Overprescribing is major contributor to opioid crisis
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4792 (Published 19 October 2017) Cite this as: BMJ 2017;359:j4792
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It is refreshing to see Martin acknowledge the way that doctors habits have contributed to the inappropriate introduction and management of opiates. There are some cautionary points I would add. We need to be careful that in raising awareness of this issue people who have a clear medical need for these medications are not denied them, an over reaction would be as much of a problem as letting the situation go unchecked.
Part of the problem is we have insufficient intelligence on the scale of prescription misuse, instead we use proxy measures such as the number of prescriptions issued or mortality rates due to overdose. We should urgently move beyond such crude indicators to gain an understanding of which sub groups in the population are particularly at risk. This would help us identify who might be at risk and offer a more targeted prevention approach.
Moving beyond prevention we need to employ interventions that support patients physically and psychologically to deal with their dependence on opiates. Policy makers in America have been slow to fund and encourage evidence based treatment such as opiate substitute prescribing programmes. But substitute prescribing on its own is not enough as we have learned to our cost in the United Kingdom, we also have record numbers of people dying due to opiates (1). Treatment needs to be individually tailored allowing sufficient time, an optimum dose of a drug such as methadone and a more assertive outreach approach to engaging people, all of which increase the chance of recovery and minimise mortality.
Unfortunately policy makers in the United Kingdom and America continue to ignorance the role of evidence based treatment. Without behaviour change at a political level people will continue to die.
References:
1. Hamilton,I. Sumnall,H. Drug related deaths are at their highest level in 25 years - here's why. The Conversation, 2017. https://theconversation.com/drug-related-deaths-are-at-their-highest-lev...
Competing interests: No competing interests
Are opioids just an American problem?
The progressive rise in opioid prescriptions and mortality in the US, highlighted by Makary et al [1], has shone a light on similar concerns in the UK. Whilst the financial incentives or ‘consumerist mentality of patient satisfaction’ may be less of a problem in the UK, doctors are still responsible for offering the best analgesia to patients who genuinely require them. There has been a 65% increase of opioid prescriptions for non-cancer pain in the U.K from 2000-2010 [2]. With increased utilisation comes an increased burden of side effects, plus further dependency and divergence. Indeed the number of opioid related drug-misuse deaths in England and Wales increased between 2012-2015 according to the Office of National Statistics [14]. The factors contributing to this increase in prescribing are likely to be different to the US and perhaps secondary to lack of effective alternatives in non-cancer chronic pain.
Concerns around drug safety have been raised with other analgesics such as COX II inhibitors [3,4], NSAIDs [5] and paracetamol [6] over the last 15 years. New evidence suggests that the several traditional analgesics are ineffective in musculoskeletal pain, one of the most common indications for opioids [7,8]. Thus, when deciding which analgesic to prescribe, it is important to have high quality evidence about the comparative benefits and harms. On a population level we now know that opioids are associated with a number of known and emerging harms, including adrenal insufficiency and serotonin syndrome highlighted by the FDA in 2016 [9]. Opioids are commonly prescribed with other drugs such as gabapentin and benzodiazepines, the combination also associated with increased accidental overdoses and mortality [10,11], possibly due to effects on respiratory depression as recently highlighted by the MHRA [12].
Rather than assigning opioids as an ‘American problem’ [13], we advise ongoing attention and vigilance in the UK. An improved understanding of the comparative safety of different opioids would be helpful to inform clinicians and patients regarding the safest opioid choice when no suitable alternative exists. Large-scale population health studies using electronic health records and, in time, incorporating patient reported benefits and harms, will allow quantification of individual benefit and harms related to opioid use. This would permit future prescription of the safest medications in those most likely to benefit – an urgent need given their escalating use.
Authors:
1. Dr Meghna Jani
2. Prof William G Dixon
Affiliations:
1. NIHR Academic Clinical Lecturer in Rheumatology. Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
2. Director of Arthritis Research UK Centre for Epidemiology and Professor of Digital Epidemiology. Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, UK
References:
1 Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ 2017;359:j4792.
2 Zin CS, Chen LC, Knaggs RD. Changes in trends and pattern of strong opioid prescribing in primary care. Eur J Pain 2014;18:1343–51.
3 Jüni P, Nartey L, Reichenbach S, et al. Risk of cardiovascular events and rofecoxib: Cumulative meta-analysis. Lancet 2004;364:2021–9.
4 Kearney PM, Baigent C, Godwin J, et al. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-inflammatory drugs increase the risk of atherothrombosis? Meta-analysis of randomised trials. BMJ 2006;332:1302–8.
5 Bhala N, Emberson J, Merhi a, et al. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013;382:769–79.
6 Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis 2015;:1–8.
7 Machado GC, Maher CG, Ferreira PH, et al. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ 2015;350:h1225–h1225.
8 Atkinson JH, Slater MA, Capparelli E V, et al. A randomized controlled trial of gabapentin for chronic low back pain with and without a radiating component. Pain 2016;157:1499–507.
9 FDA Drug Safety Communication: FDA warns about several safety issues with opioid pain medicines; requires label changes. March 22, 2016. https://www.fda.gov/Drugs/DrugSafety/ucm489676.htm
10 Gomes T, Juurlink DN, Antoniou T, et al. Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–control study. PLOS Med 2017;14:e1002396.
11 Park TW, Saitz R, Ganoczy D, et al. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ 2015;350:h2698.
12 Gabapentin (Neurontin): risk of severe respiratory depression. Medicines and Healthcare products Regulatory Agency. https://www.gov.uk/drug-safety-update/gabapentin-neurontin-risk-of-sever.... October 26, 2017
13 Why opioids are such an American problem: BBC news. http://www.bbc.co.uk/news/world-us-canada-41701718. October 25, 2017
14 Office of National Statistics: Number of drug-related deaths involving gabapentin and pregabalin with and without an opiate drug, England and Wales, 2015. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/...
Competing interests: No competing interests