By Matthew Thaxter
By now, it is likely that most people have heard about the ongoing opioid crisis in the US, as barely a day goes by without some form of media coverage. Recent stories have also emerged of a significant upward trend in opioid prescriptions in the UK. This blog explores some of the drivers behind the US crisis, and how likely we are to see a similar epidemic here in the UK.
What are opioids?
Opioids are generally used for moderate and severe pain relief, and are usually only available with a doctor’s prescription. Opioids work by attaching to receptors in the brain to release signals blocking the perception of pain. Some opioids, including codeine, oxycodone, morphine sulphate and heroin are derived from the opium poppy, while others, known as synthetic opioids such as tramadol and fentanyl, are manufactured to simulate similar effects to natural opioids.1
What are the statistics?
The US consumes roughly 80 per cent of the global supply of prescription opioids.2 However, a considerable amount of this consumption is misused, with overdose from opioids the leading cause of death for Americans under 50.3 In total, opioid deaths are at a record high throughout the US, with 72,000 deaths attributed to opioid overdose in 2017 – a 10 per cent annual increase.4 Within the UK, the Office for National Statistics (ONS) data for drug-related deaths in England and Wales in 2017 indicates that there were 3,756 deaths – the highest since records began. Opioids accounted for over half of these deaths in 2017, at 1,985 deaths, which was a 2.6 per cent decline from the previous year (see Figure 1).5
Figure 1. Deaths from opioids, England and Wales - 2008-2017
Loss of life, however, is just one of a number of far reaching effects of the US opioid crisis. For example, the number of babies born with Neonatal Abstinence Syndrome (NAS) – a drug withdrawal syndrome among infants exposed to opioids while in the womb – has quadrupled over the past 15 years. Additionally, almost three quarters of US states have seen unprecedented increases in the number of children entering foster care, with parental substance abuse cited as the primary driver.6 Recent research has also suggested that the increase in opioid prescriptions from 1999 to 2015 could account for 20 per cent of the decline in men’s labour force participation over the same period.7
What caused the US crisis?
A report in 2016, from the Deloitte Center for Government Insights - Fighting the opioid crisis: An ecosystem approach to a wicked problem, provides a comprehensive overview of the history, challenges and current and other suggested solutions to the opioid and heroin epidemic that today ‘touches nearly every American’. It notes that,’ just two decades ago, when opioids were mainly prescribed as end-of-life cancer drugs, most Americans felt little connection to the problem of opioid use and heroin abuse’. It also notes that ‘there is no agreement on the root cause of the problem. That the complex reality is that the crisis is driven by many problems, such as: lack of alternative pain management treatments for sufferers of chronic pain, loose prescribing practices, inadequate training for physicians and consumers, and treatment programmes and reimbursement strategies that haven’t evolved to support the longer-term treatment needed for addiction to opioids’. Finally, it also concludes that such a broad crisis requires an ecosystem approach, from engaging new partners in the fight and aligning action across the ecosystem, to using a portfolio of interventions, driving innovation, and using markets to support sustainable solutions.8
Fast forward to 2018, and the Trump Administration has now launched numerous initiatives in a bid to tackle the opioid epidemic and support patients who are suffering with opioid use disorder (OUD). For example, in August 2018, the US Food and Drug Administration (FDA) released new scientific recommendations aimed at encouraging increased innovation and more widespread development of novel medication-assisted treatments (MAT) for people with OUD. New draft guidance issued at the same time outline new ways for drug developers to consider measuring and demonstrating the effectiveness and benefits of new or existing MAT products. Regular adherence to MAT can help patients to gain control over their use of opioids, and coupled with relevant social, medical and psychological services is very effective for OUD treatment.9 Moreover, in May 2018 the FDA also announced an innovation challenge to address the national opioid epidemic. Specifically, the FDA is looking to the developer community to build digital health technologies, such as medical devices, diagnostic tests and mobile apps to help stem the opioid crisis. The intent is to provide unique approaches to detecting, treating and preventing addiction, addressing diversion and treating pain.10
What is happening in the UK?
The worrying trend of increased prescribing has also been observed in the UK, with over 24 million prescriptions of opioids in 2017 – an increase of 10 million since 2007.11 Furthermore, fatalities from the synthetic opioid fentanyl were up by almost 30 per cent in 2017.12 However, despite these worrying statistics, there are key differences between the US and UK healthcare systems which could work to protect the UK from the devastating crisis currently being experienced in the US.
Firstly, doctors in the UK operate under much more stringent oversight of prescribing than their US counterparts, with patients generally having to register with a GP practice to obtain an NHS prescription. With the overwhelming majority of opioid prescriptions in the UK on the NHS, any doctor seen to be prescribing excessively will be investigated as this will show up on the practice or trust’s prescribing data. Nevertheless, the fact of the matter is that prescribing has increased. Furthermore, in the US, where universal healthcare is not provided, patients are required to purchase their own health insurance, and many of these policies do not encourage alternative non drug-related pain management services such as physical therapy, in contrast to the NHS where these services are more widely available.13
What can be done to tackle the crisis?
Ultimately, a change in culture is required regarding the treatment of chronic pain with recognition given to the fact that chronic pain is a condition requiring ongoing management, rather than an acute disease that can only be treated and cured with drugs. Moreover, recent research suggests that treatment with opioid medication offers no advantages over non-opioid medications for improving long-term pain-related function.14 Many academic papers suggest that opioid use should be limited to patients with chronic cancer pain, and short-lived acute pain. However, 90 per cent of opioid prescriptions in the UK are for non-cancer chronic pain.15
Another avenue to explore could be personalised medicine, following findings suggesting that genetic factors play a key role in determining who develops an addiction to opioids. One such study suggests that genetic testing may be able to predict a person’s risk of developing an addiction to opioids.16 Armed with this type of insight in the future, physicians may be able to make more informed decisions, providing patients with a more personalised approach to pain management and possibly prevent the development of opioid addiction in those highest at risk.
With chronic pain affecting an estimated 28 million people in the UK, 8 million of whom suffer with enough pain to be disabling, it is clear that alternatives to opioids are required. Educating healthcare professionals regarding alternative non-opioid treatments for chronic pain is vital, as is investing in non-drug related pain management services in order to make these more readily available. Finally, further research into non-opioid alternatives for use in chronic pain management should also be explored, in order to arm healthcare professionals with more treatment options for their patients.