The United States is currently facing its worst drug crisis. In 2015 alone, more than 52,000 people died of drug overdoses – a number indicating that the US is now seeing more drug overdose deaths than any other period in its history.

With the increasing use of opioids in Singapore, it is crucial that doctors take the necessary steps when prescribing opioid painkillers to patients.

The historical basis of opioid administration

For the past decade, opioid painkillers have become the preferred prescription for all sorts of pain conditions - from headaches to backache to chronic pain. Opioid prescriptions started to surge in the 1990s, owing to a research study indicating that opioids could be used to reduce pain in some groups of people.

Initially, opioid was only administered to cancer patients at the end of their lives. However, following the research study, there were calls to extend opioid use to routine conditions.

In addition, various states in the US began to relax their limitations on opioid prescriptions. Some advocates even argued that the “ceiling” should be removed and that dosage can be increased if tolerance issues arise.

Compounding the problem is the practice of doctors to prescribe opioids for long periods of time. While the doctors had wanted “just to be safe”, in ensuring that the patients had sufficient painkillers should they require it, they unknowingly fuelled the dependency effect, as the likeliness for dependency increases at the five-day mark.

How addiction develops

On initial administration, opioids really do seem to work wonders, as they abolish all perceivable pain. However, the effects wear off after a while. Some patients who have used opioids for an extended period of time have reported a sudden surge in pain when attempting to stop taking the drug.

The sudden pain experienced by the patient is due to withdrawal as a result from dependence on opioids. In such cases, escalated doses may be necessary to continue to numb the pain.

Opioids, despite their initial efficacy as painkillers, can make pain worse. There is research suggesting that opioids may make people more sensitive to pain, at the same time weakening the bones and leading to painful fractures.

The situation in Singapore

According to Dr Ho Kok Yuen, vice president of the Pain Association of Singapore, the norm for doctors in Singapore is to prescribe paracetamol or other anti-inflammatory medication. This is to avoid prescribing opioids, for fear of patients getting addicted over time.

In 2013, the Pain Association of Singapore devised a few guidelines on how to prescribe opioids and monitor patients. The guideline proposes that doctors have to lay down an agreement with the patient on the terms of opioid administration. The patients will then be put on a trial for one or two months under close monitoring. If all goes well, the prescription may be extended.

Additionally, doctors have to be on the alert for patients who may show signs of addiction such as asking for increased dosages, or going to different clinics to obtain more painkillers. Doctors also need to watch out for patients with a history of alcohol or drug abuse.

Lastly, doctors have to bear treatment goals in mind. Opioid therapy should be discontinued if therapeutic goals are not achieved.

While these guidelines are not compulsory, many doctors are in favour of the document. The truth is, opioid use in Singapore will continue to grow. Therefore, such judicious guidelines can help doctors safely prescribe opioids to patients. MIMS

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