The role of opioids in the clinical management of persistent pain is fast becoming an international topic of debate and should be considered an urgent public health issue.
Chronic pain must be treated adequately and opioids remain an important treatment option. However, the benefits of appropriate opioid use need to be balanced with the risk of dependence.
In the US, more people now seek treatment for dependence on prescription opioids than for dependence on heroin. The International Narcotic Control Board recently noted that dependence on prescription opioids is a problem in almost all countries, including the UK.
How did this happen? The most important factor has been an increase in opioid prescriptions for chronic pain with causes other than cancer. In the UK, the number of opioid prescriptions rose from ~3 million in 1991 to >15 million in 2009.
So what needs to be done? The All-Party Parliamentary Group and the National Treatment Agency have made recommendations to improve awareness and increase monitoring and research.
The RCGP is developing a skills framework and support resources for safe and effective prescribing of drugs with an addictive potential, starting with guidance on how to prevent patients getting into difficulty with their medicines, identify those most at risk, and effectively case manage those who get into trouble.
We also need to better understand how to treat prescription opioid dependence. Based on US data, these patients typically have a different profile from heroin users, and often find conventional treatment pathways such as supervised methadone consumption unattractive, leading to a preference for buprenorphine-based treatments.
In the UK, we remain unclear about the nature of the patient population, and research is required to fully characterise the population to inform treatment models. Results from a recently published randomised clinical trial found that response to shorter term detox was poor but unlike treatment of heroin dependence counselling added little improvement in outcome. This suggests that patients addicted to prescription medicines may require different pathways.
Based on US data, we may expect an increase in misuse and diversion in parallel with the rise in prescription opioids. However, the aging UK population means we may wish to retain access to opioids for those whose quality of life will be improved by access to opioid therapy.
We need urgent action to build up a picture of the clinical use and misuse of opioids in the UK, particularly an understanding of what works in terms of early identification, engagement and interventions for patients with persistent pain. We must also do this across the range of professionals in primary and secondary care who support the integrated care pathways that are now commonplace in local treatment systems.
Healthcare providers and policy makers must be more aware of the emerging problem of prescription opioid dependence, understand that this may be a separate disease from dependence on illicit drugs, and proactively find ways to optimise our response. UK-based research on assessing treatment options in these patients is essential, as is the generation of an evidence-based pathway to improve outcomes, particularly from the broader perspective of societal harm.
Dr Linda Harris is medical director, RCGP Substance Misuse and Associated Health. Reckitt Benckiser Pharmaceuticals provided funding for this article; however, the opinions expressed are those of the author.