Opioids in the UK: what’s the problem?

The extensive misuse of prescription drugs in the United States has brought into sharp focus the role of opioids for persistent pain. The US has seen a marked and progressive rise in the prescription of opioid analgesics over the past two decades. This has been paralleled by an increase in deaths from these drugs—now a leading cause of accidental death in the US.1 Prescription data from the United Kingdom show comparable trends in the use of opioids for non-cancer pain.2 3 However, prescribing statistics don’t tell the whole story, and we need to look at UK statistics on addiction and opioid related mortality to understand exactly what the problems are.

The UK has fewer sources of data on opioid misuse than the US, but there are places to look for indications of a problem. Drug related deaths are reported by the Office of National Statistics (ONS), and its most recent data (2011) show an overall downward trend in deaths from analgesics. A notable exception is a steady rise in deaths from tramadol (154 in 2010-11). There has also been a rise in deaths from methadone (486), but over 97% of prescriptions for methadone in England are for treatment of opioid dependency rather than pain.2 4

Information on addiction to prescription drugs comes from the National Drug Treatment Monitoring System (NDTMS). The numbers of patients presenting for support in relation to addiction to prescribed opioids remained stable for five years until 2009-10. However, data for the past two years suggest a recent increase (around 8%) in the number of patients seeking help for analgesic dependency, with or without additional use of illicit drugs (https://www.ndtms.net/WhatWeAre.aspx). Although patients who are primarily dependent on prescription opioids form a small proportion of those in drug treatment, the prevalence of addiction to analgesics is almost certainly higher than these figures indicate, because many people do not seek medical help, particularly from drug services.

So do we have a problem with prescription opioids in the UK? The answer is yes and no, depending on how we frame the question.

First the “no”—we are probably not in the grip of an epidemic of prescription opioid misuse and mortality. However, this needs to be qualified with a “maybe not” or “not yet” because our current data sources may not be capturing everything we need to make a firm pronouncement. Any conclusions should be interpreted in the light of what we don’t know and are valid only at the time of writing. The ONS and NDTMS data emphasise the need for vigilance.

Alternatively, if we ask whether there is a problem with how opioids are being prescribed in the UK, the answer is definitely “yes.” The trends in prescribing have been paralleled by a burgeoning of the literature on opioids for persistent pain, with the balance weighing heavily towards a cautionary if not alarmist message in relation to opioid treatment. The contrary (pro-opioid) argument, usually framed in the language of pain advocacy, is unarguable in sentiment, given the distressing and disabling nature of persistent pain. Sadly, however, opioids are neither an easy nor necessarily effective solution to the problem. Opioids are prescribed more often and for longer periods than would be predicted by their known efficacy in the management of persistent pain.5 6 7 The data also suggest that opioids are often prescribed in doses above which we know that harms outweigh benefits.8

We must be careful to retain a balance despite worrying population statistics. What we do know about opioids and other drugs used to treat long term pain was elegantly summarised in a recent BMJ article.9 In short, most drugs don’t help most patients, but given the definite and potentially persistent benefits experienced by a minority of patients, we have to give a few things a try. This means that if opioids might help, they should not be withheld, but, importantly, if they don’t work in reasonable doses they should be stopped. It seems straightforward that patients should not be exposed to opioid related harms that are not balanced by a beneficial analgesic effect. However, it is hard to tell patients whose pain is intolerable that they are better off not taking drugs that don’t help, particularly if there is no therapeutic alternative.

So how do we make balanced prescribing decisions? Guidelines on the prescription of opioids have been produced and updated in many countries including the UK, but little is known about their penetration and uptake. Despite the message of restraint, opioid prescribing continues to increase.10 11 12 In the end it comes down to good medicine. Prescribing decisions should be underpinned by comprehensive assessment and formulation of the patient’s problem, shaped by their comorbidity and current circumstances. Treatment should reflect current evidence on benefits and harms and how these relate to dose. Prescribers should be aware of the broader public health concerns about opioids, although these must be interpreted in the context of what we know about opioid related harms in the UK.

We mustn’t ignore what is happening in the US, and we have much to learn from its prescription opioid disaster. Policy makers here understand the problems of the misuse of prescription opioids and its associated mortality, and in collaboration with clinicians and service users they are responsive to warning signals.13 14 As prescribers, we must keep in touch with the current debate, so that we can balance the competing imperatives of ensuring a pragmatic and compassionate approach to supporting patients with pain and avoiding the risk of creating problems for individuals and society.