09 April 2021

No NICE answers on Pain and Prescribing

Here at KFx Towers we've been offering a course about the non-medical use and diversion of Prescription and Pharmacy medicines for a couple of years. While interest and use of Novel Psychoactives abated, there had been a steady increase in questions and concerns about prescription medication.

A lot of course participants are prison health workers, alongside community drugs workers and hostel staff. Prisons have long been a "canary in the coalmine" for drugs of necessity. If prisoners are unable to access drug-of-choice X, what other medication becomes sought-after?

A long time ago, it was prisons in the North of England that were flagging up Pregabalin and Gabapentin as the go-to medications. Clamping down on these has seen an increase in demand for other medication including mirtazapine and quetiapine. And when access to these is reduced, there's always the illicit fall-back drugs such as synthetic cannabinoids, with all the attendant risks.

The non-medical use of POMs is of course nothing new. Experienced drug users in the 80s and early 90s knew their way around the BNF better than most trainee pharmacists. Growing concern about the diversion and misuse of key medications was noted in the 2016 ACMD report "the Diversion and Illicit Supply of Medicines"

At the same time the American Opioid crisis had been causing huge concern. The emergence of "pill mills" dispensing high-strength opioids had created a new generation of dependent users. Action was required but as is often the case the path to hell is paved with good intentions. Clamping down on the pill-mills - without the requisite treatment and support for those the casualties they created - drove dependent opioid users in to the arms of the illicit drug market - as availability of fentanyl was increasing.

The death toll and headlines caused concern on this side of the Atlantic, with articles such as this in the Pharmaceutical Journal saying "The United States is in the grip of an opioid misuse epidemic, with 142 opioid-related deaths every day. Could prescription painkiller misuse reach crisis levels in the UK too?"

While there was every reason to be watchful and vigilant for the over-prescribing of medicines associated with diversion, misuse or dependency, we were in truth very far from the US situation. Since the Shipman Enquiry, the scrutiny applied to stronger opioids in the UK was higher than ever.

We still had an issue with long-term prescribing of benzodiazepines and related compounds despite decades of guidance cautioning against their use on an ongoing basis. Likewise the willingness to prescribe codeine-based compounds, tramadol and weaker opioids on a liberal basis was a cause for concern. But we were still far from the American experience. And worse we were looking at only one aspect of that experience - what happens when over-prescribing takes place, not looking at what happens when you rapidly clamp down on this prescribing.

NICE released a draft set of guidelines on the management of Chronic Pain in August 2020 and the final guidance was released in April 2021 It has colossal ramifications for those experiencing pain or those already prescribed the drugs mentioned.

The key guidance on pharmacological interventions is as follows:

Locally, over the past few years we have already seen what happens when attempts are made to withdraw patients with long histories of sedative or opioid prescription without adequate preparation of support.

- too often patients are advised by their prescriber that their prescription will be reduced and stopped with little or no prior warning or discussion;
- when the patient is distressed or resistant to this change some are then referred straight to Drugs Services without any further support intervention, their anxiety with change being viewed as an addiction issue rather than unmanaged fear of symptoms recurring or withdrawal issues.

The NICE guidance is heavily predicated on the timely availability of high quality, non-pharmacological interventions such as talking therapies, alternative models of pain attenuation and physical therapies. But in many parts of the country access to such interventions have waiting lists, have limited availability or simply don't exist.

So what happens when people find that their prescriptions are being reduced, the promised non-pharmacological interventions aren't available and the local drug services isn't the right place for them? Predictably people turn to self medicating. And thanks to legitimate on-line pharmacies, dubious overseas suppliers and wholly illicit dark-web sources there is no limit to what people seeking relief from pain can obtain - without recourse to the street drug dealer.

The downside of course is that by pushing people away from NHS-managed pain management to less legitimate channels is fraught with additional dangers.
- the drugs may be fake, of unknown strength or composition;
- the patient no longer gets product information, dose guidance or any other advice;
- there's no scrutiny of dosage, meaning this can escalate without any oversight to levels way outside recommended doses
- the former patient is at risk of criminalization
- if the prescriber is unaware of the purchase of these products, they cannot record and watch for side effects or avoid known drug interactions;
- the stability of patient supply is uncertain, dependent on websites or suppliers that may cease to be available at short notice.

We have already seen the devastating consequences of this in relation to benzodiazepines. Attempts to reduce over-prescribing were well-intentioned. But people seeking relief from anxiety, stress, insomnia or trauma had ready access to benzodiazepines - first from overseas pharmacies, then from the NPS market and finally from the dark web and street dealers. Far from reducing dependency on diazepam we saw the emergence of a cohort of people dependent on - and dying from - the non-medical use of stronger "street" benzos such as etizolam or flualprazolam.

There is undoubtedly a need to question the need to explore prescribing for chronic pain, and improve non-pharmacological offerings. But to do so without ensuring that these offerings are in place, that GP training to support and reassure people when their prescriptions are reduced and stopped, and without appropriate joint working with drug services is a recipe for disaster.

The intention may well be good but without great care with the implementation we will end up closer to the American experience. While it is far from ideal for people to be prescribed opioids or other medication which may be ineffective from within the NHS it is far safer to do so than for people to source similar, stronger drugs illicitly outside of the NHS.