Professional, Regulatory and Public Concerns

Guidelines for the use of opioids in pain management have been available in the UK and elsewhere for a number of years but have made no impact on the increasing use of opioids, particularly for persistent pain. There are as many different clinical situations as there are patients and treatment decisions should be individualised depending on the balance of benefits and harms and the needs and preferences of the patient. This resource does not suggest whether opioids are the most appropriate treatment for a patient but gives the prescriber and the patient the information needed to make an initial prescribing decision and next best steps at subsequent clinical review.

The increase in opioid prescribing is set in the context of a number of professional, regulatory and public health concerns: 

  • Lack of effectiveness of opioids for persistent pain

Opioids have demonstrable effectiveness in the treatment of acute pain and pain related to cancer (particularly at the end of life) but there is little evidence for the effectiveness of opioids for the treatment of persistent pain. In particular, there are no data that demonstrate improved quality of life for patients taking opioids for persistent pain and an association has been shown between opioid treatment and poorer health related outcomes.

  • Complexity of chronic pain

It is important to recognise that pain, both acute and chronic, is a complex sensory and emotional experience shaped not only by biological but also emotional, social and cultural factors and it should be evaluated and managed in this context. Persistent pain is difficult to treat with the aim of therapy being to improve quality of life despite on-going symptoms. Medications should always be used as part of a broader pain management plan including discussion about the causes and consequences of pain, advice about activity and management of low mood.

  • The prescription opioid ‘epidemic’ in the United States

The upward trend in opioid prescribing is seen elsewhere in Europe, in Australia and in the US. The increase in prescribing in the US has been associated with a parallel increase in misuse of prescription opioids and opioid related harms including overdose and death. In 2011 there were 15 000 prescription opioid deaths in the US and a catastrophic burden of opioid related emergency admissions, addiction to and widespread non-medical use of prescription opioids. In the UK the prescribing trends are similar to those in the US and the potential for a burgeoning epidemic of prescription opioid misuse and death exists but there are a number of important cultural and healthcare differences between the US and the UK which should prompt caution in drawing direct comparisons between the two contexts.

  • Addiction to medicines in England and elsewhere in Europe

Use of prescription opioids in combination with illicit drugs or, less often, as a sole drug of dependency, is noted by professionals working in drug misuse and recovery services. There are now some limited data that describe the scale of prescription drug misuse in those presenting to drug services. These data confirm that prescription opioid misuse exists in England and although rates of reported addiction to prescription opioids over the past five years have been stable in comparison to the upward trend in opioid prescribing, most recent data suggests a recent upward trend. The data however, underestimate the scale of prescription opioid misuse as not all patients with addiction to prescription opioids will present to drug services. The extent of prescription opioid misuse elsewhere in Europe is not well documented.

  • Poisoning deaths in England and Wales

The Office for National Statistics produces data on drug related deaths in England and Wales. Notably there has been a consistent rise in deaths associated with Tramadol since the first reported death in 1996 (240 deaths in 2014). Deaths related to codeine and dihydrocodeine have been relatively stable with the most recent analysis (2014) which showing 222 deaths.

  • Misuse of prescription opioids: findings from the Crime Survey for England and Wales

The Crime Survey for England and Wales examines the extent and trends in illicit drug use among a nationally representative sample of 16 to 59 year olds resident in households in England and Wales, and is based on results from the 2014/15 Crime Survey for England and Wales (CSEW). For the first time this survey includes questions relating to misuse of prescription painkillers (use of prescription analgesics by those for whom they are not prescribed). Findings include:

  • Overall, 5.4 % of adults aged 16 to 59 years had misused a prescription-only painkiller not prescribed to them
  • Painkiller misuse is more common in younger ages
  • 7.2 % of 16 to 24 year olds had misused a prescription-only painkiller in the last year, while 4.9 % of 25 to 59 year olds had done so