Overprescribing is major contributor to opioid crisisBMJ 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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I don't think overprescribing is the biggest cause for the opioid crises. The pharmacy has a job to do its due diligence as to whether or not they should fill that perscription. Usually pharmacies have a list of red flags and if your prescription has atleast 1 red flag that script can be turned down by the pharmacist in charge(PIC). Some pharmacies have ignored some of these red flags and choose to fill the prescription anyway. Which has led to the over dispensing of narcotics. A good way to solve this problem would be for the wholesaler to limit the quantity your able to purchase per month. Pharmacies are able to order over 10,000 tablets per month of some narcotics. If the wholesaler takes that 10,000 tablets and brings it down to 3000 a major change can occur. For example Mckesson wholesaler allows you a maximum of 3 bottles of oxycodone 30mg or oxymorphone 40mg instead of 10 bottles of each. I used these two drugs because these drugs are highly sought after, and unfortunately due to overprescribing and over dispensing an opioid crisis has occurred. Limiting the quantities each pharmacy can receive per month will definitely slow down, if not eliminate the circulation of narcotics on the streets. Independent pharmacies in particular need to be a lot more selective with which patients they're dispensing to as well. Pharmacies are the last line of defense against the opioid crisis.
Competing interests: No competing interests
The progressive rise in opioid prescriptions and mortality in the US, highlighted by Makary et al , 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 . 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 . 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  and paracetamol  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 . 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 .
Rather than assigning opioids as an ‘American problem’ , 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.
1. Dr Meghna Jani
2. Prof William G Dixon
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
1 Makary MA, Overton HN, Wang P. Overprescribing is major contributor to opioid crisis. BMJ 2017;359:j4792.
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Competing interests: No competing interests
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.
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