Differences in Opioid Use and Abuse Between the UK and US 

Becky McCall

Disclosures

February 11, 2020

What is happening in the US with respect to opioid use is not happening in the UK, according to a UK-based expert in pain medicine, dispelling common myths about opioid use and misuse.

Opioids have a valuable place in pain management, said Dr Cathy Stannard, consultant in pain medicine at NHS Gloucestershire, speaking at a news briefing in London earlier this week. The briefing addressed prominent issues relating to opioid use in the UK including whether misuse was as great a threat as in the US.

Commonly used opioids include codeine, dihydrocodeine, tramadol, oxycodone, morphine, buprenorphine and fentanyl. As widely documented, opioid-related deaths remain a public health crisis in the US. In 2018, according to the Centers for Disease Control and Prevention (CDC), there were 67,367 drug overdose deaths in the US, although this represents a 4.1% decline from 2017 (70,237 deaths).

Myth Busting

Busting prevailing myths around pain and pain management in the UK, Dr Stannard highlighted that "what is happening in the US is not happening here in the UK". She referred to data on opioid consumption levels, pointing out that the US prescribed more than 40,000 daily doses per million inhabitants compared with 12,500 in the UK.

"The US prescribes nearly four times as much as the UK, and in terms of Europe, we are also low prescribers," said Dr Stannard. She mainly focussed on the UK but said that Germany was worth a mention for being the second highest prescriber in the world with 29,000 daily doses per million inhabitants. Surprisingly however, they actually have one of the lowest opioid-related death rates. "Germany is doing something right," added Dr Stannard.

Medscape UK approached Dr Winfried Häuser, professor of internal medicine at the Klinikum Saarbrücken, Germany, to ask why this might be the case. "Since 2009, guidelines in Germany on opioids for chronic non-cancer pain have always been cautious in recommending opioids for these conditions, and in 2014 we defined potential indications as well as contraindications of opioids for chronic non-cancer pain."

Also, he pointed out, in Germany non-pharmacological alternatives to opioids, and treatments such as physiotherapy and psychological therapies, are nearly fully reimbursed by health insurance companies. "Prescription of strong opioids is only possible by special receipts which must be kept in a safe."

UK Prescriptions Dropped in Last 2 Years

Despite an increase from 2008 to 2018, over the past 2 years prescribing of opioids has gone down in the UK. In comparison with the opioid epidemic in the US, Dr Stannard pointed out that there had been time to look at what happened in the US and learn from it.

"The UK has a publicly funded healthcare system, so paternalism might play into this because the patient is not always right," she said. "In the US, if one doctor doesn’t prescribe then you can go to another who will."

The UK also has significant regulatory oversight in terms of licensing, use of, and scheduling (categorisation of drugs of potential abuse), she pointed out. In addition, there is also good clinical oversight, so any clinical commissioning group can tell a prescriber about their prescribing habits compared with others, based on quantitative data. The UK also provides ready access to opioid substitution treatment for those who need it, whereas in the US this is expensive.

She also highlighted that the culture of litigation played a part in the US. "Time was that in the US, clinicians were sued for undertreating pain. Looking at records of the General Medical Council (GMC), there has never been an incident due to a clinician undertreating pain," said Dr Stannard, noting an important difference between the countries. 

Alternatives to Opioids and the Importance of Wider Mental Health 

Opioids work well in short-term pain and in anaesthesia, and in some people in the long term, said Dr Stannard. She disputed the ‘myth’ that there were better medications for pain than opioids. "For long-term pain that is distressing and disabling, there are no medical treatments that work really well. In our effort not to prescribe opioids, we really don’t want to use other treatments that at best don’t work but are also harmful."

However, she noted that pain was complex and that pain management needed to encompass more discussion around mental health problems. "When I ran a high-dose opioid clinic, I never saw anyone who didn’t have some profound emotional burden. We know now that there’s a close relationship between adverse childhood experiences and chronic pain. It doesn’t mean it hurts less, but it means that using a medicine that is there to stop injury signals is not logical and in fact we should be looking at emotional health."

Jamie Coleman, professor in clinical pharmacology at University of Birmingham, also speaking at the briefing, commented on the links between mental health and pain management. He explained that anti-depressants and anti-epileptic drugs were sometimes used in pain management. "These drugs can change mechanisms in the brain that have other beneficial effects in pain, but in reality, different patients experience pain in various different ways… it’s hard to objectify pain."

He added that the role of stress should not be downplayed. "There might be other psycho-social burdens in people’s lives, and this affects the experience of pain and how that pain is managed."

Long-term Use is Not Addiction

In the real world, only around 1 in 10 people with long-term pain gain effective relief with opioid treatment. Dr Stannard stressed that there was a difference between long-term use and addiction. "It’s the norm for people to return with pain, it isn’t the exception. We know some people are on it [an opioid] for many years, but it does not mean they are addicted, it might just mean they are getting benefit. We should not conflate long-term use with addiction."

She reflected that despite the 1 in 10 statistic it was important to remember that some people will find the drug has a life-changing benefit. "Because things might not go well with the other nine you can’t deprive that one person the benefits – you can’t throw the baby out with the bathwater." She said that a responsible prescriber should try it for 2 weeks and if, after that time, there is no improvement, then it probably will not work in the long term.

Clinical Decision-Making Around Treating Pain is Complex 

Shifting from myths to truths, Dr Stannard highlighted that decisions to prescribe are complex and that, "there is an enormous amount of baggage that gets brought to a consultation".

She was frank in saying that if the consultation finished with a patient thinking ‘so you are going to leave me in pain then’, "this is an existential threat to me as a pain consultant. It is very difficult to say ‘no, I’m not going to treat you’. Our identity as healthcare professionals is based on trying to help."

As clinicians, we respond compassionately to people and might prescribe the strongest drug possible even knowing that this might not be the right thing.

Another truth, said Dr Stannard, was that responses to overprescribing are not only in the healthcare domain. Social housing, law enforcement, recovery services, social policy, criminal justice are all big pieces of the picture, she stressed.  "Yes, we should have responsible opioid stewardship and prescribe appropriately, but actually we need to change the picture of our relationship with dependency medicines and this includes reconceptualising persistent pain as something other than a medical condition needing treatment. It is more of an articulation of distress." 

Prof Coleman is chair of the opioid expert working group at the Medicines and Healthcare products Regulatory Agency (MHRA). He drew attention to the fact that it should not be forgotten that concerns around opioid use were well founded and were based on the risks of addiction, dependence, overdose and death; the overprescribing in many countries; the range of non-medical use including use at a higher dose or greater frequency than prescribed, and use without a legitimate prescription.

He strongly advocates that opioid stewardship needs to be the new mantra in a similar way to antimicrobial stewardship, involving the right doses available for patients, and these should be within limits, with guidance if the patient is using more than [the recommended] morphine equivalent daily. "We also need to decide whether the weak opioid, codeine, should be available over-the-counter as it is currently. There’s a public consultation ongoing."

Lastly, he pointed out that education and public perception of pain medications needed addressing. He took issue with the term painkillers, noting that, "painkillers don't exist" because pain medications do not actually kill pain. "Pain reliever is a more accurate term," he added.  

Science Media Centre briefing, London, 5th February 2020.

COI: Dr Stannard, Professor Coleman and Professor Häuser have declared no relevant conflicts of interest.

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