflected on how beguiling these powerful painkillers are.
After nearly two decades of practicing specialist palliative care, I only really became aware of this when I was creating a course about safely prescribing opioids for cancer pain. My respect for these drugs has deepened and our relationship has changed.
Oversimplify the issue
Let’s face it, opioids are very good at treating some pain. A BBC News investigation found that almost 24 million opioid items were prescribed in 2017 in England, double the amount prescribed a decade earlier.
The World Health Organization’s analgesic ladder promotes a simple, stepped approach to prescribing these drugs and the processes involved are nicely linear: start the dose low, gradually titrate to effect and manage side effects.
Don’t be fooled though. As the amount of prescriptions has risen, so have opioid-related deaths. Safe opioid prescribing takes time - a scarce resource - to counsel the patient, check renal function, calculate the dose, anticipate problems and review…then review again.
The desire to deliver effective pain management must always be weighed up against potential risk and patient safety.
For instance, prescribing drugs in anticipation of symptoms is important for the delivery of high quality end of life care, however, the Gosport Inquiry highlights the need for precise clinical acumen and knowledge among those who are administering opioids in this way.
Unsurprisingly, the increased emphasis on the danger of opioids has resulted in the demise of dose ranges and the inevitable under-treatment of symptoms.
This dilemma highlights that prescribing opioids is as much about fostering relationships as it is about understanding pharmacology.
The relationship between prescribers, patients and the people who care for them is vital to successfully and sustainably negotiating the risks and benefits of opioids. Equally important are inter-professional working relationships, underpinned by excellent communication and collaboration.
We cannot assume that someone else will pick up the opioid baton, without confirming they have the skills and capacity to do this safely and effectively.
Writing the course made me aware of another relationship - the one between drug and patient. Is it working to improve the person’s quality of life.
Is it a long-term thing or a brief encounter? Should the relationship turn bad - for instance if the patient has developed opioid tolerance or the risk of illicit activity is present - strategies to sensitively and respectfully bring it to an end are required.
The first step in embracing complexity is to acknowledge its existence. Managing opioids is a continual balance of treating pain and mitigating the ever-present risk of harm, some of which is potentially catastrophic.
This is neither simple nor easy. It isn’t quick and it certainly isn’t a one-off activity. We need to reframe opioids as agents in a complex physical, social, economic and emotional dynamic. Our attitudes towards these essential drugs must shift if we are to play our part in tackling the opioid crisis.
Rather than decrying the erroneous ways of well-intentioned clinicians we would do better to acknowledge that opioids are complex with few easy answers and focus our efforts on working together to make our systems of care safer.
Dr Victoria Hewitt is a specialist palliative physician based in Gateshead