Opioid prescribing is rising in many countries

Smith et al. describe in their editorial widespread opioid prescribing and use in European and North American countries, and the risk of deaths related to that use, with the opioid epidemic in the United States as the most prominent exposition.

The editorial is focussed on opioid prescriptions, and neglects some important factors that play a major role in the US opioid crisis. Opioid-related deaths are related much more often to illicit opioids than to prescription opioids, and recent research has highlighted the contribution of socioeconomic factors such as social capital or workforce participation to opioid-overdose deaths (Heyman et al. 2019).

Smith et al. do not mention other literature highlighting the lack of an opioid crisis in Europe (Hauser et al. 2016). They mention Germany as the country with prescription rates resembling those of the US most closely, but do not mention that Germany does not have any overdose death problem.

Detailed data by the Federal Statistical office from death certificates (https://www.destas.de/DE/Publikationen/Thematisch/Gesundheit/Todesursach...) provides a total number of 225 opioid-related deaths for 2015 (data for subsequent years not yet available), including 90 heroin-related deaths. This comes down to 2.7 opioid-related deaths per million inhabitants, compared to 102.9 in the US in the same year.

I have worked in chronic pain management and palliative care in Germany for more than 25 years, and throughout this time I have seen first a lot of enthusiasm for opioid treatment for chronic noncancer pain and then gradually a more critical and careful attitude. Many specialist pain treatment centres by now will report cases of chronic pain patients with inappropriate opioid therapy, who then have to be weaned off the medication. However these are only isolated cases and there is no increase in inappropriate use of opioids in Germany in general. Anti-corruption legislation prevents aggressive marketing by pharmaceutical companies. Good clinical guidance, widespread education, for example with inclusion of pain management and palliative care in the undergraduate curriculum, and balanced regulations ensuring adequate access to opioids for those who need them as well as prevention of abuse seem to prevent the development as seen in the US. Guidelines on the long-term use of opioids for noncancer pain have been published in 2010 and 2015 (Hauser et al. 2015) and are currently being updated.

In Germany regulations for opioid prescription have been changed throughout the years to allow easier access to these medicines - for example, extending the maximum amount per prescription or the maximum duration of each prescription. I am a member of the expert committee of the Federal Opium Agency, which regulates and monitors medical and non-medical use of opioids in Germany. This panel includes experts from pain management, palliative care and substance use disorder. There is consensus in the committee that there is no indication of anything similar to the opioid crisis in the US, and no indication of an increase in inadequate prescribing of opioids in Germany.

Treatment of chronic noncancer pain may be very resource intensive. Germany has a well established social security network, including full health insurance coverage, and this means that economic reasons (opioid therapy offering a cheaper alternative to complex multimodal interventions) may have a lesser role in Europe compared to the US. Many of the chronic pain patients would not consider expensive and time consuming nonmedical interventions if they would have to pay for it themselves.

For most countries in the world, the crisis is not misuse or abuse of opioids, but the lack of access to opioids for acute pain and palliative care (Knaul et al. 2018). For some high income countries, rising opioid prescribing raises red flags. However, even in these countries guidelines and regulations need to ensure an adequate balance between access to opioids for those who need it and prevention inappropriate use on the other hand.

I agree completely with the conclusions of Smith et al., that long term public health and political approaches are necessary to deal with the challenges of chronic noncancer pain management.

References
Hauser W, Bock F, Engeser P, Hege-Scheuing G, Huppe M, Lindena G, Maier C, Norda H, Radbruch L, Sabatowski R, Schafer M, Schiltenwolf M, Schuler M, Sorgatz H, Tolle T, Willweber-Strumpf A, Petzke F (2015). [Recommendations of the updated LONTS guidelines : Long-term opioid therapy for chronic noncancer pain]. Schmerz 29(1): 109-30.
Hauser W, Petzke F, Radbruch L, Tolle TR (2016). The opioid epidemic and the long-term opioid therapy for chronic noncancer pain revisited: a transatlantic perspective. Pain Management 6(3): 249-263.
Heyman GM, McVicar N, Brownell H (2019). Evidence that social-economic factors play an important role in drug overdose deaths. International Journal of Drug Policy online first.
Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, Arreola-Ornelas H, Gomez-Dantes O, Rodriguez NM, Alleyne GAO, Connor SR, Hunter DJ, Lohman D, Radbruch L, Del Rocio Saenz Madrigal M, Atun R, Foley KM, Frenk J, Jamison DT, Rajagopal MR, Lancet Commission on Palliative C, Pain Relief Study G (2018). Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet 391(10128): 1391-1454.