Re: Oxycodone – How did we get here and how do we fix it?
I read with interest the prescribing rates for oxycodone in your latest update sent to all GPs. I would like to make
a few points.
The first is that the article is unlikely to be convincing to those doctors who prescribe oxycodone, and is more likely
to be a pleasant message to those who do not. If this is true the article is pointless as nothing will change!
Thinking on that a little deeper the question is “why do we (GPs and hospital doctors) prescribe oxycodone?
I think the answer is the widely held belief that this is a medication with some reduction in side effects. I think
perhaps that needs to be directly and thoroughly addressed, quoting serious research, if there is to be a sea change
in prescribing habits. Having said that there are countless times that GPs have claimed certain drugs are better or worse
despite so called evidence and in the end we have often been found to be correct. So the research has to be very, very
good, i.e. double blind crossover, etc.
The suspicion is that the main reason for publishing articles on various opioids is that funding for bpac and other
organisations like yours, e.g. Pegasus, comes with strings attached asking you to help save money – perhaps this should
be stated? To me the money is irrelevant as my clients would be incensed to think it is relevant.
The third point is if you add up all opioid scripts apart from codeine, then the overall trend for the total is going
up strongly. Is this true? The drivers for this could be widespread abuse of non-cancer pain but it also reflects a growing
trend for total failure of the health system to keep up with demands for orthopaedic procedures. This should be highlighted.
Dr Hammond Williamson, General Practitioner
We thank our correspondent for his candid comments which add to the debate on the challenges of prescribing opioids
for use in the community.
In the article “Oxycodone – How did we get here and how do we fix it?”
(BPJ 62, Jul, 2014), we discussed the available
evidence on the efficacy and adverse effects of oxycodone. The problem is that there are very few high quality, head-to-head
trials comparing oxycodone with other strong opioids. Perhaps it is better to view the evidence in terms of what is
not proven, which would lead to the conclusion that we cannot say for certain that oxycodone is superior to morphine
in terms of adverse effects. There is some evidence that oxycodone may be less associated with nausea and vomiting than
morphine, but there is also some evidence that it is more associated with constipation. If in balance, these two medicines
are considered similar in efficacy and adverse effect profile, it then comes down to a decision based on other risks
and benefits. The emerging misuse and addiction problems with oxycodone in New Zealand, coupled with the lessons learnt
from other countries that have been dealing with these problems, swings the balance in favour of morphine, if a strong
opioid is required at all. This is actually the bigger message in the “oxycodone story” – with the exception for use
in malignant pain, why are we prescribing strong opioids in the community at all?
Although the prompt to explore and write about medicines is often directed at those medicines with significant cost
to the health system, in order to reap the health benefit of this expenditure the medicines need to be used in accordance
with best available evidence and practical application of this evidence, which is the thrust of many of our articles.
This is true of medicines that are relatively inexpensive and used frequently in medicine (often general practice),
as it is true of more expensive treatments that are used in a very few patients. Cost is relevant to many patients,
who make cost-benefit decisions daily in all aspects of their lives. Patients are sometimes flabbergasted when they
find out the actual cost of their medicine, as opposed to the $5 prescription fee they pay at the pharmacy.
In the case of oxycodone, we have collaborated with both PHARMAC and Medsafe to highlight the general safety issues
with this medicine, and cost has not been a significant factor in these discussions.
As for the final point - the amount of strong opioids being used in New Zealand is increasing, as evidenced by national
pharmaceutical dispensing data. It is difficult to say with certainty what is driving this increased use, but it is
likely to be a combination of many factors, including widespread use of strong opioids for both malignant and non-malignant
pain, misuse and misappropriation of prescriptions and pressures on the health care system to meet demands for definitive
treatment of painful conditions.
We hope that the article in this edition, “Helping patients cope with
chronic non-malignant pain: it’s not about the opioids” may at least give clinicians some tools to help stem the tide of opioids.