Is Europe Facing an Emerging Opioid Crisis Comparable to the U.S.?

Fentanyl and its derivatives: Pain-killers or man-killers?

Fentanyl is a synthetic μ-opioid receptor agonist approved to treat severe to moderate pain with faster onset of action and about 100 times more potent than morphine. Over last two decades, abuse of fentanyl and its derivatives has an increased trend, globally. Currently, the United States (US) faces the most serious situation related to fentanyl overdose, commonly referred to as the opioid epidemic. Nowadays, fentanyl is considered as the number one cause of death for adults aged 18-45 in the US. Synthesis and derivatization of fentanyl is inexpensive to manufacture and easily achievable. Indeed, more than 1400 fentanyl derivatives have been described in the scientific literature and patents. In addition, accessibility and efficacy of fentanyl and its derivatives can play a potential role in misuse of these compounds as a chemical weapon. In this review, the properties, general pharmacology, and overdose death cases associated with fentanyl and selected derivatives are presented. Moreover, current opioid epidemic in the US, Moscow theatre hostage crisis, and potential misuse of fentanyl and its derivatives as a chemical weapon are disclosed.

Amelioration of morphine withdrawal syndrome by systemic and intranasal administration of mesenchymal stem cell-derived secretome in preclinical models of morphine dependence

BACKGROUND

Morphine is an opiate commonly used in the treatment of moderate to severe pain. However, prolonged administration can lead to physical dependence and strong withdrawal symptoms upon cessation of morphine use. These symptoms can include anxiety, irritability, increased heart rate, and muscle cramps, which strongly promote morphine use relapse. The morphine-induced increases in neuroinflammation, brain oxidative stress, and alteration of glutamate levels in the hippocampus and nucleus accumbens have been associated with morphine dependence and a higher severity of withdrawal symptoms. Due to its rich content in potent anti-inflammatory and antioxidant factors, secretome derived from human mesenchymal stem cells (hMSCs) is proposed as a preclinical therapeutic tool for the treatment of this complex neurological condition associated with neuroinflammation and brain oxidative stress.

METHODS

Two animal models of morphine dependence were used to evaluate the therapeutic efficacy of hMSC-derived secretome in reducing morphine withdrawal signs. In the first model, rats were implanted subcutaneously with mini-pumps which released morphine at a concentration of 10 mg/kg/day for seven days. Three days after pump implantation, animals were treated with a simultaneous intravenous and intranasal administration of hMSC-derived secretome or vehicle, and withdrawal signs were precipitated on day seven by i.p. naloxone administration. In this model, brain alterations associated with withdrawal were also analyzed before withdrawal precipitation. In the second animal model, rats voluntarily consuming morphine for three weeks were intravenously and intranasally treated with hMSC-derived secretome or vehicle, and withdrawal signs were induced by morphine deprivation.

RESULTS

In both animal models secretome administration induced a significant reduction of withdrawal signs, as shown by a reduction in a combined withdrawal score. Secretome administration also promoted a reduction in morphine-induced neuroinflammation in the hippocampus and nucleus accumbens, while no changes were observed in extracellular glutamate levels in the nucleus accumbens.

CONCLUSION

Data presented from two animal models of morphine dependence suggest that administration of secretome derived from hMSCs reduces the development of opioid withdrawal signs, which correlates with a reduction in neuroinflammation in the hippocampus and nucleus accumbens.

Patterns of filled prescriptions and the association with risk of drug-induced death. A population-based nested case-control register study

PURPOSE

Opioid analgesics (OA) and other pharmaceuticals have been associated with drug-induced deaths. However, there is a lack of knowledge regarding patterns of use of these pharmaceuticals in the population and regarding such associations. We identify and describe subgroups of people with different patterns of filled prescriptions of OA and other relevant pharmaceuticals and examine associations with drug-induced deaths. In addition, we estimate the proportion of drug-induced deaths with a filled OA prescription and OA as cause of death.

METHODS

A Norwegian population-based nested case-control register study with cases (drug-induced deaths 2010-2018, N = 2388) and population controls matched for age, gender and year of inclusion (N = 21 465). Patterns of filled prescriptions for opioid analgesics (OA), benzodiazepines and benzodiazepine-related drugs, gabapentinoids, ADHD medication and antidepressants/antipsychotics were explored by k-means cluster analysis. Associations with drug-induced deaths were estimated by conditional logistic regression adjusted for sociodemographic characteristics. Overlap of filled OA prescriptions and OA as cause of death was estimated.

RESULTS

Five clusters were identified: 'few prescriptions', 'weak OA', 'ADHD medication', 'sedative/psychiatric morbidity' and 'strong OA'. The 'strong OA' cluster had higher socioeconomic status compared to the other groupings. The risk of drug-induced death was also highest in this cluster (OR = 35.5; CI 25.6-49.3) and, for 68% (CI 64-73) of cases, filled prescriptions for OA was indicated as the underlying cause of death.

CONCLUSIONS

The cluster analysis identified a subgroup with filled prescriptions of OA and other pharmaceuticals and a higher socioeconomic status than other subgroups. This subgroup had a high risk of drug-induced death that needs to be addressed.

How do opioids control pain circuits in the brainstem during opioid-induced disorders and in chronic pain? Implications for the treatment of chronic pain

ABSTRACT

Brainstem areas involved in descending pain modulation are crucial for the analgesic actions of opioids. However, the role of opioids in these areas during tolerance, opioid-induced hyperalgesia (OIH), and in chronic pain settings remains underappreciated. We conducted a revision of the recent studies performed in the main brainstem areas devoted to descending pain modulation with a special focus on the medullary dorsal reticular nucleus (DRt), as a distinctive pain facilitatory area and a key player in the diffuse noxious inhibitory control paradigm. We show that maladaptive processes within the signaling of the µ-opioid receptor (MOR), which entail desensitization and a switch to excitatory signaling, occur in the brainstem, contributing to tolerance and OIH. In the context of chronic pain, the alterations found are complex and depend on the area and model of chronic pain. For example, the downregulation of MOR and δ-opioid receptor (DOR) in some areas, including the DRt, during neuropathic pain likely contributes to the inefficacy of opioids. However, the upregulation of MOR and DOR, at the rostral ventromedial medulla, in inflammatory pain models, suggests therapeutic avenues to explore. Mechanistically, the rationale for the diversity and complexity of alterations in the brainstem is likely provided by the alternative splicing of opioid receptors and the heteromerization of MOR. In conclusion, this review emphasizes how important it is to consider the effects of opioids at these circuits when using opioids for the treatment of chronic pain and for the development of safer and effective opioids.

Exploring the facilitators and barriers in opioid deprescribing for non-cancer pain treatment experienced by general practitioners: A qualitative study

BACKGROUND

Guidelines recommend opioid deprescribing in patients on long-term opioid treatment for chronic non-cancer pain. This study aims to explore facilitators and barriers in opioid deprescribing among general practitioners in the Netherlands. In addition, this study aims to identify possibilities for improvement regarding opioid deprescribing in primary care.

METHODS

Focus group discussions with Dutch General practitioners were held by two skilled moderators. The focus group discussions were transcribed verbatim and analysed using MAXQDA software. Three independent reviewers searched for overarching themes using thematic analysis with an inductive approach. Discussions were organized until data saturation was reached.

RESULTS

Twenty-two general practitioners participated in four focus group discussions. Five main themes emerged from the data: (1) patient-centred care; (2) ensuring proper pain management (3) dilemmas and hardships in dealing with opioid use disorder; (4) the competency gap; (5) needs and possibilities to improve opioid deprescribing in primary care. The first theme addresses the main facilitators in opioid tapering. The following three themes emerged as main barriers in opioid deprescribing. The fifth theme identified possibilities for change.

CONCLUSIONS

This study indicates the importance of intrinsic motivation and a tailored approach to deprescribe opioids in patients with chronic pain on long-term opioid treatment. Identified barriers include struggles in pain management, challenges caused by opioid use disorder, insufficient capacities such as time constraints and lack of skills. Recommendations for improvement involve enhanced collaboration with healthcare professionals in primary and secondary care, provision of practical tools and assurance of sufficient time.

SIGNIFICANCE

This focus group study among 22 Dutch general practitioners elucidates the complexities of opioid deprescribing and reveals pivotal themes such as patient-centred care, pain management challenges, and competency gaps. The findings underscore the crucial role of intrinsic motivation and that of a tailored approach in opioid deprescribing, while demonstrating how a lack in effective pain treatments, practical capacities and challenges caused by opioid dependence, impede opioid deprescribing. By uncovering these complexities, this study aims to inform future deprescribing strategies.

Pills and the damage done: the opioid epidemic as man-made crisis

The prescription opioid epidemic has slowly evolved over the past quarter century with increasingly detrimental consequences for public health. Man-made crises are often unforeseen and characterized by a situation without natural causes where - because of human intent, error, negligence, or the failure of manmade systems - the level of needs in the population exceeds available resources to counter the problem. This paper presents the prescription opioid epidemic as a man-made crisis and explores the public health impact of opioid manufacturers and other industries producing commodities with addictive potential as a shared vulnerability among countries. We examine this concept within the framework of the commercial determinants of health. We address three key aspects of the commercial determinants of health: (1) Cross-industry mechanisms, (2) policy inertia, and (3) the role of industry in science. Within cross-industry mechanisms, we explore parallels between prescription opioid epidemic and unhealthy commodity industries in terms of marketing, corporate use of misinformation, and diversionary tactics. Next, we examine how policy inertia has dominated the slow response to this man-made crisis. Lastly, we discuss how results from clinical trials are used as a key marketing strategy for drugs. The origins of the prescription opioid epidemic may be traced to innovations in drug development with the promise of improved pain management. However, through multiple factors, including fraudulent marketing from pharmaceutical industry and policy inertia, the resulting crisis represents a multi-system failure of regulation exploited by corporate greed.

Initial opioid prescription characteristics and risk of opioid misuse, poisoning and dependence: retrospective cohort study

OBJECTIVE

To identify individual and initial prescription-related factors associated with an increased risk for opioid-related misuse, poisoning and dependence (MPD) in patients with non-cancer pain.

METHODS

Cohort study linking several databases covering 5 million inhabitants of the region of Valencia, Spain, including all adults initiating prescription opioids in the period 2012-2018. To ascertain the association between the characteristics of the initial prescription choice and the risk of opioid MPD, we used shared frailty Cox regression models. We additionally considered death as a competing risk in sensitivity analyses.

RESULTS

958 019 patients initiated opioid prescription from 2012 to 2018, of which 0.13% experienced MPD. Most patients were prescribed tramadol as initial opioid (76.7%) followed by codeine (16.3%), long-acting opioids (6.7%), short-acting opioids (0.2%) and ultrafast opioids (0.1%). Initiation with ultrafast (HR 7.2; 95% CI 4.1 to 12.6), short-acting (HR 4.8; 95% CI 2.3 to 10.2) and long-acting opioids (HR 1.5; 95% CI 1.2 to 1.9) were associated with a higher risk of MPD when compared with tramadol. Initial prescriptions covering 4-7 days (HR 1.3; 95% CI 1.0 to 1.8), 8-14 days (HR 1.4; 95% CI 1.0 to 1.9), 15-30 days (HR 1.7; 95% CI 1.2 to 2.3) and more than one a month (HR 1.8; 95% CI 1.3 to 2.5) were associated with more MPD risk than initial prescriptions for 1-3 days. Treatments with >120 daily morphine milligram equivalents (MME) increased MPD risk (vs <50 MME, HR 1.6; 95% CI 1.1 to 2.2). Main individual factors associated with increased risk of MPD risk were male sex (HR 2.4; 95% CI 2.1 to 2.7), younger age (when compared with patients aged 18-44 years, patients aged 45-64 years, HR 0.4; 95% CI 0.4 to 0.5; patients aged 65-74 years, HR 0.4; 95% CI 0.3 to 0.5 and patients aged 75 years old and over, HR 0.7; 95% CI 0.6 to 0.8), lack of economic resources (2.1; 95% CI 1.8 to 2.5) and registered misuse of alcohol (2.9; 95% CI 2.4 to 3.5). Sensitivity analyses yielded overall comparable results.

CONCLUSIONS

Our study identifies riskier patterns of opioid prescription initiation for non-cancer indications, as well as patient subgroups with higher risk of misuse, poisoning and dependence.

Patients' perspectives on tapering programmes for prescription opioid use disorder: a qualitative study

OBJECTIVES

Approximately 10% of chronic pain patients who receive opioids develop an opioid use disorder (OUD). Tapering programmes for these patients show high drop-out rates. Insight into chronic pain patients' experiences with tapering programmes for prescription OUD could help improve such programmes. Therefore, we investigated the perspectives of chronic pain patients with prescription OUD to identify facilitators and barriers to initiate and complete a specialised OUD tapering programme.

DESIGN

A qualitative study using semi-structured interviews on experiences with initiation and completion of opioid tapering was audio recorded, transcribed and subject to directed content analysis.

SETTING

This study was conducted in two facilities with specialised opioid tapering programmes in the Netherlands.

PARTICIPANTS

Twenty-five adults with chronic pain undergoing treatment for prescription OUD participated.

RESULTS

Participants indicated that tapering is a personal process, where willingness and motivation to taper, perceived (medical) support and pain coping strategies have an impact on the tapering outcome. The opportunity to join a medical-assisted tapering programme, shared decision-making regarding tapering pace, tapering location, and receiving medical and psychological support facilitated completion of an opioid tapering programme.

CONCLUSIONS

According to patients, a successful treatment of prescription OUD requires a patient-centred approach that combines personal treatment goals with shared decision-making on opioid tapering. Referral to a specialised tapering programme that incorporates opioid rotation, non-judgmental attitudes, and psychological support can create a safe and supportive environment, fostering successful tapering and recovery.

Perioperative analgesic efficacy and adverse events of fentanyl in dentistry: A systematic review

OBJECTIVES

To assess the efficacy and adverse events linked to the utilization of fentanyl for perioperative pain management in dentistry.

METHODS

This systematic review of randomized clinical trials (RCTs) adhered to the PRISMA guidelines and incorporated various databases.

RESULTS

Eleven RCTs studying 674 patients were analyzed. Perioperative pain was predominantly evaluated in patients undergoing surgery for impacted molars, although some studies also included patients with other conditions such as oral submucous fibrosis, maxillary cancer, bony temporomandibular joint ankylosis, irreversible pulpitis, among others. Combined with dexmedetomidine, fentanyl produced enhanced analgesic effects. It demonstrated comparable efficacy when compared to nefopam and nalbuphine. Both intranasal and intravenous administration routes proved equally effective. In four RCTs, the transdermal fentanyl patch outperformed the control group, except in the clinical trial where it was compared to ropivacaine. The main adverse events associated with the use of fentanyl included nausea, vomiting, drowsiness, delirium, and respiratory depression; however, they were like those reported in the comparison groups.

CONCLUSIONS

While fentanyl demonstrated satisfactory perioperative analgesic efficacy, there were other alternatives that displayed better or comparable outcomes. Due to the risks and potential for misuse of fentanyl, these alternatives must be considered although adverse events were also reported.

Low-dose ketamine infusions for chronic pain management: Does this qualify as evidence-based practice?

Chronic pain is becoming increasingly prevalent and burdensome both worldwide and in the United Kingdom. Due to the complexity of chronic pain and the therapeutic challenge associated, management is often difficult and requires multidisciplinary care encompassing a combination of pharmacological and non-pharmacological strategies. Conventional analgesic treatments, such as opioids and anticonvulsants, are effective in less than half of chronic pain sufferers and are typically limited to short-term use to prevent complications associated with long-term use such as tolerance and dependence. Consequently, research and clinical interest in alternative management options for chronic pain have increased in recent years, with ketamine being one example under investigation. However, since ketamine has been licensed as an anaesthetic for decades, it has bypassed the traditional scrutinous drug development sequence that is typically seen for therapeutics marketed for pain. As such, data supporting the unlicensed administration of ketamine for chronic pain management is lacking and is being outpaced by the rates of off-label use in pain clinics. Recent limited evidence suggests that ketamine, when given as an intravenous infusion in subanaesthetic doses for refractory pain patients, may provide modest analgesic effects in nearly all aetiologies of chronic pain, with side effects common but typically mild. However, there are concerns over the safety of this practice due to the paucity of robust supportive evidence and the accompanying lack of clinical guidelines or standardised protocols. This review shall summarise the literature examining the use of subanaesthetic-dose ketamine infusions for chronic pain to comment on the current level of evidence, with limitations of existing research and future recommendations discussed.

Factors related to opioid misuse among patients undergoing elective surgery in Poland

In many countries, the consumption of illicit opioids is rising, becoming a major public health issue called the "opioid crisis". Many reasons contribute to this phenomenon. One of them is opioid misuse, defined as the use of legally prescribed opioids for a purpose different than pain treatment. This matter has not been well studied in Poland, where the opioid crisis has not been identified so far. This study was conducted among patients admitted for elective surgery with opioid-based postoperative pain treatment. The frequency of opioid misuse was found to be 10.8% in a sample comprising 92 patients. The group of individuals with potential opioid use disorder had a more frequent history of inadequately controlled postoperative pain compared to the group of non-misusers (p = 0.023). Furthermore, this group asked to receive additional pain treatment almost six times more often than the control group (p < 0.000). Also, patients declaring opioid misuse reported substantial differences concerning their knowledge and opinions about pain treatment and opioid analgesics: supporting the administration of opioids for pain when needed, finding opioids less harmful, and supporting messages that opioids are safe, effective, well-tolerated, easy to cutoff more often than control. There is an urgent need for the education of patients to avoid the spreading of the opioid crisis.

Opioid Analgesics after Bariatric Surgery: A Scoping Review to Evaluate Physiological Risk Factors for Opioid-Related Harm

The persisting use of opioids following bariatric surgery has emerged as a prevalent complication, heightening the probability of opioid-related harm (ORM), such as opioid-related fatalities and prescription opioid use disorder (OUD). A comprehensive review of PubMed literature from 1990 to 2023 was conducted to pinpoint physiological influences on postoperative ORM. As a result, we found that patients undertaking bariatric operations often exhibit an inherently higher risk for substance use disorders, likely attributable to genetic predisposition and related neurobiological changes that engender obesity and addiction-like tendencies. Furthermore, chronic pain is a common post-bariatric surgery complaint, and the surgical type impacts opioid needs, with increased long-term opioid use after surgeries. Additionally, the subjective nature of pain perception in patients with obesity can distort pain reporting and the corresponding opioid prescription both before and after surgery. Furthermore, the postoperative alterations to the gastrointestinal structure can affect the microbiome and opioid absorption rates, resulting in fluctuating systemic exposure to orally ingested opioids. The prospect of ORM development post-bariatric surgery appears amplified due to a preexisting susceptibility to addictive habits, surgically induced pain, modified gut-brain interaction and pain management and the changed pharmacokinetics post-surgery. Further research is warranted to clarify these potential risk variables for ORM, specifically OUD, in the bariatric population.

A scoping review of mHealth technologies for opioid overdose prevention, detection and response

ISSUES

Opioid overdose kills over 100,000 people each year globally. Mobile health (mHealth) technologies and devices, including wearables, with the capacity to prevent, detect or respond to opioid overdose exist in early form, or could be re-purposed or designed. These technologies may particularly help those who use alone. For technologies to be successful, they must be effective and acceptable to the at-risk population. The aim of this scoping review is to identify published studies on mHealth technologies that attempt to prevent, detect or respond to opioid overdose.

APPROACH

A systematic scoping review of literature was conducted up to October 2022. APA PsychInfo, Embase, Web of Science and Medline databases were searched.

INCLUSION CRITERIA

articles had to report on (i) mHealth technologies that deal with (ii) opioid (iii) overdose.

KEY FINDINGS

A total of 348 records were identified, with 14 studies eligible for this review across four domains: (i) technologies that require intervention/response from others (four); (ii) devices that use biometric data to detect overdose (five); (iii) devices that automatically respond to an overdose with administration of an antidote (three); (iv) acceptability/willingness to use overdose-related technologies/devices (five).

IMPLICATIONS

There are multiple routes in which these technologies may be deployed, but several factors impact acceptability (e.g., discretion or size) and accuracy of detection (e.g., sensitive parameter/threshold with low false positive rate).

CONCLUSION

mHealth technologies for opioid overdose may play a crucial role in responding to the ongoing global opioid crises. This scoping review identifies vital research that will determine the future success of these technologies.

A systematic review of patient-centered interventions for improving pain outcomes and reducing opioid-related risks in acute care settings

Objectives

This systematic review evaluates the literature for patient-oriented opioid and pain educational interventions that aim to optimize pain management using opioid-sparing approaches in the orthopaedic trauma population. The study protocol was registered with PROSPERO (CRD42021234006).

Data Sources

A review of English-language publications in CINAHL (EBSCO), MEDLINE through PubMed, Embase.com, PsycInfo (EBSCO), and Web of Science Core Collection literature databases published between 1980 and February 2021 was conducted using PRISMA guidelines.

Study Selection

Only studies implementing patient-oriented opioid and/or pain education in adult patients receiving acute orthopaedic care were eligible. Outcomes were required to include postinterventional opioid utilization, postoperative analgesia and amount, or patient-reported pain outcomes.

Data Extraction

A total of 480 abstracts were reviewed, and 8 publications were included in the final analysis. Two reviewers independently extracted data from selected studies using a standardized data collection form. Disagreements were addressed by a third reviewer. Quality of studies was assessed using the Cochrane Risk of Bias Tool.

Data Synthesis

Descriptive statistics characterized study findings, and content analysis was used to discern themes across studies.

Conclusion

Our findings indicate the merit for patient-centered educational interventions including verbal/written/audio-visual trainings paired with multimodal approaches to target opioid-sparing pain management and reduce short-term pain scores in urgent and acute care settings after acute orthopaedic injuries. The scarcity of published literature warrants further rigorously designed studies to substantiate the benefit of patient-centric education in reducing prolonged opioid utilization and associated risks after orthopaedic trauma.

Level of Evidence

Therapeutic level III.

Practice variation in opioid prescribing for non-cancer pain in Dutch primary care: A retrospective database study

BACKGROUND

Prescription opioid use has increased steadily in many Western countries over the past two decades, most notably in the US, Canada, and most European countries, including the Netherlands. Especially the increasing use of prescription opioids for chronic non-cancer pain has raised concerns. Most opioids in the Netherlands are prescribed in general practices. However, little is known about variation in opioid prescribing between general practices. To better understand this, we investigated practice variation in opioid prescribing for non-cancer pain between Dutch general practices.

METHODS

Data from 2017-2019 of approximately 10% of all Dutch general practices was used. Each year included approximately 1000000 patients distributed over approximately 380 practices. The primary outcome was the proportion of patients with chronic (>90 days) high-dose (≥90 oral morphine equivalents) opioid prescriptions. The secondary outcome was the proportion of patients with chronic (<90 oral morphine equivalents) opioid prescriptions. Practice variation was expressed as the ratio of the 95th/5th percentiles and the ratio of mean top 10/bottom 10. Funnel plots were used to identify outliers. Potential factors associated with unwarranted variation were investigated by comparing outliers on practice size, patient neighbourhood socioeconomic status, and urbanicity.

RESULTS

Results were similar across all years. The magnitude of variation for chronic high-dose opioid prescriptions in 2019 was 7.51-fold (95%/5% ratio), and 15.1-fold (top 10/bottom 10 ratio). The percentage of outliers in the funnel plots varied between 13.8% and 21.7%. Practices with high chronic high-dose opioid prescription proportions were larger, and had more patients from lower income and densely populated areas.

CONCLUSIONS

There might be unwarranted practice variation in chronic high-dose opioid prescriptions in primary care, pointing at possible inappropriate use of opioids. This appears to be related to socioeconomic status, urbanicity, and practice size. Further investigation of the factors driving practice variation can provide target points for quality improvement and reduce inappropriate care and unwarranted variation.

Outcome of Kidney Transplants from Viremic and Non-Viremic Hepatitis C Virus Positive Donors into Negative Recipients: Results of the Spanish Registry

Historically, donor infection with hepatitis-C virus (HCV) has been a barrier to kidney transplantation. However, in recent years, it has been reported that HCV positive kidney donors transplanted into HCV negative recipients offer acceptable mid-term results. However, acceptance of HCV donors, especially viremic, has not broadened in the clinical practice. This is an observational, multicenter, retrospective study including kidney transplants from HCV positive donors into negative recipients reported to the Spanish group from 2013 to 2021. Recipients from viremic donors received peri-transplant treatment with direct antiviral agents (DAA) for 8-12 weeks. We included 75 recipients from 44 HCV non-viremic donors and 41 from 25 HCV viremic donors. Primary non function, delayed graft function, acute rejection rate, renal function at the end of follow up, and patient and graft survival were not different between groups. Viral replication was not detected in recipients from non-viremic donors. Recipient treatment with DAA started pre-transplant avoids (n = 21) or attenuates (n = 5) viral replication but leads to non-different outcomes to post-transplant treatment with DAA (n = 15). HCV seroconversion was more frequent in recipients from viremic donors (73% vs. 16%, p < 0.001). One recipient of a viremic donor died due to hepatocellular carcinoma at 38 months. Donor HCV viremia seems not to be a risk factor for kidney transplant recipients receiving peri-transplant DAA, but continuous surveillance should be advised.

A prescription drug monitoring program, data sharing, and upholding states' rights under the United States Constitution

Abuse of physician prescribed opioids contributes to health and economic burdens associated with dependency, overdose, and death. Since the 1900s, the United States (U.S.) Congress has legislated use and misuse of controlled substances. Under the U.S. Constitution, states developed prescription drug monitoring programs (PDMPs) that determine how the program is managed, what data to track, and what information to share with other states. Lack of a standard data set that allows providers to see prescribing data for designated controlled substances across state lines, limits benefits of state PDMPs. A federal PDMP with a standard minimal set of variables shared across states could enhance patient care. States would exercise their police powers while sharing standard data to decrease adverse consequences of the opioid epidemic.

Long-term opioid use following bicycle trauma: a register-based cohort study

PURPOSE

Chronic opioid use is a significant public health burden. Orthopaedic trauma is one of the main indications for opioid prescription. We aimed to assess the risk for long-term opioid use in a healthy patient cohort.

METHODS

In this matched cohort study, bicycle trauma patients from a Swedish Level-I-Trauma Centre in 2006-2015 were matched with comparators on age, sex, and municipality. Information about dispensed opioids 6 months prior until 18 months following the trauma, data on injuries, comorbidity, and socioeconomic factors were received from national registers. Among bicycle trauma patients, the associations between two exposures (educational level and injury to the lower extremities) and the risk of long-term opioid use (> 3 months after the trauma) were assessed in multivariable logistic regression models.

RESULTS

Of 907 bicycle trauma patients, 419 (46%) received opioid prescriptions, whereof 74 (8%) became long-term users. In the first quarter after trauma, the mean opioid use was significantly higher in the trauma patients than in the comparators (253.2 mg vs 35.1 mg, p < 0.001) and fell thereafter to the same level as in the comparators. Severe injury to the lower extremities was associated with an increased risk of long-term opioid use [OR 4.88 (95% CI 2.34-10.15)], whereas high educational level had a protecting effect [OR 0.42 (95% CI 0.20-0.88)].

CONCLUSION

The risk of long-term opioid use after a bicycle trauma was low. However, opioids should be prescribed with caution, especially in those with injury to lower extremities or low educational level.

Abuse, dependence and withdrawal associated with fentanyl and the role of its (designated) route of administration: an analysis of spontaneous reports from Europe

PURPOSE

Fentanyl, a highly potent synthetic opioid used in cancer and non-cancer pain, is approved for various routes of administration. In Europe, fentanyl consumption increased substantially in the last decades but information on abuse, dependence and withdrawal associated with fentanyl is scarce, especially with respect to its different formulations.

METHODS

We analysed case characteristics of spontaneous reports of suspected fentanyl-associated abuse, dependence or withdrawal from European countries recorded in the EudraVigilance database up to 2018 with respect to the (designated) routes of administration and potential indications.

RESULTS

A total of 985 reports were included (mainly from France and Germany) with 43% of cases referring to transdermal fentanyl. Median age was 45 years (48.8% female) and 21.6% had musculoskeletal disorders. Only 12.6% of those using transdermal fentanyl had a cancer diagnosis compared to 40.2% and 26.8% of those using intranasal and oral transmucosal fentanyl, respectively. Depression was common (10.7%) and highest in cases with musculoskeletal disorders (24.9%) as was the use of benzodiazepines. Overall, 39.5% of reports resulted in a prolonged hospital stay and for 23.2% a fatal outcome was recorded. The respective proportions were especially high in cases with musculoskeletal disorders (56.3% with prolonged hospitalisation) and in those using transdermal fentanyl (35.2% fatalities).

CONCLUSIONS

In suspected cases of abuse, dependence or withdrawal, fentanyl was mainly used for non-cancer pain indications and most often as transdermal formulations. Depression and prolonged hospitalisations were common, especially in patients with musculoskeletal disorders, indicating a vulnerable patient group and complex treatment situations.

Real-world patterns of opioid therapy initiation in Spain, 2012-2018: A population-based, retrospective cohort study with 957,080 patients and 1,509,488 initiations

Introduction: Europe has seen a steady increase in the use of prescription opioids, especially in non-cancer indications. Epidemiological data on the patterns of use of opioids is required to optimize prescription. We aim to describe the patterns of opioid therapy initiation for non-cancer pain and characteristics of patients treated in a region with five million inhabitants in the period 2012 to 2018. Methods: Population-based retrospective cohort study of all adult patients initiating opioid therapy for non-cancer pain in the region of Valencia. We described patient characteristics at baseline and the characteristics of baseline and subsequent treatment initiation. We used multinominal regression models to identify individual factors associated with initiation. Results: A total of 957,080 patients initiated 1,509,488 opioid treatments (957,080 baseline initiations, 552,408 subsequent initiations). For baseline initiations, 738,749 were with tramadol (77.19%), 157,098 with codeine (16.41%) 58,436 (6.11%) with long-acting opioids, 1,518 (0.16%) with short-acting opioids and 1,279 (0.13%) with ultrafast drugs. When compared to tramadol, patients initiating with short-acting, long-acting and ultrafast opioids were more likely to be older and had more comorbidities, whereas initiators with codeine were more prone to be healthier and younger. Treatments lasting less than 7 days accounted for 41.82% of initiations, and 11.89% lasted more than 30 days. 19.55% of initiators with ultrafast fentanyl received more than 120 daily Morphine Milligram Equivalents (MME), and 16.12% of patients initiating with long-acting opioids were prescribed more than 90 daily MME (p < 0.001). Musculoskeletal indications accounted for 65.05% of opioid use. Overlap with benzodiazepines was observed in 24.73% of initiations, overlap with gabapentinoids was present in 11.04% of initiations with long-acting opioids and 28.39% of initiators with short-acting opioids used antipsychotics concomitantly. In subsequent initiations, 55.48% of treatments included three or more prescriptions (vs. 17.60% in baseline initiations) and risk of overlap was also increased. Conclusion: Opioids are initiated for a vast array of non-oncological indications, and, despite clinical guidelines, short-acting opioids are used marginally, and a significant number of patients is exposed to potentially high-risk patterns of initiation, such as treatments lasting more than 14 days, treatments surpassing 50 daily MMEs, initiating with long-acting opioids, or hazardous overlapping with other therapies.

Knowing the Enemy Is Halfway towards Victory: A Scoping Review on Opioid-Induced Hyperalgesia

Opioid-induced hyperalgesia (OIH) is a paradoxical effect of opioids that is not consensually recognized in clinical settings. We conducted a revision of clinical and preclinical studies and discuss them side by side to provide an updated and renewed view on OIH. We critically analyze data on the human manifestations of OIH in the context of chronic and post-operative pain. We also discuss how, in the context of cancer pain, though there are no direct evidence of OIH, several inherent conditions to the tumor and chemotherapy provide a substrate for the development of OIH. The review of the clinical data, namely in what concerns the strategies to counter OIH, emphasizes how much OIH rely mechanistically on the existence of µ-opioid receptor (MOR) signaling through opposite, inhibitory/antinociceptive and excitatory/pronociceptive, pathways. The rationale for the maladaptive excitatory signaling of opioids is provided by the emerging growing information on the functional role of alternative splicing and heteromerization of MOR. The crossroads between opioids and neuroinflammation also play a major role in OIH. The latest pre-clinical data in this field brings new insights to new and promising therapeutic targets to address OIH. In conclusion, although OIH remains insufficiently recognized in clinical practice, the appropriate diagnosis can turn it into a treatable pain disorder. Therefore, in times of scarce alternatives to opioids to treat pain, mainly unmanageable chronic pain, increased knowledge and recognition of OIH, likely represent the first steps towards safer and efficient use of opioids as analgesics.

Opioid sales and opioid-related poisonings in Switzerland: A descriptive population-based time-series analysis

Background

To examine time trends and characteristics of calls related to opioid poisonings reported to the National Poison Centre and opioid sales in Switzerland.

Methods

We used population-level data from the Swiss National Poisons Information Centre on reported opioid-related poisonings and data provided by the Swiss Pharmacists’ Association (pharmaSuisse) based on IQVIA data to identify sold opioid packages. The rate of opioid-related poisoning calls and dispensed opioid packages per 100,000 Swiss inhabitants between 2000 and 2019 were plotted by year and annual trends were assessed. All analyses were stratified by individual opioid and potency (strong vs weak).

Findings

There was a significant 177% increase in the rate of calls for opioid-related poisonings (1·4 to 3·9 per 100,000 inhabitants, p<0·001) and a 91·3% increase in opioid sales (from 14,364·0 to 27,477·6 per 100,000 inhabitants, p<0.001). The increase associated with strong opioids was higher when compared to weak opioids, in both poison centre calls and sales. In 2019, tramadol was the most frequently reported opioid in the poison centre data (35·7%, n=133) and sales (37·5%, n=8,863,377), followed by oxycodone calls (24·4%, n=91) and sales 23·4%, n= 552,751). Poisoning calls and sales related to oxycodone increased substantially between 2009 and 2016, as did the rate of poison centre calls requiring medical care.

Interpretation

Calls to the Swiss National poison centre and sales for opioid have increased substantially in Switzerland in the last two-decades. Increases were primarily driven by oxycodone and tramadol; however, sales have attenuated since 2016. Our findings mirror other European countries and stress the importance of surveillance and monitoring.

Funding

The research did not receive external funding. Translation of the abstract in German, French and Italian are available in the Supplementary section.

Nationwide Population-Based Study About Patterns of Prescription Opioid Use and Misuse Among Young Adults in Spain

Objective: Prescription opioid misuse has become one of the most common ways drugs are consumed among young adults. The objective of our study was to describe the prevalence and factors associated with prescription opioid use and misuse among young adults living in Spain.

Methods: A nationwide, cross-sectional epidemiological study on the use and misuse of prescription opioids in Spanish Youngers. We used individualized secondary data provided by the Household Survey on Alcohol and Drugs in Spain 2017–2018.

Results: Prevalence of prescription opioid use among young adults was 4.89%. Misuse among this population reached prevalence values of 13.4%, with higher values observed among women . The variables associated with a greater probability of prescription opioid use and misuse were misuse of tranquilizers, sedatives, and sleeping pills, along with using cannabis and other illicit psychoactive drugs (aOR = 2.99; 95% CI: 1.10–8.15).

Conclusion: Prescription opioid use and misuse in Youngers has important implications for the Spanish public health system, because, even though not currently comparable to the situation in other countries, this drug use could be on the verge of creating similar problems.

Acute Headache Management for Patients with Subarachnoid Hemorrhage: An International Survey of Health Care Providers

BACKGROUND

Severe headaches are common after subarachnoid hemorrhage. Guidelines recommend treatment with acetaminophen and opioids, but patient data show that headaches often persist despite multimodal treatment approaches. Considering an overall slim body of data for a common complaint affecting patients with SAH during their intensive care stay, we set out to assess practice patterns in headache management among clinicians who treat patients with SAH.

METHODS

We conducted an international cross-sectional study through a 37-question Web-based survey distributed to members of five professional societies relevant to intensive and neurocritical care from November 2021 to January 2022. Responses were characterized through descriptive analyses. Fisher's exact test was used to test associations.

RESULTS

Of 516 respondents, 329 of 497 (66%) were from North America and 121 of 497 (24%) from Europe. Of 435 respondents, 379 (87%) reported headache as a major management concern for patients with SAH. Intensive care teams were primarily responsible for analgesia during hospitalization (249 of 435, 57%), whereas responsibility shifted to neurosurgery at discharge (233 of 501, 47%). Most used medications were acetaminophen (90%), opioids (66%), corticosteroids (28%), and antiseizure medications (28%). Opioids or medication combinations including opioids were most frequently perceived as most effective by 169 of 433 respondents (39%, predominantly intensivists), followed by corticosteroids or combinations with corticosteroids (96 of 433, 22%, predominantly neurologists). Of medications prescribed at discharge, acetaminophen was most common (303 of 381, 80%), followed by opioids (175 of 381, 46%) and antiseizure medications (173 of 381, 45%). Opioids during hospitalization were significantly more prescribed by intensivists, by providers managing higher numbers of patients with SAH, and in Europe. At discharge, opioids were more frequently prescribed in North America. Of 435 respondents, 299 (69%) indicated no change in prescription practice of opioids with the opioid crisis. Additional differences in prescription patterns between continents and providers and while inpatient versus at discharge were found.

CONCLUSIONS

Post-SAH headache in the intensive care setting is a major clinical concern. Analgesia heavily relies on opioids both in use and in perception of efficacy, with no reported change in prescription patterns for opioids for most providers despite the significant drawbacks of opioids. Responsibility for analgesia shifts between hospitalization and discharge. International and provider-related differences are evident. Novel treatment strategies and alignment of prescription between providers are urgently needed.

Pharmacovigilance Signals of the Opioid Epidemic over 10 Years: Data Mining Methods in the Analysis of Pharmacovigilance Datasets Collecting Adverse Drug Reactions (ADRs) Reported to EudraVigilance (EV) and the FDA Adverse Event Reporting System (FAERS)

In the past twenty years, the consumption of opioid medications has reached significant proportions, leading to a rise in drug misuse and abuse and increased opioid dependence and related fatalities. Thus, the purpose of this study was to determine whether there are pharmacovigilance signals of abuse, misuse, and dependence and their nature for the following prescription opioids: codeine, dihydrocodeine, fentanyl, oxycodone, pentazocine, and tramadol. Both the pharmacovigilance datasets EudraVigilance (EV) and the FDA Adverse Events Reporting System (FAERS) were analyzed to identify and describe possible misuse-/abuse-/dependence-related issues. A descriptive analysis of the selected Adverse Drug Reactions (ADRs) was performed, and pharmacovigilance signal measures (i.e., reporting odds ratio, proportional reporting ratio, information component, and empirical Bayesian geometric mean) were computed for preferred terms (PTs) of abuse, misuse, dependence, and withdrawal, as well as PTs eventually related to them (e.g., aggression). From 2003 to 2018, there was an increase in ADR reports for the selected opioids in both datasets. Overall, 16,506 and 130,293 individual ADRs for the selected opioids were submitted to EV and FAERS, respectively. Compared with other opioids, abuse concerns were mostly recorded in relation to fentanyl and oxycodone, while tramadol and oxycodone were more strongly associated with drug dependence and withdrawal. Benzodiazepines, antidepressants, other opioids, antihistamines, recreational drugs (e.g., cocaine and alcohol), and several new psychoactive substances, including mitragynine and cathinones, were the most commonly reported concomitant drugs. ADRs reports in pharmacovigilance databases confirmed the availability of data on the abuse and dependence of prescription opioids and should be considered a resource for monitoring and preventing such issues. Psychiatrists and clinicians prescribing opioids should be aware of their misuse and dependence liability and effects that may accompany their use, especially together with concomitant drugs.

Oxycodone-related deaths in Sweden 2006-2018

AIM

To identify and characterize oxycodone related deaths in Sweden from 2006 to 2018 and to compare them to other opioid-related deaths.

METHODS

To assess the factors contributing to the deaths, we used multinomial logistic regression to compare oxycodone-related deaths extracted from all forensic autopsy examinations and toxicology cases in the age groups 15-34 (reference group), 35-54 and 55-74 with regard to sex, presence of benzodiazepines and alcohol at the time of death, prescription of oxycodone, benzodiazepines and antidepressants, previous substance use-related (SUD) treatment, and manner of death. The oxycodone related deaths were compared with deaths with presence of other opioids.

RESULT

We identified 575 oxycodone-related deaths, and the rate increased during the study period from 0.10 to 1.12 per 100,000 in parallel with an increase of oxycodone prescriptions from 3.17 to 30.33 per 1000. Oxycodone-related deaths amounted to 10.0% of all opioid-related deaths. The deaths occurred mainly in older patients previously being prescribed oxycodone. Benzodiazepines were present at the time of death in 403 (70%) and alcohol in 259 (45%). Prescriptions of any opioid for pain (61%), oxycodone (50%), benzodiazepines (67%) and antidepressants (55%) were common. Only 15% had received treatment for SUD during the last year.

CONCLUSION

Oxycodone-related deaths increased in Sweden between 2006 and 2018 in parallel to an increase in oxycodone prescriptions. The increase occurred mainly in older patients being prescribed oxycodone for pain. There might be specific interventions needed to avoid oxycodone-related deaths compared to other opioid-related deaths associated with illicit opioid use.

Oxycodone-Related Deaths: The Significance of Pharmacokinetic and Pharmacodynamic Drug Interactions

BACKGROUND AND OBJECTIVES

Oxycodone is frequently prescribed as well as detected in postmortem cases. Concurrent use of pharmacodynamically or pharmacokinetically interacting drugs can cause adverse effects or even fatal intoxication. The aims of this study were to investigate differences in prescriptions for and toxicological findings of pharmacodynamically and pharmacokinetically interacting drugs in fatal oxycodone-related intoxications and other causes of death. We also aimed to investigate the differences in prevalence of oxycodone prescriptions, and the detected postmortem oxycodone concentrations between fatal oxycodone-related intoxications and other causes of death.

METHODS

Forensic autopsy cases (2012-2018) where oxycodone was identified in femoral blood (n = 1236) were included. Medical history and prescription data were retrieved from national databases and linked to the forensic toxicology findings.

RESULTS

Oxycodone-related deaths were found to have higher blood concentrations of oxycodone (median 0.30 µg/g vs. 0.05 µg/g) and were less likely to have a prescription for oxycodone (OR 0.62) compared to nonintoxication deaths. Pharmacodynamically interacting drugs were prescribed in 79% and found in blood in 81% of the cases. Pharmacokinetically interacting drugs were rarely prescribed (1%). Oxycodone-related deaths were more likely to have prescriptions for a pharmacodynamically interacting drug (OR 1.7) and more often have co-findings of one or multiple pharmacodynamically interacting drugs (OR 5.6).

CONCLUSION

The results suggest that combined use of oxycodone and pharmacodynamically interacting drugs is associated with oxycodone-related death and that non-medical use of oxycodone is a potential risk factor for oxycodone-related intoxication.

Novel Synthetic Opioids (NSO) Use in Opioid Dependents Entering Detoxification Treatment

INTRODUCTION

Over the last decade, the use of New/Novel Synthetic Opioids (NSO) has emerged as an increasing problem, and especially so in the USA. However, only little is known about the prevalence and history of NSO use in European heroin dependents.

METHOD

A cross-sectional multicenter study, carried out with the means of both standardized interviews and urine toxicology enhanced screening, in a sample of opioid addicted patients referred for an in-patient detoxification treatment.

RESULTS

Sample size included here n = 256 patients; prior to admission, 63.7% were prescribed with an opioid maintenance treatment. Lifetime use of heroin and opioid analgesics was reported by 99.2 and 30.4%, respectively. Lifetime NSO/fentanyl use was reported by 8.7% (n = 22); a regular use was reported by 1.6% (n = 4), and ingestion over the 30 days prior to admission by 0.8% (n = 2). Most typically, patients had started with a regular consumption of heroin, followed by maintenance opioids; opioid analgesics; and by NSO. Self-reported data were corroborated by the toxicology screenings carried out; no evidence was here identified for the presence of heroin being contaminated by fentanyl/derivatives.

DISCUSSION

NSO and also opioid analgesics did not play a relevant role in the development and the course of opioid/opioid use disorders in German patients referred for an inpatient detoxification treatment.

A 13-Year National Monitoring Study to Assess Narcotic Prescriptions and Indications (2007-2019)

INTRODUCTION

Analgesics are among the most widely used drugs worldwide. This study describes the population treated with narcotic analgesics, their therapeutic indications and how the data have evolved over a decade.

METHODS

A cross-sectional, national, multicentre survey study was conducted that included surveys taken every year from 2007 to 2019 in a national sample of 1500 randomly selected dispensing pharmacies.

RESULTS

The mean age of patients, mostly women (around 60%), remained stable over the study period (63.2 ± 17.1 years in 2007, 68.2 ± 17.2 years in 2019). The proportion of patients treated for more than 3 months increased from 2007 to 2019. Most prescriptions involved morphine, oxycodone and fentanyl (98.5% of all prescriptions in 2019). Morphine prescriptions dropped dramatically from 49.6% (2007) to 32.3% (2019) of the total narcotic analgesics. Fentanyl prescriptions varied from 40.1% in 2007 to 32.2% in 2019. Prescriptions of oxycodone, regardless of the indication, increased steadily from 2007, from 8.3 to 34% in 2019, becoming the most prescribed narcotic analgesic for the first time since the beginning of the survey.

CONCLUSIONS

This study demonstrates how narcotic opioids are prescribed, thanks to the active participation of health professionals, and confirms the striking increase in the prescription of oxycodone.

Automated Classification of Whole Body Plethysmography Waveforms to Quantify Breathing Patterns

Whole body plethysmography (WBP) monitors respiratory rate and depth but conventional analysis fails to capture the diversity of waveforms. Our first purpose was to develop a waveform cluster analysis method for quantifying dynamic changes in respiratory waveforms. WBP data, from adult Sprague-Dawley rats, were sorted into time domains and principle component analysis was used for hierarchical clustering. The clustering method effectively sorted waveforms into categories including sniffing, tidal breaths of varying duration, and augmented breaths (sighs). We next used this clustering method to quantify breathing after opioid (fentanyl) overdose and treatment with ampakine CX1942, an allosteric modulator of AMPA receptors. Fentanyl caused the expected decrease in breathing, but our cluster analysis revealed changes in the temporal appearance of inspiratory efforts. Ampakine CX1942 treatment shifted respiratory waveforms toward baseline values. We conclude that this method allows for rapid assessment of breathing patterns across extended data recordings. Expanding analyses to include larger portions of recorded WBP data may provide insight on how breathing is affected by disease or therapy.

Pharmacists opioid risk and safety counseling practices: A latent class analysis approach

BACKGROUND

The opioid crisis is a global public health issue, especially present in the United States. Limited research addresses pharmacists' opioid medication counseling practices particularly their risk and safety counseling practices.

OBJECTIVES

The objective of this paper is to categorize pharmacists based on their opioid risk and safety counseling practices to inform future interventions and research to improve practice. The percent of pharmacists falling into each of these underlying, unobservable subgroups is identified using latent class analysis.

METHODS

This study was conducted as a statewide survey of pharmacists using the modified Dilman technique. The survey consisted of ten items about pharmacists' opioid risk and safety practices when dispensing an opioid medication. Descriptive statistics were conducted followed by latent class analysis. This approach categorized pharmacists based on their responses to the survey items.

RESULTS

Responses from 216 pharmacists were used in this study. In the three-class model which was deemed the best fit, the first class shows a profile of pharmacists who counsel on almost all opioid risk and safety topics and composed 16.75% of the total respondent population. The second class shows a profile of pharmacists who hardly counsel on any opioid risks and safety topics and comprised 39.80% of the respondent population. The third class shows a profile of pharmacists counseling on opioid risk and safety topics mostly for new or long-term prescriptions, but not for refill or short-term prescriptions. This group constituted 43.45% of the respondent population.

CONCLUSION

This study identifies distinct classes of pharmacists in terms of the frequency with which their opioid counseling does or does not include key elements of risk and safety topics. A small minority usually include the risk and safety issues. Training and resource interventions targeting pharmacists who do not counsel patients about opioid risks are important to help them become more comfortable and adept as opioid risk and safety educators.

Harm related to recreational ketamine use and its relevance for the clinical use of ketamine. A systematic review and comparison study

BACKGROUNDS

Ketamine is a dissociative anesthetic that is currently considered for several new indications.

AIM

To deduce the safety of long-term ketamine treatment using the harm of heavy recreational (non-medical) ketamine use as a proxy for maximal possible harm of ketamine treatment.

METHODS

Systematic literature review according to PRISMA guidelines to identify controlled studies on ketamine-related harm in heavy recreational ketamine users. Results were compared with serious adverse events (SAEs) in patients treated with ketamine according to three systematic reviews considering dosing regimen and cumulative dose.

RESULTS

The systematic search yielded 25 studies. Heavy recreational ketamine use can escalate to ketamine dependency and was often dose-dependently associated with other SAEs, including cognitive and mental disorders, and gastrointestinal and urinary tract symptoms, which disappeared upon marked reduction of ketamine use. Heavy ketamine users have a much higher cumulative exposure to ketamine than ketamine treated patients (>90 times), which may explain why SAEs in the clinical context are mostly mild and reversible and why ketamine dependence was not reported in these patients.

CONCLUSION

Treatment of patients with ketamine is not associated with ketamine dependency or SAEs. However, caution is needed since data on long-term clinical ketamine use with a long-term follow-up is lacking.

Is Europe facing an opioid crisis like the United States? An analysis of opioid use and related adverse effects in 19 European countries between 2010 and 2018

Background

Given the ongoing opioid crisis in the United States (US), we investigated the opioid situation in Europe. The aims of the study are to provide an overview of trends in prescription opioid (PO) use and opioid-related adversities between 2010 and 2018 for different opioids in 19 European countries and to present a comparison with similar data from the US.

Methods

A multisource database study with national data from 19 European countries evaluating trends between 2010 and 2018 in (a) PO consumption, (b) high-risk (HR) opioid users, (c) opioid-related hospital admissions, (d) opioid-related overdose deaths, (e) opioid use disorder treatment entries, and (f) patients in opioid substitution therapy (OST). Within and between-country comparisons and comparisons with data from the US were made.

Results

There was considerable variation between European countries. Most countries showed increased PO consumption with the largest increase and the highest consumption in the United Kingdom (UK) compared to the rest of Europe and the US in 2018 (UK: 58,088 defined daily doses for statistical purposes/1000 population/day). In 2018, Scotland had the highest rates (per 100,000 population) of HR opioid users (16·2), opioid-related hospital admissions (118), opioid-related deaths (22·7), opioid use disorder treatment admissions (190), and OST patients (555) of all included European countries. These rates were similar or even higher than those in the US in 2018. Other countries with high rates of opioid-related adversities were Northern Ireland (synthetic and “other” opioids), Ireland (heroin and methadone), and England (all opioids). All other countries had no or little increase in opioid-related adversities.

Conclusions

Apart from the British Isles and especially Scotland, there is no indication of an opioid crisis comparable to that in the US in the 19 European countries that were part of this study. More research is needed to identify drivers and develop interventions to stop the emerging opioid crisis in the UK and Ireland.

Is Europe also facing an opioid crisis?-A survey of European Pain Federation chapters

BACKGROUND

There is considerable public interest in whether Europe is facing an opioid crisis comparable to the one in the United States and the contribution of opioid prescriptions for pain to a potential opioid crisis.

METHODS

A task force of the European Pain Federation (EFIC) conducted a survey with its national chapter representatives on trends of opioid prescriptions and of drug-related emergency departments and substance use disorder treatment admissions and of deaths as proxies of opioid-related harms over the last 20 years.

RESULTS

Data from 25 European countries were received. In most European countries opioid prescriptions increased from 2004 to 2016. The levels of opioid consumption and their increase differed between countries. Some Eastern European countries still have a low opioid consumption. Opioids are mainly prescribed for acute pain and chronic noncancer pain in some Western and Northern European countries. There was a parallel increase in opioid prescriptions and some proxies of opioid-related harms in France, Finland and the Netherlands, but not in Germany, Spain and Norway. In United Kingdom, opioid overdose deaths, but not opioid prescriptions increased between 2016 and 2018. There are no robust data available on whether prescribed opioids for pain patients contributed to opioid-related harms.

CONCLUSIONS

There are marked differences between European countries in trends of opioid prescribing and of proxies for opioid-related harms. Europe as a whole is not facing an opioid crisis. Discussions on the potential harms of opioids should not obstruct their prescription for cancer pain and palliative care.

SIGNIFICANCE

Europe as a whole is not facing an opioid crisis. Some Eastern European countries have limited access to opioid medicines. Discussions on the potential harms of opioid medicines for noncancer pain should not obstruct opioid therapy for cancer therapy and palliative care.