Will the UK face an opioid abuse epidemic?
Prescription drug abuse, in particular opioid abuse, has reached epidemic proportions in the USA. While the situation in the UK is currently less clear cut, increasing awareness among health professionals and greater investment in services may help to avoid a similar public health crisis in the future.
The USA currently faces an “epidemic” of opioid abuse that’s developing into a “public health crisis”.1 Each day, some 78 Americans die from opioid-related overdoses. Prescription opioids contribute to at least half of these deaths.1 Meanwhile, the number of drug-related deaths is rising in England, Wales and Scotland2 and each year millions of people take a prescription-only analgesic that was not prescribed to them.3 So, is the UK also on the verge of a public health crisis? What should prescribers watch for? And how can prescribers walk the tightrope between helping to relieve the suffering of people in chronic pain and avoiding abuse?
A common problem?
According to the 2015–16 Crime Survey for England and Wales, 7.5% of adults aged 16 to 59 years had taken a prescription-only painkiller that was not prescribed for them in the year before being interviewed. In almost all cases (7.4% of adults), they used the analgesic for purely medical reasons. Only 0.2% of adults interviewed for the survey took the prescription-only painkiller specifically for the feeling or experience. A very small number of people took the prescription-only painkiller for both reasons.3
Nevertheless, we don’t really know the extent of abuse of opioid painkillers and other prescription-only medicines (POMs). “The UK doesn’t specially measure the diversion of prescription medicines,” says Cathy Stannard, consultant in complex pain and Pain Transformation Programme clinical lead at NHS Gloucestershire CCG.
“It’s clear, however, from several sources that while the prescription of opiates has increased, we’ve not had the same problem with diversion and misuse as the USA. Moreover, most of those who take diverted drugs do so to treat pain or as an anxiolytic. The proportion of adults who take diverted drugs to intentionally get ‘high’ is very low.”
“It is difficult to establish how common diversion is, mostly because it’s difficult to monitor,” adds Roz Gittins, chief pharmacist, Addaction, a drug and alcohol treatment charity. “The numbers of people seeking treatment for problems with prescription-only and over-the-counter [OTC] medications are probably increasing, but it may also be that we’re becoming more aware of the problem and improving how we engage people in treatment services. We definitely need more research.”
Indeed, information about misuse of prescription drugs is patchy across Europe as a whole, says Roumen Sedefov, head of the Supply and New Drugs Unit at the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). The EMCDDA, based in Lisbon, provides the EU and its member states with an evidence base to inform policymaking and practice. “Signals from the EU Early Warning System on new psychoactive substances, and from other EMCDDA monitoring, are raising concerns,” Dr Sedefov explains. “For instance, the diversion and misuse of pregabalin appears to be growing in some countries.”
Dr Sedefov notes that monitoring systems in the UK and across the rest of Europe need to be strengthened to better identify the medicines being misused, the level of misuse and the related harms. “Strengthening the monitoring systems would allow us to identify priority substances, emerging issues and ways to reduce harms. This could include improved prescription practices and diversion prevention programmes – such as medicine take-back schemes – as well as investigations into the criminal groups involved in the supply of diverted, unlicensed and counterfeit medicines,” he says. “Wholesale and consumer supply through the internet – including anonymous marketplaces, such as the ‘darknet’ – poses a huge challenge to public health and enforcement.”
Last year, for instance, Glasgow police seized 750,000 diazepam tablets, worth an estimated £376,000, which had been diverted from the legitimate supply chain over a year. Criminal gangs also divert zopiclone and temazepam.3,4 Despite the involvement of criminal gangs, diverted drugs tend to supplement, rather than act as a gateway to, traditional illicit drugs.3 Dr Sedefov explains, for example, that “an opioid user would use benzodiazepines for additive effects, as well as to self-medicate, while stimulant users may use them to help them to ‘come down’.”
Dr Stannard remarks that the move from prescription to illicit drugs “is very rare and when it occurs, it tends to be in people already known to the drug and alcohol services. Nevertheless, prescription drugs can form part of a substance abuser’s polydrug use.” Mrs Gittins agrees: “Prescription opioids are rarely a gateway, but this is something we do sometimes see in substance misuse services. Several factors affect the use of prescription drugs in this group, such as the availability and cost of other substances.”
Despite the lack of firm data, it is clear that the risk of diversion in the UK and Europe is currently much lower than in the USA, for several reasons. UK doctors are, for example, under much more oversight than their colleagues in the USA. “Only 1% of prescriptions in the UK are private. The overwhelming majority of prescriptions for opiates and other psychoactive drugs, such as pregabalin, are on the NHS,” Dr Stannard points out. “A practice’s or trust’s prescribing data soon shows if one doctor prescribes excessive amounts and the prescribing adviser will investigate. The oversight of opioid prescribing in the UK is quite tight.”
Indeed, patients find that accessing potentially psychoactive prescription medicines is much more difficult in the UK than in the USA. “In a privately funded system, such as the USA, doctors tend to focus much more on patient satisfaction than in the NHS,” Dr Stannard observes. “Patients who are prescribed an opiate in the USA are more likely to report being satisfied, which helps drive use.”
In addition, patients can more easily move between prescribers in the USA until they find one willing to acquiesce to the request for a prescription – a phenomenon known as ‘doctor shopping’. “In a vertically integrated system, such as the NHS, this is very difficult to do,” Dr Stannard explains.
The drugs most likely to be abused also differ between countries. “As with the use of illicit drugs, there are regional and country variations. With respect to prescription medicines, this may be due to the differences in availability on the legitimate and the illicit markets, prescription practices, law-enforcement priorities as well as user demand and preferences,” Dr Sedefov remarks. “For example, in Finland, buprenorphine is the most frequently misused opioid.”
The Advisory Council on the Misuse of Drugs (ACMD) reports that opioids and benzodiazepines are the most commonly diverted drugs, although gabapentin and pregabalin are growing in importance.3 “OTC codeine and related products are also particularly liable to diversion,” Dr Stannard says. “Some OTC drugs are used in isolation, or sometimes combined with other legally obtained or illicit substances.” Indeed, the ACMD suggests that misuse of OTC codeine can be a “precursor to the misuse of prescription opioids” and warrants “further attention”.3
Methadone, for example (see Figure 1), is a proportionally more important contributor to deaths from prescription opioids in the UK than in the USA, reflecting our more liberal attitudes to opioid substitution treatment. In contrast, in the USA, analgesics are responsible for most of the problems posed by prescription opioids. “In the UK, we offer methadone substitution to anyone who needs it,” Dr Stannard remarks. “The USA has a very high bar for substitution treatment. People’s access to methadone in the USA can cease after one small violation.”
Figure 1. Methadone is a more important contributor to deaths from prescription opioids in the UK than in the USA, reflecting our more liberal attitudes to opioid substitution treatment
Nevertheless, a paper published in 2013 noted a rise in tramadol-related deaths in the UK. In 1996, tramadol was linked to one death in England and Wales. By 2011, the analgesic was linked to 154 deaths. The rise may in part reflect an increase in tramadol prescriptions. But the paper also called for close monitoring of “any increase in deaths caused by opioid analgesics because it may signal an emerging problem in the UK similar to the issue that is now well established in the USA”.2
Watching for diversion
So, what should prescribers watch for? “Some signs – such as stealing or forging prescriptions, symptoms of dependency, withdrawal or intoxication – are relatively easy to spot. Visiting numerous healthcare professionals, frequent reports of ‘losing’ medicines, needing higher doses and requests for early supplies or specific medicines may also indicate a problem. Women are perhaps more likely to misuse POMs than men, which is the opposite to what we typically see with traditional illicit substances,” Mrs Gittins comments. “People with a history of mental health problems including substance misuse, a history of issues with pain, difficult life events, time spent in secure environments and relatively easy access to POMs may be at increased risk.”
In addition, prescribers need to be aware that people with chronic pain often misuse opiates albeit usually with different intentions than polydrug users. “People in chronic pain don’t commonly use opioid analgesics to attain a ‘high’, but to blunt emotional trauma,” Dr Stannard observes. “They use them to self-medicate their emotional needs. Patients start using opioids to alleviate pain. They keep using them to help them get through the day.”
Opioid analgesic effects often wear off relatively rapidly and in a patient with chronic pain, increasing the dose is unlikely to yield much additional benefit. “If conventional doses of analgesics do not alleviate the pain, it is probably better to consider alternatives – such as referral to a pain service – than to keep increasing the dose,” Dr Stannard advises. “There is a pressing need to educate patients and prescribers that increasing the dose might not be the most appropriate approach. If someone remains in pain while taking high-dose opiates, the drugs aren’t working.”
Dr Stannard adds that prescribers need to be cognisant of the unmet and often undisclosed emotional needs among people taking high-dose opiates. “Prescribers need to drill down into the psychology of a person taking high-dose opioid analgesics,” she suggests. “Often you’ll find domestic violence, a history of sexual or physical abuse, or another emotional trauma. You can then refer the patient to counselling, psychotherapy, an addiction service or another appropriate service. All prescribers need to be mindful of this: it really is very common.”
Nevertheless, Dr Stannard notes that prescribers can easily feel “disempowered” when trying to alleviate the distress of a patient with chronic pain, especially given the lack of services to address their emotional and psychological needs. “A consultation with a person in pain is challenging, stressful and emotionally loaded,” she observes. “It’s easy to feel you have little to offer. So, there is a temptation, as in the palliative setting, to keep increasing the dose.”
Dr Stannard remarks that the lack of services means that prescribers may sometimes offer drugs, even when they know it is not the best option. “The problems are mainly dealt with in general practice,” Mrs Gittins adds. “By resourcing specialist drug services, such as Addaction, to support primary care we can help this group of people back into wellness and employment.”
Dr Stannard argues that investing in services could pay dividends. “We know that people in chronic pain and those with medically unexplained symptoms tend to be heavy users of primary and secondary care,” she says. “So, if we can manage these patients more effectively, there is the opportunity to free a lot of resources. This needs someone to take the lead and create a cross-community approach. But there is a need for further research and to share best practice. Investing in the services at the moment takes a leap of faith.”
So, even though the UK doesn’t face an epidemic of prescription drug misuse on the scale of that in the USA, there is still an urgent need to invest in services, monitoring and education. “Raising awareness, including among healthcare professionals, such as the prescribers who write the prescriptions and pharmacy staff who dispense the medicines, should be a priority,” Mrs Gittins concludes. “There simply is not enough information, advice and support for those addicted to prescribed or OTC medications.”
Declarations of interest
Mark Greener is a full-time medical writer and, as such, regularly provides editorial and consultancy services to numerous pharmaceutical, biotechnology and device companies and their agencies. He has no shares or financial interests.
Mark Greener is a freelance medical writer
1. Mancini GJ. Challenges and opportunities to change the course of the opioid epidemic: a surgeon’s perspective. Postgrad Med 2017;129:1–4.
2. Giraudon I, et al. Prescription opioid abuse in the UK. Br J Clin Pharmacol 2013;76:823–4.
3. Advisory Council on the Misuse of Drugs. Diversion and Illicit Supply of Medicines. December 2016. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/580296/Meds_report-_final_report_15_December_LU__2_.pdf.
4. Bews L. Police find 750,000 tablets in £400k drugs raid in Glasgow: Man and woman in custody Daily Record 27 February 2016. Available from: www.dailyrecord.co.uk/news/scottish-news/police-find-750000-tablets-400k-7452761 [accessed April 2017].