Warning over painkiller addiction

“'Disaster' looms over addiction to painkillers,” reported The Independent .

This news story is based in part on a recent editorial published in the British Medical Journal , which discusses the rising use of opioid painkillers and the risk of death associated with these types of drugs.

Opioids are a class of drugs that include morphine, methadone and codeine. They can be addictive and may produce withdrawal symptoms if their use is suddenly stopped. They are commonly used for the treatment of cancer pain, but this editorial focused on their rising use for the treatment of chronic pain not related to cancer.

The authors mostly focused on North America and discussed trends in the prescription of opioid painkillers for chronic pain, as well as trends in opioid-related deaths. They also made recommendations for policy changes in North America that they said will reduce the number of these deaths.

The relevance of these recommendations for England is limited, due to different marketing practices and regulations between here and the US. However, the recommendations do highlight important areas for future policy discussions in England. These discussions are already planned. The Independent reported Public Health Minister Anne Milton as saying that experts will convene next month to discuss new evidence from recent studies on addiction to prescription medicines.

Where did the story come from?

This editorial was written by several researchers at the University of Toronto. The article was published in the British Medical Journal (BMJ) and was not peer reviewed.

In addition to the BMJ editorial, the media reports referred to findings from a report by the National Treatment Agency for Substance Misuse, which is an NHS special health authority overseeing the treatment of drug addiction in England.

The report, ‘Addiction to Medicine’, investigated the treatment services that support people who develop problems with prescription-only or over-the-counter medicine. It was published in May 2011. The main statistics reported in both the_ Daily Mail_ and the Independent (the increase in ‘prescribing of opioid analgesics by GPs from 228 million items in 1991 to 1.38bn items in 2009’), appear to be from this report. This report has not been reviewed in depth here, but can be found on the NTA website.

What kind of research was this?

This editorial was on trends in deaths and harm related to prescription opioid drugs and prescribing practices, primarily focusing on the US, although other countries are also mentioned. The article was not an opinion piece, was not a systematic review of the literature and has not been subject to peer review. The authors are lecturers and researchers at the University of Toronto.

The authors discussed the history of opioid use and trends in opioid-related deaths. They went on to make recommendations on health policy changes that could result in a decrease in the number of these deaths in the US.

What did the editorial say?

The authors said that deaths involving opioid painkillers in the US increased from about 4,000 in 1999 to nearly 14,500 in 2007. Such increases have been seen in other countries as well, including the UK. They also reported that most of these deaths are unintentional and are most often in young people.

The editorial highlighted concerns expressed by the former chair of the House of Commons All Party Parliamentary Group on Drug Misuse on the possibility that the UK will see a similar spike in opioid-related deaths within the next decade. It also referenced a 2010 BMJ article which reported that deaths involving methadone and codeine, two opioid drugs, nearly doubled in England and Wales between 2005 and 2009.

The authors discussed their growing concern that many of today’s opioid-related deaths could be prevented with adequate regulation of drug companies and more responsible and evidence-based prescribing practices.

The authors put forth several recommendations aimed at reducing the number of deaths involving opioid painkillers in the US, including:

• Restricting the marketing practices of drug companies, especially the current practice of rewarding drug sales representatives with large bonuses based on the number of drugs they sell. The authors also recommend that drug companies no longer be allowed to give coupons to new patients for free prescriptions of potentially addictive drugs.
• Requiring physicians and patients to register the prescription of methadone for the treatment of addiction so that prescribing habits can be tracked and drug-seeking behaviour can be detected.
• Developing electronic databases that provide information on all patients’ prescriptions, and requiring doctors and pharmacists to check this database before prescribing or dispensing opioid painkillers.
• Increasing physician education regarding the lack of evidence supporting the long-term use of opioids for non-cancer related pain, the toxicity of different opioids, the potentially fatal interaction between opioids and other drugs (including alcohol), and the lack of trials comparing opioids to other alternative forms of analgesia, such as paracetamol and non-steroidal anti-inflammatory drugs.
• Increasing public education efforts designed to inform people of the dangers of mixing opioid painkillers and other drugs.
• Encouraging well-designed, long-term research into the effectiveness of opioids compared to other forms of pain relievers.

How did the author interpret the findings?

The authors concluded that there is no clear indication that the long-term benefits of prescribing opioid painkillers outweigh the risks. They said that opioid painkillers can be a ‘valuable option for the treatment of acute pain and chronic cancer pain’, but that care needs to be taken when prescribing them for other conditions. The authors added that there must be a balance between making sure the drug is available to patients for whom the benefit has been supported by evidence, while reducing its use in patients for whom the benefit has not been proven or adequately researched.

Conclusion

This was an editorial written in response to the increasing number of opioid-related deaths in the US. The editorial reflected the views of the authors and the research and statistics that they had considered. While the article made several recommendations on possible ways to reduce the number of opioid-related deaths, without a formal systematic review it is not known whether all relevant evidence on the topic has been consulted. As such these recommendations may be considered to be opinion-based.

While similar trends in opioid use may exist in the UK, this editorial does not focus on the UK situation. Though research on the effectiveness and safety of opiods for non-cancer pain would be valuable, many other of the authors’ recommendations and suggested policy changes would not be as relevant to the UK as they would be in the US due to different marketing practices and regulations. For example, in the UK, prescription drugs are not advertised or marketed to those outside of the healthcare profession.

This editorial did highlight important areas for future policy discussions on the UK’s drug prescribing practices. Addressing this potential problem before it reaches the scale reported in the US could prevent avoidable deaths. People who live with chronic pain should discuss the management of chronic pain and the risks of long-term use of opioid painkillers with their GP or other relevant pain specialist health professional, especially if they are taking other prescription or non-prescription drugs.