Opioid prescribing is rising in many countriesBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l5823 (Published 17 October 2019) Cite this as: BMJ 2019;367:l5823
- Blair H Smith, professor of population health science1,
- Emma H Fletcher, consultant in public health2,
- Lesley A Colvin, professor of pain medicine1
- 1Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
- 2NHS Tayside, Dundee, UK
- Correspondence to: B H Smith
Opioids are effective in managing acute and cancer pain.1 However, their effectiveness in chronic pain is uncertain, with limited evidence of consistent pain relief beyond 12 weeks. Tolerance and opioid induced hyperalgesia can develop, leading to prescription of higher doses with minimal benefit.2 In addition, adverse effects occur with prolonged use and higher doses, including dependency, overdose (intentional and unintentional), cardiovascular events, and impaired respiratory, endocrine, and immune functioning.34
The United States is currently in the middle of a so called opioid epidemic. Its causes are complex but include an ageing population with increased risk of chronic pain, changes in prescribing practice with new opioid formulations, changes in recommendations about opioid use for chronic pain, and aggressive marketing by drug companies (including direct marketing to patients) that overstated the benefits and misrepresented the potential dangers.5
Although marketing may have a less prominent effect outside the US, there are indications that opioid prescribing is increasing worldwide, with considerable variation among and within countries.3678 For example, in the 10 years up to 2013, the number of opioid doses prescribed in the US doubled from 16 046 to 31 453 per million people per day, while in western and central Europe it trebled from 3079 to 9320. Germany had the closest rates to those in the US (23 352 doses/million people/day). In the UK prescribing rose from 1658 to 5227 doses/million people/day.5 In Scotland, over a similar period, the number of prescriptions of high strength opioids more than doubled from 474 385 to 1 036 446 a year,9 though, as elsewhere, there are signs that rates may be slowing.10
The result is that opioid prescription and use are widespread. As Public Health England recently reported,3 13% of the population were dispensed an opioid pain medicine between 2017 and 2018. Furthermore, some 540 000 people were prescribed opioid pain medication continuously between April 2015 and March 2018. A systematic review found that 4.7% of people prescribed opioids for pain went on to develop formally diagnosed misuse or addiction.11 A key focus of the new Medicines and Healthcare Products Regulatory Agency’s (MHRA) new opioid expert working group will therefore be to explore risk minimisation measures aimed at improving appropriate use of prescription opioids.
Of particular concern is the effect of increasing opioid prescribing rates on risk of drug related deaths. In Canada, more than half of all opioid related deaths in 2016 involved prescription drugs (dispensed or diverted) and roughly one third of people who died from an opioid related overdose between 2013 and 2016 had been prescribed an opioid at time of death.12
Drug related deaths in England, Wales, and Scotland have increased substantially in recent years. In 2018 there were 5672 such deaths: 871 (18%) more than in 2017 and the highest number ever recorded.1314 Opioids were implicated in 1039 (79%) drug related deaths in Scotland and 2208 of 4359 (51%) drug related deaths in England and Wales—again, the most ever recorded. However, while the proportion of drug related deaths involving opioids has increased only marginally (75% in 2008 v 79% in 2018) in Scotland, the proportions related to other substances (illicit or prescribed) have risen steeply. These include etizolam (0 v 42%), alprazolam (0.1% v 10.4%), gabapentin (0.4% v 15.2%), pregabalin (0% v 16.5%), and cocaine (5.6% v 21.2%).14 In one area of Scotland the mean number of substances found in toxicology at postmortem examination was 6.8 (range 1-14).15 Polysubstance use is therefore of considerable concern, and our vigilance must extend beyond opioids.
Tackling opioid prescribing alone therefore may not reduce substance related harm. Furthermore, there may be a risk of unintended consequences such as substitution of other substances and undertreatment of pain. Rather, a whole systems approach must be adopted that considers all aspects of pain management and prevention and (potential) opioid misuse.
As Public Health England recommended, chronic pain management must include personalised treatment plans balancing effectiveness and risk, with patients fully informed to enable shared decision making.3 This is the focus of the recently revised Scottish Intercollegiate Guideline Network (SIGN) guideline on management of chronic pain, which includes professional and patient versions.4 The plans should prioritise supported self management, frequent review of medications, physical activity, and psychologically based interventions.4 The challenge will be to ensure equitable access to non-pharmacological therapies and will probably require innovative community based approaches.
Optimising direct individual care is only part of the wider strategic mechanism for reducing substance related harm in people with chronic pain. Evidence clearly shows that people living in the most socioeconomically deprived areas are more likely to be prescribed opioids,39 and both chronic pain and substance use are strongly associated with socioeconomic deprivation and life adversity. Unless we apply long term public health and political approaches, these challenges are here to stay.
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. BHS is the Scottish government’s national lead clinician for chronic pain. BHS and LAC led the recent revision of the Scottish Intercollegiate Guidelines Network (SIGN) 136 (Management of Chronic Pain), which focused on opioid prescribing. The authors declare no other competing interests.
Provenance and peer review: Commissioned; not externally peer reviewed.