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If you have been following the messages coming from experts in the pain field in recent times, you will notice one clear resonating message. Pain management is complex. There are often no silver bullets, and short cuts in the management of pain often lead to longer, and harder pathways for everyone involved.
We have seen this unfold in a myriad of ways, most painful of which perhaps has been the so called ‘Opioid Crisis’. It’s hard to see how a class of drugs that have become synonymous with the phrase ‘pain-killer’, may actually be doing everything but. The overwhelming evidence now shows us that in the long run, opioids are ineffective for the management of long term chronic pain. In fact there is substantial evidence now that they have a significant potential for harm: from nausea and constipation to physical dependence and neuropsychological problems. However, we know that there may be people with chronic pain conditions and their practitioners who will still consider them a useful part of their treatment regime and we know there are exceptions to any hard and fast rule of thumb especially in a complex area.
We can’t deny that the impact of opioid misuse has been significant. We lose around three people a day to opioid related misuse, and opioid harm causes over 5000 ED presentations and over 9000 hospitalisations each year. The root of this problem is grounded in opioid prescribing. Like many issues in the management of pain, this is not an issue that has an overnight fix. In Australia, our regulatory response to curbing opioid harm has seen the roll out of real time prescription monitoring programs, as well as the wielding of some very big sticks.
There is now a general reluctance across the medical community to prescribe opioids, even in instances where it may be a clinically viable and necessitated option. Anecdotal evidence from consumers in our networks shows that even consumers for whom opioids have often been the last resort of treatment are now facing increasing resistance to ongoing prescribing, with reports of some doctors issuing blanket ban notices on prescribing of opioids, as well as reports of forced tapering.
Painaustralia has also heard from GP’s who practice predominantly in the aged care sector who have been scrutinised for their prescribing of opioids in a palliative care context. Clearly in the context of aged and palliative care, we need more effective and timely pain management strategies, and using a broad brush approach that limits all opioid prescribing will have some serious, unintended consequences.
In the US, we can see the devastating impact that similar punitive regulatory responses have had on the very cohort who rely most on both regulation and effective pain management: people living with chronic pain.
Painaustralia and other key Australian experts and groups supported and endorsed the efforts of our American Colleagues including Dr Sean Mackey and Dr Beth Darnell from Stanford University, as well as other international colleagues, who have been leading the effort to co-ordinate over 300 pain experts and leaders in addressing forced opioid tapering regulationsin Oregon, US.
We must recognise that pain management is a nuanced discussion. There is no one size fits all pathway here. While we do have a problem with excessive opioid prescribing, we must invest the time and effort to improve understanding and awareness of best practice pain management among both consumers and health professionals. This requires a long- term approach. It is also important that we invest in the range of treatments and services that can assist people to manage their pain condition. We should not expect this to be a quick and easy road.
This week has seen some good news finally emerge from this vexed policy struggle between regulators and consumers in the US. The US Food and Drug Administration (FDA) has now clearly identified the harms associated with sudden discontinuation of opioid pain medicines.
I hope that we can learn from the American experience and return to a more considered discussion around appropriate, well-informed pain management supported by regulation that won’t inflict further harm on people living with pain.
Carol Bennett, CEO