Using opioids in general practice for chronic non-cancer pain: an overview of current evidence

We note with interest the recent article by Currow and colleagues,1 discussing the use of opioids for the management of non-cancer pain. This piece highlights increased opioid use occurring in Australia and elsewhere. As large scale providers of residential medication management reviews (RMMRs) in the residential aged care facility setting, we write to provide a different insight into the use of these analgesics among older people. We recently analysed aggregated, de-identified data from 15 178 RMMR reports — provided in response to general practitioner referrals from 2014 to 2016 — examining the use of potent oral analgesia. We found that there was little use of methadone or hydromorphone, and the subsequent analysis was limited to addressing only oral morphine, oxycodone and tramadol. Unlike the data from the Australian statistics on medicines,2 the RMMR represents a snapshot picture of all medicines prescribed, regardless of whether these were subsidised by the Pharmaceutical Benefits Scheme.

In 4474 cases (29.5%), residents who received an RMMR were treated with at least one of the three agents. Oxycodone alone accounted for 3356 cases (22.1%), followed by morphine (n = 611, 4.0%) and tramadol (n = 500, 3.3%). The World Health Organization stipulates a defined daily dose (DDD) for pharmaceutical drugs, specified as the assumed average maintenance dose per day for a drug used for its main indication in adults.3 The DDD is set at 75 mg daily for oxycodone, 100 mg daily for morphine and 300 mg daily for tramadol.3 For 2014 and 2015, each drug was prescribed below the DDD in more than 99% of cases, but for 2016 until May, oxycodone doses above the DDD have increased to 9.1%. Data reveal that, although prescribing rates for morphine and tramadol have remained stable, prescribing rates for oxycodone have increased rapidly (738 cases in 2014, 1512 in 2015, and 1106 for the first 5 months of 2016).

As older people are more susceptible to direct and indirect effects of potent analgesics, these preliminary data suggest that closer examination of opioid prescribing in the residential aged care facility setting appears warranted.