How can GPs best approach patients dependent on opioids?

Associate Professor Mark Morgan has thought a lot about how to best treat patients with opioid dependence.
 
It’s no surprise, given the RACGP Expert Committee – Quality Care (REC-QC) Chair co-wrote the college’s guidelines to prescribing drugs of dependence.
 
Professor Morgan believes that the way doctors respond to people with dependencies can often be framed by suspicion or negativity.
 
But the challenge is sorting out patients who are genuinely seeking help versus those who are spinning a story to obtain drugs of dependence or ‘doctor shopping’.  
 
‘GPs don’t like feeling manipulated and lied to – you’re quite sensitised to that. But there’s a need to remain professional and keep an eye on the health needs,’ he told newsGP.
 
‘GPs often have a very emotive response to drug seekers and substance abuse in general, and the way that is handled is sometimes very detrimental or out of synch with the empathic side [of general practice].’
 
Many people on methadone programs have told Dr Morgan about negative experiences in the healthcare field, both in general practice and in emergency departments. 
 
‘They’re treated very much with suspicion and sometimes hostility. They feel quite isolated from the ability to seek medical care,’ he said.
 
‘[They] need to be treated with respect, as patients with needs, not criminals to be got out of your room with the least effort possible.’
 
But respect and empathy doesn’t mean having to prescribe drugs of dependence.
 
‘The flipside of that is there needs to be very strong governance around prescription for opioids. You have to know how to say no, while also knowing they have their own needs,’ Professor Morgan said.
 
‘There’s a long game of helping people to be managed successfully and rehabilitating them.’
Professor Morgan’s own approach is to listen to the patient’s story in full until any request is clear.
 
‘Once I understand what the full request is, I start making appropriate enquiries to back up the story with other sources and collateral information to support or refute a patient’s request,’ he said.
 
‘I don’t start with “no” until I’ve heard the full story, because just occasionally, a person is in strife and does need immediate help.’
 
With a patient’s permission, Professor Morgan will call their previous prescriber or pharmacist, or check if there is recent prescription information on My Health Record.
 
If Professor Morgan denies a request, he makes it clear that he can offer not the opioids for their addiction but a structured approach to support, bringing in drug and alcohol counselling and an opioid substitution program.
 
‘Sometimes people ask for a last little box of 20 and then they’ll never bother you again – but that’s actively contributing to a problem, as it builds patterns of behaviour.’
 
Drug-seeking behaviour can be reduced by placing signs on the practice door saying ‘Doctors in this practice will not prescribe drugs of dependence to visiting patients,’ according to Professor Morgan.
 
‘If you do decide a story is genuine and the patient is in acute pain and should be on drugs of dependence, it’s helpful to have good practice policies about whether to have a contract with the patient over what the goals of treatment are, when you will review them, and what arrangements to make to continue a prescription,’ he said.
 
The RACGP’s guidelines, Prescribing drugs of dependence in general practice are in two parts.
 
Part C1 covers opioid use, patient selection, governance and pharmacology.
 
Part C2 covers the role of opioids in pain management.
 

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