GPs have concerns about prescribing strong opioids for chronic non-cancer pain (CNCP), a qualitative study has shown. The issue most cited was the potential for development of tolerance and dependence.

Seventeen GPs from the South West of England were interviewed individually about their current prescribing practices using semi-structured interviews. Information was supplemented through a focus group meeting involving another five GPs. Transcripts of the interviews and focus group were analysed by thematic analysis.

Of the 22 GPs included in the study, ten had had no formal training in pain management or palliative care, while 12 recalled educational input during their GP training or at other times. Some had experience of prescribing opioids in specialist situations such as hospices. The GPs’ time in general practice ranged from 9 months to 30 years, 15 were male and seven female.

All participants had prescribed strong opioids for CNCP, following the stepwise or ladder approach for treating cancer pain but perceived CNCP as different from cancer pain.

One of the main concerns for prescribers was the length of time patients could end up using opioids for CNCP, especially if started at a younger age. The concern most cited was the potential for development of tolerance and dependence.

GPs admitted difficulty in assessing the level of CNCP and therefore titrating the opioid dose. Participants had considered referral to a pain clinic when prescribing. They recognised that total analgesia may not be achievable for CNCP patients.

They were also alert to other consequences of prescribing strong opioids including medication diversion.

There were variations in reported practice which may be associated with experience. Four GPs who had an interest in pain management or palliative care were less concerned about prescribing opioids for CNCP.

Over recent years there has been an increase in the prescribing of opioid analgesics to manage CNCP, and recent surveys indicate that around 12% of these patients in the UK are currently prescribed regular strong opioids by their GP.

The authors conclude that the GPs involved in the study demonstrated a thoughtful attitude when considering strong opioid prescribing in CNCP, using stepwise strategies that are in line with current guidance, and maintained awareness of the potential pitfalls of prescribing, including misuse, tolerance and dependence.

They suggest that GPs may benefit from training in pain assessment and the long-term management of CNCP.

Dr Jez Thompson

• Seamark D, Seamark C, Greaves C, Blake S. GPs prescribing of strong opioid drugs for patients with chronic non-cancer pain. Br J Gen Pract 2013;63 (617):821-8