New guidelines on prescribing strong painkillers

This story was first published in The Straits Times on April 29, 2013

PATIENTS suffering from chronic pain are set to benefit more from a group of controversial drugs that may prove better at managing their conditions.

For the first time in Singapore, guidelines have been published on how to prescribe these strong painkillers, which include morphine.

This will give doctors, who are worried about the risk of addiction, more confidence in using them to treat patients.

Dr Tay Kwang Hui, who heads National University Hospital's pain management unit, believes the guidelines on the use of opioids are significant for Singapore, given its ageing population.

Already, it is estimated that one in 10 adults here suffers from chronic pain.

Opioids, which are drugs either derived from or mimic opium and are commonly given to treat cancer, can also be prescribed for common, painful ailments such as those of the muscles and joints.

This class of drugs also includes oxycodone, fentanyl and methadone.

But Dr Ho Kok Yuen, president of the Pain Association of Singapore, said many doctors prefer to steer clear of prescribing such medication due to the risk of patients getting hooked.

Instead, they turn to weaker options such as Panadol or anti-inflammatory medication.

Most studies put the risk of painkiller addiction at 10 per cent.

"Many have moderate to severe pain so drugs like Panadol don't work for them," said Dr Ho, who also heads pain management at Raffles Hospital. "More people need stronger medication but do not have access to it."

Which was why the Pain Association of Singapore led a 10-man task force, comprising specialists such as anaesthesiologists, oncologists and psychiatrists, to draw up local guidelines on how to prescribe opioids and monitor patients.

The guidelines, which were published in the latest edition of local medical journal Annals Academy of Medicine, cover 10 types of long-term pain ranging from headaches to back, neck and chronic post-surgery pain.

They advise doctors to set an "opioid agreement" with the patient by signing a form detailing terms of the treatment.

Patients who do not agree will not be given the drugs. For those who agree, a trial period of one or two months is recommended before the prescription is extended.

They should then be monitored regularly - for example by taking urine and blood tests - to make sure they are taking the right doses.

Doctors are also advised to be on the alert for telltale signs of addiction, such as forging of prescriptions, asking for higher dosages and "doctor-shopping" - going to many clinics to obtain more painkillers but without the knowledge of the original physician.

Such patients are to be gradually taken off the drugs to prevent withdrawal symptoms. The regimen should also be stopped if the patient's pain fails to subside.

The guidelines also instruct doctors to be especially cautious when it comes to patients with a history of alcohol or drug abuse, as they may become addicted to the medication more easily.

The guidelines are not compulsory and come as the use of opioids here is growing. The amount consumed per capita in Singapore doubled from 2005 to 2010, according to data from the University of Wisconsin in the United States, which tracks opioid consumption worldwide.

Doctors welcomed the new guidelines, with Singapore General Hospital's Dr Michelle Tan saying that it "lays the ground" for whether opioids are suitable for the patient and sets the "rules" to follow if the drugs are prescribed.

Dr Tan, who is an anaesthesiologist, said judicious prescription of opioids may help to minimise problems of drug abuse faced by some Western countries, where use of such drugs is widespread.

With "almost all doctors" likely to come across someone with chronic pain, the document can help those who are not pain specialists in managing such patients, added Dr Alvin Yeo, a consultant with Khoo Teck Puat Hospital's anaesthesia department.

These could be general practitioners, allied health workers such as physiotherapists and pharmacists, or trainee doctors.

He said: "More well-informed patients will also avail themselves to such guidelines and this will help them to work together with their doctors to manage the pain."

This story was first published in The Straits Times on April 29, 2013 

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