Opioids in the UK: what’s the problem?
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5108 (Published 15 August 2013) Cite this as: BMJ 2013;347:f5108
All rapid responses
Dr Stannard is to be congratulated for her succinct contribution to the growing qualitative literature examining concerns over prescription opiate use for chronic non-malignant pain (1). Unfortunately like many others (2) she highlights the lack of reliable data and so we can only infer if this is a growing problem in the UK.
The well known issues in relation to inappropriate opiate use have a long historical basis but concerns are now being expressed that the long term use of opiates use for non malignant pain may lead to poorer clinical outcomes as well as significant side effects in their own right (3). We suggest that the time is long overdue for a national regulatory monitoring system for the prescription of long term step 3 opiates (as well as Tramadol) for non-malignant pain. Accumulating evidence shows that prescription-monitoring programmes can lead to better practice (4). Until such a system exists in the UK, we will remain unaware of the extent of the potential problems, and powerless to make any effective improvements.
In the meantime, we would suggest mandatory coding of step 3 opioid use in the electronic patient records within primary and secondary care. This would allow interrogation of data on opioid use nationally and could be cross referenced against their other coded diagnoses e.g. chronic back pain, previous self harm, alcohol/substance dependence. Only then will we be able to begin to reliably address any issues but more importantly safegaurd the use of opiates which, when used appropritely, are hugely important therapeutic agents.
Dr Gordon Stewart
Clinical Fellow
Glasgow Royal Infirmary
Dr Michael H Basler
Consultant in Anaesthesia and Pain Medicine
Glasgow Royal Infirmary
Glasgow
References -
1. Stannard, Cathy. "Opioids in the UK: what’s the problem?" BMJ: British Medical Journal 347 (2013).
2.Grady, Deborah, Seth A. Berkowitz, and Mitchell H. Katz. "Opioids for chronic pain." Archives of internal medicine 171.16 (2011): 1426-1427.
3. British Pain Society. Opioids for persistent pain: good practice. 2010. www.britishpainsociety.org/pub_professional.htm#opioids.
4. Reifler, Liza M., et al. "Do prescription monitoring programs impact state trends in opioid abuse/misuse?." Pain medicine 13.3 (2012): 434-442.
Competing interests: No competing interests
Dear editor,
Prescription drug misuse and dependence is an emerging epidemic in several developed countries. In the US over the last two decades, there has been a rapid rise in opioid prescribing for chronic, non-cancer pain, driven in part by aggressive pharmaceutical marketing (1). As prescribing of opioids increased, so did non-medical use (2). Prescription opioid misuse is now the leading drug problem in the US, with overdose fatalities involving prescription opioids surpassing fatalities associated with heroin use (3).
In the US, most opioids are obtained by prescription from primary care practitioners. It has always seemed less likely that the UK, with a very different health care system, would follow the American trend to an epidemic of prescription drug misuse. However, the recently released data on drug-related mortality in England and Wales (4) show that deaths related to prescription opioids are increasing. In particular, the report noted that deaths due to the painkiller tramadol have doubled in the past four years to 179 last year.
As part of our ongoing monitoring of drug trends, Global Drug Survey explored the issue of prescription medication misuse at the end of 2012. Questions on tramadol were included for the first time and a total of 369 respondents in the UK reported using tramadol during the past year. Our sample comprised 245 males (66%), 105 females (29%) and 19 who did not specify (5%). Their mean age was 29.6 years (SD=11.3; range 16-71) and the majority (334; 91%) were white. Thirteen (4%) were mixed race and the remainder were black, Asian, or other ethnicities. Most respondents (80%) were heterosexual, 37 (10%) were bisexual, 22 (6%) homosexual and 16 (4%) preferred not to specify or did not answer. GPs were reported to be the most common source for tramadol (n=235, 64% of respondents). Thirty-four percent of respondents reporting they obtained the drug from friends, 3% from dealers, and 3% from the internet (the numbers reflect the fact that people can obtain tramadol from more than one source). Asked their reason for using tramadol, 75% reported to alleviate pain, 31% to help them relax, 26% to get high, and 16% to relieve boredom. Although most of 91 respondents who reported they used the drug to get high obtained it from friends or a dealer, 20% reported obtaining the drug by prescription. Among the 264 respondents for whom tramadol was the only prescription medication they had used in the past year, 75 (28.4%) reported that they had mixed tramadol with alcohol and/or other drugs to enhance its effect, 51 (19.3%) had taken more tramadol than was prescribed, 27 (10.2%) reported feeling physically or emotionally unwell when attempting to use less tramadol and 24 (9.1%) reported trying to obtain extra tramadol.
Heroin remains the leading cause of overdose deaths (579 cases) in the UK, but the trend over the last several years is of falling heroin deaths and rising prescription drug deaths. Our data are a timely reminder that most pharmaceutical opioids are obtained by prescription and that responsible prescribing of opioids is the best way to ensure that we do not emulate the US, Australia and other developed countries in creating a new epidemic of opioid dependence.
Dr Adam Winstock
Honorary Consultant Addictions Psychiatrist & Clinical Senior Lecturer
South London and Maudsley NHS Trust
Addictions Clinical Academic Group
Dr James Bell
Consultant Physician
Addictions Clinical Academic Group, Kings College London
Dr Rohan Borschmann
Clinical Psychologist
Institute of Psychiatry, King's College London
References
1. Van Zee A. (2009). The promotion and marketing of Oxycontin: commercial triumph, public health tragedy. Am J Public Health 99; 221–7
2. Dasgupta N, Kramer D, Zalman M, Carino S, Smith MY, Haddoxa JD, Wright C (2006). Association between non-medical and prescriptive usage of opioids Drug and Alcohol Dependence 82 ; 135–142
3. Paulozzi LJ, Budnitz DS, Xi Y. (2006). Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf;15(9):618-627
4. Office of National Statistics. (2013). Deaths related to drug poisoning in England and Wales, 2012. Accessed 2/09/2013: http://www.ons.gov.uk/ons/rel/subnational-health3/deaths-related-to-drug...
Competing interests: Dr Bell has been funded to present at a conference by Mundipharma, which is associated with a formulation of tramadol, Global Drug Survey has received funding for a data report on prescription opioids from Mundiapharma Research.
Opioids are not the only class of drug used for severe pain that are causing problems. Those of us treating substance misusers are seeing increasing numbers of polydrug users requesting pregabalin, and increasing numbers of those users dying of mixed drug overdoses in which pregabalin is implicated. The danger of diversion and abuse of pregabalin deserves more widespread recognition.
Competing interests: I am a GP caring for many patients with substance misuse problems.
Opiods in the UK: What’s the problem? Answer – Good Clinical Practice needs to cover all population groups including sickle cell disease patients.
Cathy Stannard’s important editorial (15 August) really boils down to what good clinical practice is all about [1]. When she says “if we ask whether there is a problem with how opiods are being prescribed in the UK, the answer is definitely ‘yes’” that is another way of saying that with regard to opiod prescription good clinical practice in the UK is lacking.
Nowhere is this more glaring than in treating sickle cell disease patients in pain for whom clinical experience has always shown that Morphine/Diamorphine is highly dangerous. [2-14]. Sadly, Dr Stannard does not say a word about this category of UK patients. Why? Because perhaps NICE [13] does not find anything wrong in continuing to recommend strong opiods to treat sickle cell disease patients whose in vivo sickling worsens through the respiratory suppression that the opiods produce, even when UK’s NCEPOD Report revealed they died in large numbers [2 3 4 6 8].
It is also not correct to imply that the UK has nothing to learn from the USA, because while Diamorphine is used regularly for sickle cell disease patients in the UK this is not the case in the USA [15]. The bottom line is this: when it comes to opiod prescription whether for sickle cell disease patients or for others, the Consultant in charge of the patient must take full responsibility for what the patient receives, exactly how much, and for how long. To rely on Guidelines, however NICE, leaves a lot to be desired.
Felix I D Konotey-Ahulu MD(Lond) FRCP(Lond) FRCP(Glasg) DTMH(L’pool) FGA
Kwegyir Aggrey Distinguished Professor of Human Genetics University of Cape Coast, Ghana and Consultant Physician Genetic Counsellor in Sickle Cell and Other Haemoglobinopathies. Nine Harley Street Ltd, Phoenix Hospital Group, London W1G 9AL [Website http://www.sicklecell.md Email: felix@konotey-ahulu.com]
Competing Interests: Three of my parents’ 11 children had sickle cell disease. See www.konotey-ahulu.com/images.generation.jpg To think if my siblings had grown up in the UK they would have been prescribed morphine or diamorphine for pain gives me palpitations. This is why I am never tired of pointing out that this was not what I was taught at London University’s Westminster Hospital School of Medicine.
1 Stannard Cathy. Opiods in the UK: What’s the problem? BMJ 2013; 347: f5108
http://www.bmj.com/content/347/bmj.f5108
2 NCEPOD (National Confidential Enquiry into Patient Outcome and Death): Sickle: A Sickle Cell Crisis? (2008) [Sebastian Lucas (Clinical Co-ordinatoer), David Mason (Clincal Co-ordinator). M Mason (Chief Executive), D Weyman (Researcher), Tom Treasurer (Chairman)] info@ncepod.otg
3 Mason S. Enquiry shows poor care for patients with sickle cell disease. BMJ 2008; 336: 1152
4 Konotey-Ahulu FID. Opiates for pain in dying and in those with sickle cell disease. BMJ Rapid Response 11 October 2007. http://www.bmj.com/rapid-response/2011/11/01/opiates-pain-dying-patients...
5 Konotey-Ahulu FID. Morphine for painful crises in sickle cell disease. BMJ 1991; 302(6792): 1604 (June 29) http://www.bmj.com/content/302/6792/1604.2
6 Konotey-Ahulu FID. Opiates for sickle cell crisis? Lancet 1998; 351: 1438 (May 9)
7 Konotey-Ahulu FID. Opiates for sickle cell crisis. Lancet 1998; 352: 651-652 (August 22)
8 Konotey-Ahulu FID. Poor care for sickle cell disease patients: This wake-up call is overdue. BMJ Rapid Response May 28 2008 to Susan Mayor on “Enquiry shows poor care for patients with sickle cell disease” on NCEPOD Report SICKLE: A Sickle Crisis. http://www.bmj.com/rapid-response/2011/11/02/poor-care-sickle-cell-disea...
9 Konotey-Ahulu FID. Current “hit and miss” care provision for sickle cell disease patients in the UK. BMJ Rapid Response July 22 2008. http://www.bmj.com/rapid-response/2011/11/02/current-hit-and-miss-care-p...
10 Konotey-Ahulu FID. Management of sickle cell disease versus management of the sickle cell disease patient. BMJ Rapid Response 17 September 2008. http://www.bmj.com/rapid-response/2011/11/02/management-sickle-cell-dise...
11 Konotey-Ahulu FID. Inquest into diamorphine deaths: Does NCEPOD Sickle Cell Patients Report warrant a similar inquest? BMJ Rapid Response March 7 2009. http://www.bmj.com/rapid-response/2011/11/02/inquest-diamorphine-deaths-...
12 Konotey-Ahulu FID. The politics (and economics) of pain relief in the West and Third World. BMJ Rapid Response to T Anderson “The politics of pain” 11 August 2010 doi: 10.1136/bmj.c3800 http://www.bmj.com/rapid-response/2011/11/02/politics-and-economics-pain...
13 Konotey-Ahulu FID. Management of an acute painful sickle cell episode in hospital. NICE Guidance is frightening! BMJ Rapid Response September 7 2012 (42 References) http://www.bmj.com/content/344/bmj.e4063/rr/599158
14 Konotey-Ahulu FID. The Sickle Cell Disease Patient: Natural History from a clinico-epidemiological study of the first 1550 patients of Korle Bu Hospital Sickle Cell Clinic 1991/1992 The Macmillan Press Ltd, London and reprinted 1996 TA’D Co Watford, Herts WD17 3ZH, UK (645 pages) http://www.sicklecell.md/aboutscd.asp
15 Ballas SK. Sickle Cell Pain. IASP Press. Seattle, USA.
Competing interests: Competing Interests: Three of my parents’ 11 children had sickle cell disease. See www.konotey-ahulu.com/images.generation.jpg To think if my siblings had grown up in the UK they would have been prescribed morphine or diamorphine for pain gives me palpitations. This is why I am never tired of pointing out that this was not what I was taught at London University’s Westminster Hospital School of Medicine.
Re: Opioids in the UK: what’s the problem?
Heroin users often abuse a wide variety of other drugs, the most common of which are benzodiazepines, amphetamine, antidepressants, methadone and ethanol. Recently concerns have been raised that the three prescription drugs gabapentin (1), pregabalin (2) and buprenorphine (3) are being diverted and abused. We retrospectively reviewed the case files of 82 heroin users who had died in central Scotland over 2 1/2 years and re-analysed blood samples for these three prescription drugs.
Gabapentin was detected in 23 cases (28%), of which only 3 were prescribed gabapentin, suggesting that the drug was being obtained illicitly. Health care providers were aware of this abuse in 7 of the cases. However, since gabapentin has “occasionally” been found in recent seizures of street heroin in Scotland (4), its detection in fatalities may not always indicate specific misuse of gabapentin. Pregabalin was detected in 6 cases (7%) of which only 1 was prescribed pregablin, indicating a lower level of illicit use than gabapentin. Buprenorphine was found in only 1 case and had been prescribed.
Medical practitioners prescribing gabapentin and pregabalin need to be aware of the potential for diversion of the drug for illicit use. Although we found no evidence of similar diversion of bupenorphine in this study of fatalities in our area, this may not be true of other parts of the UK.
Ian J Donald
Medical Student
Centre for Forensic and Legal Medicine, University of Dundee
Peter D Maskell
Lecturer in Forensic Toxicology
Centre for Forensic and Legal Medicine, University of Dundee
Giorgia De Paoli
Lecturer in Forensic Toxicology
Centre for Forensic and Legal Medicine, University of Dundee
Nitin Seetohul
Lecturer in Forensic Toxicology
Centre for Forensic and Legal Medicine, University of Dundee
Derrick J Pounder
Professor of Forensic Medicine
Centre for Forensic and Legal Medicine, University of Dundee
References
1. Smith BH, Higgins C, Baldacchino A, Kidd B, Bannister J. Substance misuse of gabapentin. Br J Gen Pract. (2012) 62: 406-7.
2. Millar J, Sadasivan S, Weatherup N, Lutton S. Lyrica Nights – Recreational Pregabalin Abuse in an Urban Emergency Department. Emergency Medical Journal (2013) 30:874.
3. Taikato M, Kidd B, Baldacchino A. What every psychiatrist should know about buprenorphine in substance misuse. Psychiatric Bulletin (2005) 29: 225-227.
4. SCDEA Report on the Quality of Diamorphine seized in Scotland 2010-2011 (2012) http://www.communityplanningaberdeen.org.uk/web/FILES/ADP/REP_20120328_d... (Accessed 11th Sept 2013)
Competing interests: No competing interests