An open letter to the RACGP and Dr Simon Holliday,
Re: Article and interview with Dr Simon Holliday: Can pain self-management avoid the need for opioids?
In short, for a few maybe. For most? No. Absolutely not.
There are a number of egregious errors in the article by Dr Simon Holliday that contribute to the misinformation and disinformation in the GP community in relation to prescribing opioids for chronic non-cancer pain (CNCP).
Firstly, Dr Simon Holliday is an addiction medicine specialist. He may have an interest in pain, but nowhere has he listed his qualifications in pain medicine. He has completed training in ADDICTION MEDICINE, which is hardly the same thing. Its fallacious to refer to Dr Holliday as a GP and “pain expert” when he has no post graduate training in pain medicine. He is not an expert. He clearly has a very strong bias against opioid pain medications, presumably due to his background in addiction medicine.
Secondly, Dr Holliday states “opioids now kill more people than the road toll in in Australia.”
This is completely false. OVERDOSES kill more people than the road toll. In 2018 there were 1,135 road fatalities. According to the Pennington Institutes “Australia’s Annual Overdose Report 2020” there were 900 unintentional opioid related overdose deaths in 2018. Last time I checked, 900 is less than 1,135. Please print a retraction and correct the article on your website.
Dr Holliday also states “‘But the evidence is that opiates don’t have any role in chronic pain at all, frankly.” Yet he provides no evidence. Where is this evidence?
Without evidence, this is just an opinion, and an uninformed one at that. This article is full of statements that are not evidence based, that demonstrate Dr Holliday’s bias, and his desire to spread that bias to the GP community and ultimately cause great harm to chronic non-cancer pain patients who have been stable and well managed on opioids for years, sometimes decades.
There IS a cohort of patients who do well on long term opioids, and addiction is very rare in this population.
In fact, Dr Holliday’s own link states:
“Opioids are recommended in the treatment of chronic pain where other pharmacological and non-pharmacological treatment strategies have not been effective”
A quick search reveals many studies that conclude there is a role for opioids in CNCP management and the risk of addiction is very low.
“The findings of this systematic review suggest that proper management of a type of strong painkiller (opioids) in well‐selected patients with no history of substance addiction or abuse can lead to long‐term pain relief for some patients with a very small (though not zero) risk of developing addiction, abuse, or other serious side effects. “
Findings In this meta-analysis that included 96 randomized clinical trials and 26 169 patients with chronic noncancer pain, the use of opioids compared with placebo was associated with significantly less pain (−0.69 cm on a 10-cm scale) and significantly improved physical functioning (2.04 of 100 points)
It is repeatedly stated that the evidence shows there is no role for opioids in chronic non-cancer pain, but there are no links to this ‘evidence’. This is nothing more than myth building and the RACGP should do better.
Dr Holliday also relies on US statistics which are completely irrelevant to Australia. There is no opioid crisis here.
Dr Holliday states:
“A key challenge is the fact opioids are comparatively simple and initially effective, though efficacy reduces over time, potentially leaving people in pain – and ultimately dependent.”
However the provided link states the opposite:
“However, there are no prospective studies documenting the development of opioid tolerance or OIH in patients with chronic pain. This preliminary study in 6 patients with chronic low back pain prospectively evaluated the development of tolerance and OIH.”
An additional limitation is that this is a tiny study of SIX patients! Surely Dr Holliday can find better evidence than that.
The science has yet to prove that opioid induced hyperalgesia is a clinical entity, most studies conclude that more research is required and that previous studies were more likely measuring tolerance or disease progression than true opioid induced hyperalgesia.
Conclusions Although OIH is mentioned as a potential cause of opioid dose escalation without adequate analgesia, true evidence in support of this notion is relatively limited. Most studies conducted in the context of acute and experimental pain, which seemingly demonstrated evidence for OIH, actually might have measured other phenomena such as acute opioid withdrawal or tolerance.
The extent to which this phenomenon is relevant to the long-term opioid therapy administered to most patients with chronic pain is unknown. Although experimental evidence suggests that opioid-induced hyperalgesia might limit the clinical utility of opioids in controlling chronic pain (Chu, Clark, & Angst., 2006), there have been no reports of observations in the clinical literature to suggest that it should be a prominent problem.
Opioid induced hyperalgesia is far from a proven clinical entity, has only been shown in experimental pain, not clinically in chronic pain, and most studies conclude that it is a very rare entity IF it in fact exists at all.
Dr Holliday states “‘The evidence we do have is that it can make chronic pain worse, make function worse and come with side effects, including increased pain as well as diversion, overdose and death.’”
Again, where is this evidence? Clearly this is his opinion, and hardly an unbiased opinion, from years spent in addiction medicine, not treating chronic non cancer pain. It is not scientific fact and he provides no data.
Dr Holliday’s goals are laudable, and his self-management program for GPs is likely a positive step, provided it does not teach his personal anti-opioid bias. His own statements make it clear that he has force tapered all of his chronic non-cancer pain patients off their opioid pain medications, with no regard to their own preferences nor if they were stable and well managed on their opioid pain medications.
Dr Holliday writes:
“Evidence-informed chronic pain management emphasises non-pharmacological and non-invasive pain self-management [a multidisciplinary engagement with multimorbidity], the non-initiation or deprescribing of opioids, and a harm minimisation approach to addictive pharmacotherapies,’ Dr Holliday and his co-authors note.”
The “non-initiation and deprescribing of opioids” in ALL cases should NEVER be taught as a standard of care.
Chronic pain management needs to be personalised to the patient. Pain management should NEVER take this “one size fits all” approach. To teach this to GPs is to do immeasurable harm to those patients who live with high impact chronic pain caused by any number of degenerative diseases that cause intractable, constant, severe pain. There ARE patients who benefit from opioid therapy and to deny these patients effective pain relief is nothing short of cruelty. It is certainly not patient-centred care. In fact, is not care at all. It is neglect and negligence of a GP’s duty of care.
The evidence shows that there is a cohort of patients for whom opioids are safe and effective, that opioids reduce pain and improve physical function and quality of life, and that the rate of addition in this cohort is very low, less than 1%.
Providing courseware that teach GPs the opposite is a travesty. Promoting this as evidence-based care is betraying chronic non-cancer pain patients who live with high impact chronic pain.
The new opioid regulations were never meant to be a blanket ban on opioids, or a reason to deprescribe all chronic non-cancer pain patients. The TGA regulations state:
“The regulatory changes will not lead to a ban on prescribing opioids to any category of patient, if ongoing use is considered to be clinically appropriate. The changes will prompt prescribers to reflect on their opioid prescribing practice, to ensure that, when either initiating or continuing to prescribe an opioid, they have a discussion with their patient and consider whether they will benefit from opioid treatment and how the risks and harms are managed. “
Clearly any deprescribing needs to be done in consultation with the patient and with the patient’s best interests in mind. These regulations do not say that all patients must be deprescribed.
“Opioids can be used as part of the management of chronic non-cancer pain in circumstances where other pharmacological and non-pharmacological treatment strategies have not been effective, and the impact of poorly controlled pain has been considered. “
Also from the regs:
“Prescribers are also required to obtain their patient’s informed consent when either initiating or varying opioid treatment and will be provided with detailed guidance on opioid prescribing in managing pain by their professional associations.”
Please ensure the ‘guidance’ that you are providing is in fact evidence-based, and not opinion, conjecture or experimental artifact. Chronic non-cancer pain patients are now being force tapered en masse and being left in terrible pain for no reason other than anti-opioid zealots say they should. GPs need to be provided with the proper evidence and tools to make appropriate clinical prescribing decisions. And the evidence shows that for those living with high impact chronic pain, opioids are a safe, effective option that should be trialled when all other modalities have failed.
Force tapering and blanket deprescribing are barbaric actions and beneath the education level and compassion of the average GP.
Pain Patient Advocacy