Evidence collected by Public Health England (PHE) shows an increase in the use of over-the-counter codeine medicines. It is also increasingly recognised by health professionals that opioid medications used to treat pain become less effective over time. Often, doses can be increased to high levels of opioid medication and this often does not work, creating a dependency on opioid medications in the long run, particularly codeine based ones (PHE, 2014; 2019).
From data collected by PHE, 11.5 million adults received at least one prescription, which was for over 36 months in duration. Of those receiving medications for over 36 months were: 5.6 million on opioid pain medicines, 1.4 million on benzodiazepines and a growing number on gabapentiods. These figures illustrate there is significant bulk of prescribing in this area and therefore PHE has encouraged commissioning services to try and address this issue (PHE, 2019).
In America, the prescribing and the illicit drugs trade in opioid painkillers has led to an increase in mortality figure. The government has called the situation are present a national crisis as 130 people die every day from opioid related drug overdoses. In the UK there is evidence that opioid analgesic prescribing has increased in the last decade with a doubling of mortality figures also increasing. Hence a need to address this issue:
Good practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context and understanding the clinical use of the drug (PHE, 2019).
This paper argues that nurses who are also Non-Medical Prescribers (NMPs) in addictions can be best placed to develop a service to meet this increasing need. Providing advice and plans for reductions as well as working with the patients. These will be patients who, whilst in pain, have also developed an addictive behaviour pattern that needs to be recognised and worked with, in general practice.
The Benzodiazepine and Opiate Withdrawal Service (BOWS) was set up across Camden and Islington based in primary care. It has its expertise in treating addictive behaviour patterns and hence transferred these skills to the field of treating opioid dependency and benzodiazepines. Often they would use substitute medications used in the field of addictions, which proved effective, these medications being methadone and buprenorphine. This paper is an illustration of what can be achieved with this client group with a particular focus in buprenorphine.
Benzodiazepine opiate withdrawal service
The Benzodiazepine and Opiate Withdrawal Service (BOWS) service is a recently developed service to treat patients for dependency on codeine based drugs prescribed or used illicitly, benzodiazepines and other prescribed medications which have led to dependency such as gabapentin and pregablin (PHE, 2014). It is often that the service does see patients who have these dependencies, but they are also wrapped up in other drugs such as heroin, crack dependencies and alcohol. The service has expanded to treat patients that have a dependency on prescribed drugs and the cohort examined in this paper are those on codeine-based medications. BOWS works on reducing dependency on prescribed medication and a reduction where possible, of overall doses of medication. In some cases, substitute prescribing of buprenorphine and methadone can be used to stop overuse of medication and overall reductions as well.
BOWS was started in October 2018 in an Inner borough in London and is now firmly established in nine primary care (General Practitioners) surgeries across the borough. To date it has seen assessed and treated 240 patients. The service is based in the local drug and alcohol service.
The idea of having knowledge of substitute prescribing for opioid dependency can be very useful in switching patients away for codeine based medications to buprenorphine or methadone where a patient can then stabilise and then reduce their level of medication.
The case studies presented in this paper illustrate the point that the prescribing of buprenorphine and methadone can be effective in stabilising patients overuse of codeine medications and be effective in reducing the overall dose as well. Also, it can enable at times, more effective pain management. Psychological tools used for patients are motivational interviewing that is seen as an effective tool to increase a patient's insight and change behaviour to engage with a healthier lifestyle when showing patterns of dependency (Department of Health, 2017). This can also be used in a group setting and the BOWS service has set-up a support group to talk about addictions to codeine and offer support and a safe space to talk about these issues. This has been well received by the patients that are part of the overall service.
The BOWS service team consists of two very experienced NMP nurses and a specialist GP and psychologist. The BOWS service offers a team approach. The NMPs have a wide scope of practice that covers the major analgesics and medications associated with substance misuse such as codeine based preparations to methadone and buprenorphine. It also covers medications such as pregablin and gabapentin. This scope of practice is under constant review as the service is still developing and expanding.
The case studies used here are to show how having BOWS team and in particular the NMPs in primary care, can plan effective treatment for patients and can enable them to start to break-away from their addictive patterns.
Pain management medications
People presenting with chronic pain are often a treated with a range of analgesia. Often the strong codeine based analgesics such as oxycodone can lead to patients developing addictive behavior patterns around their prescribed medications. As a result they often experience difficulty coming off their prescription despite the pain easing.
Opioid analgesics are often used to treat moderate to severe pain such as codeine-based analgesics. Strong opioids are often used in general practice are (British National Formulary (BNF), 2020).
Morphine
This is used to treat chronic and severe pain and is often used for patients in the latter stages of palliative care. It does have side effects nausea and it is often used with cyclizine to accommodate this.
Buprenorphine
This is an effective analgesic and can be used to treat severe pain. It has a longer duration of action then morphine and if taken sublingually can be effective quickly to relieve pain. It has been used to address dependency on codeine-based medication to good effect in BOWS.
Diamorphine (heroin)
This can be used in extreme cases, often used in palliative care and not in general practice unless initiated by a pain management consultant.
Oxycodone
More widely prescribed in the US, this is a drug used to treat chronic pain if morphine is not tolerated. As mentioned this can lead to some patients developing dependency on this medication.
Methadone
Commonly used in opioid substitution therapy it is also a very effective analgesic. It is less sedating then morphine and can act for longer periods of time. It is used in the BOWS service and has proved effective for some patients. Some patients were put on low doses of methadone by pain clinics and often moved to substance misuse services. Often they had never used illicit drugs.
Pethidine and fentanyl
These are often never used in General practice to treat pain. They are short-acting and often have led to patients being dependent of these medications. However, often the patients presenting to the BOWS service are on opioid based pain medicine and not Pethidine or Fentanyl (BNF, 2020).
Buprenorphine
The approach from BOWS is to look at a wide area of prescribing that can be used to treat codeine dependency. Often reducing the dose of codeine (their current medication) can be successful but for some patients that is not possible. For those patients substitute prescribing becomes a more useful option to address overuse and stabilise the patient in terms of dependency behaviour.
In the BNF (2020), buprenorphine is described as a drug suitable for opioid dependency and pain management. It is described as a strong opioid that is an effective analgesic for patients when and if prescribed.
It is commonly used in the treatment of opioid addiction where patients have dependency on drugs such as heroin, diamorphine and crack cocaine. Patients that have come off opioid dependencies have used it successfully. Hence, the logic would be it has a role to play on patients who present with opioid/codeine dependencies and often patients, in the past, have presented to drug and alcohol services with such problems and have been started on buprenorphine or low doses of methadone. This has been the experience of the NMPs working in BOWS and they have transferred their experience to primary care. Buprenorphine can be effective in treating pain management and addiction for patients that have failed to reduce off their dose of codeine successfully. The next part of the paper uses case studies to illustrate the effective use of buprenorphine for pain management.
First, buprenorphine has a high binding affinity for the μ-opioid receptor, which is responsible for pain relief. Moreover, buprenorphine has a slow rate of dissociation from the μ-opioid receptor, meaning that it stays attached longer to the receptor and has prolonged effect.
Buprenorphine is attracted to the μ-opioid receptor; it acts only as a partial μ-opioid receptor agonist, which means that while buprenorphine prevents opioid withdrawal, its actions are less potent than opioids. This may lead to titration at some doses slightly higher than a straight conversion would indicate.
Third, buprenorphine is a full κ-opioid receptor antagonist. Activation of the κ-opioid receptor results in the euphoric and psychotic effects of opioids. In other words, buprenorphine won't make you ‘high’.
A systematic review (Aiyer et al, 2017) found that in treating patients who presented with chronic pain, prescribing buprenorphine could provide the following benefits:
- Increased efficacy in neuropathic pain
- Less immune-suppression than morphine based medications and fentanyl
- Less development of tolerance and better as a long-term analgesic.
Audit at 18 months for the BOWS Service
This section will show some basic statistics that illustrate some of the patients seen by the BOWS service that present with pain management issues. The charts shown here examine those patients who have converted to buprenorphine for their pain management. It will hopefully illustrate that this should be a treatment pathway explored as routine for the BOWS service.
Figure 1 shows the patients that have presented to the service over the past year from October 2018 to March 2020 and this was 240 at the time of writing. It shows that of the 240 who presented 34% of the patients converted from opiate medications to buprenorphine, methadone or decreased slowly off their codeine based medications. As seen from the chart, the majority of the patients seen are those presenting to primary care with problematic benzodiazepine use at 47% with another 19% presenting with a mixture of prescribed medications such as gabapentin, pregablin and other analgesics such as tramadol and heroin use. Some of these patients are on methadone for pain and this has proved effective for pain management. However, as mentioned, this paper is focusing on those patients who have converted to buprenorphine for pain management and how this has proved to be a successful pathway for the patients who have done so.
Figure 1 is showing the 34% percentage that is referred for pain management of their prescribed medication. Often, as the case studies will show, the patients referred overused their medications and presented to the GP surgeries asking for more pain relief over a period of many years. The BOWS service can manage these presentations well and implement a more compliant and safe medical regime for patients. They are also skilled at treating the dependency as well.
A significant proportion of patients are converted to buprenorphine at 47% and this will be the focus of the study and will illustrate how this can work for patients (Figure 2). It can make their pain better controlled and lead to a break from overusing codeine-based medications. It can also be useful to reduce and detoxify off as it has a shorter self-life then most other analgesics.
Case Studies
Case studies are used to illustrate what is possible in terms of medicine and can be used in clinical settings to see what is possible, as also in turn presenting cases that are atypical (McNiff, 2014).
They can also enlighten and increase the knowledge base and, when shared can increase expertise and the skill-set of teams. This paper shows what is possible when helping patients with codeine dependent patterns, in terms of treatment and what can be effective. This is now explored.
Case study one
- Age: 60
- Gender: female
- Years on codeine phosphate: 12 years
- Dose on conversion: 240 mgs
Client A lived alone and her children had grown up and were living away from London. She has been in her flat in Islington for five years. It was a housing association flat and there are currently no problems with the tenancy. She currently is only on fluoxetine for depression and codeine for pain relief.
This patient had been on codeine phosphate 60 mgs QDS for 12 years and she had initially started on 120 mgs and this she said when she had first started, had been effective. She was not aware that codeine over a period of time can grow less effective and she increased her dose as she just felt she needed more medication. Now she felt that the medication was growing less effective. She at the time of assessment, she stated she was in pain again and was not sleeping through the night because of the pain. She was very anxious as well as her lack of sleep resulting to more anxiety. She did have a low mood but rather then having depression it seemed linked to the lack of sleep and her frustration of having effective pain management.
She has had a history of substance misuse fifteen years ago and has had a history of methadone treatment as well. Also, she had a dependent drinking pattern five years ago and had accessed addiction services for this. She has had Motivational Interviewing (MI) and Cognitive Behavioural Therapy (CBT). She is aware of the psychological approach to dependent behaviours and has found this useful in the past.
It was discussed that she had a dependent pattern around her codeine use and she did admit that but, was not sure of how to address this issue. She did not want to change her regime but wanted to manage this better. However, in the past she had always overused her medication. The idea of substitute medication was introduced and buprenorphine was discussed.
At first she was reluctant to change her medication as she had not heard of buprenorphine and despite talking about the benefits of switching she wanted to stick with what she knew. She was reluctant to decrease her dose despite recognising that her dose was ineffective. However, due to the pain and lack of sleep was open to seeing me again to discuss alternative medication.
On her fourth appointment she asked to be switched to buprenorphine and her equivalent dose of buprenorphine was at the range of a starting dose of 4 mgs. (Dose equivalent of over 10 mgs of methadone 240 mgs of codeine is equivalent to 24 mgs of methadone and therefore the start dose should be 4 mgs and titrated up). Her dose of codeine indicated that 24 hours would be needed from her last dose of codeine to her first dose of buprenorphine, This was completed and she has now to date successfully converted to 4 mgs of buprenorphine daily. Usually a dose of 240 mgs of codeine would require a buprenorphine dose of 6-8 mgs but Client A has been able to stabilise on 4 mgs. Her pain is now well managed and she has been able to sleep better as well. Her mood is much better but she still takes fluoxetine. She is now glad to have switched her medication and would like to stay on this dose with a view to reduce this long-term if possible.
Through MI the patient was able to recognise her addictive behaviour and recognise it similar pattern to her alcohol and illicit drugs years before. She was familiar with how MI could increase her insight and ability to problem solve as well. She engaged well in the sessions that were a mainly using MI with a review of her medication as well. She also attended the BOWS group weekly for the support.
The review session was every two weeks and when she had stabilised she was seen every four weeks; this is her current regime. She is still on 4 mgs and her pain is well managed on this and the plan is to reduce further over the next six months.
Case study two
- Age: 52
- Gender: female
- Years on codeine: 15 years
- Dose on conversion: 240 mgs
Client B lives in her own flat with her grown up children. All family members work in the house and she has no housing issues. He has been diagnosed with osteoarthritis and has no other medical problems.
Client B was working on the shop-floor at Marks & Spencer for the past five years. She has a job that needs her to be fairly mobile as she works in the food department. She has been suffering from lower back pain for many years and this has got worse after she developed osteoporosis after the menopause.
She had been on replacement hormone therapy known as HRT but this did not prove effective. Her pain in her back worsened so her dose of codeine increased to 360 mgs daily. She also felt the tablets were not working as well as before and therefore thought she was growing tolerant to the medication. She did not recognise that there was a dependency developing. She started to overuse her medication and wanted to see if there were alternatives. It was at that point her GP referred her to me.
This patient had started off on codeine of 60 mgs once a day for back pain, She had had physiotherapy and the exercises had made her back worse and she stopped going but her pain had increased. Over the course of two years her dose increased to 360 mgs daily and she had started to overuse. The pain was still difficult for her to manage and instead of going up further, she wanted to look at what else was out there that she could look at and take that would cover her pain much better. Therefore, she was booked with the BOWS service and was assessed. It was discussed that codeine for many patients who experience pain does has limited effectiveness overtime, and that she would be better on a stronger non opioid painkiller, buprenorphine was suggested and she was very interested in this.
The BOWS NMP also discussed her dependency on codeine that she did not recognise at first as she thought the medication was growing ineffective, as her tolerance increased. However, through using MI in the session, it was possible to promote the idea of a dependency developing and this consolidated her desire to switch to buprenorphine.
The conversion of 360 mgs would be in the region of 4-12 mgs daily and she was interested to start. She was informed of stopping her codeine medication and starting the buprenorphine 24 hours after her last dose of codeine. She wanted to start on 2 mgs and if needed she would see me and titrate up to a higher dose of needed.
She stabilised on 4 mgs and then reduced to 2 mgs and felt much better. Her sleep pattern improved and she also felt her pain was better managed. She started walking more and has been going out, which has made her feel so much better psychologically.
This conversion has worked well. To date she has now been on 2 mgs daily of buprenorphine for two months and is still feeling the positive benefits of this medication. She will continue to be reviewed monthly but this looks to have improved her situation already.
Conclusion
The BOWS is now over eighteen months is an established service. The case studies illustrate what can be an effective service for patients who have dependencies on opiates and prescribed drugs. This paper illustrates that a specialist nurse NMP working for BOWS is able to treat patients with other codeine dependencies with some success and this has proved effective from the case studies shown here. An important point is that by having experience in prescribing buprenorphine and being experienced in delivering psychological interventions for dependency has proven very useful and effective in treating people with codeine dependencies. This is because the nurses are experienced in treating patients with dependent patterns whilst also being experienced NMPs. In the cases presented here it has enabled them to recognise their dependency on prescribed codeine as well as increase their insight and problem solving skills to increase their health.
Therefore, in developing the service from a base where there is experience and knowledge of treating patients who have developed patterns of dependencies can be very effective. In summary, having a service which employs experienced nurses from addictions can work well for people who have developed dependencies on codeine based medication that are prescribed. This should therefore be an area that commissioners look towards to expand provision in this area as well as expanding specialist pain clinics.
Key Points
- Non-medical Prescribing can be flexible and effective in response to this growing medical problem
- Explorative case studies can be very useful teaching tools
- Experienced Non-medical Prescriber can be very effect for treatment in codeine dependency
- Buprenorphine prescribing can be useful in pain management
CPD reflective questions
- Should buprenorphine prescribing be promoted in pain management?
- What should the frequency of the review process in NMP for pain management when prescribing buprenorphine as it is a controlled drug ?
- Does the concept of ‘experience’ really add to increasing the effectiveness non medical prescribing ?
- Does the role of the NMP really need reviewing to increase the effectiveness of this role ?