A recent report has been completed by researchers from the University of Toronto and published in the British Medical Journal (BMJ). Although research was carried out in North America it is said to have a limited bearing on the UK. The reason for only a minimal effect is the dissimilar regulations and ways of marketing between both societies.
The area discussed and investigated in the report was opioid painkillers and their increased usage. The increased risk of death when taking these drugs was also discussed. Opioids are a group of painkillers derived from morphine, methadone and codeine. Because they can be addictive their main usage has been for the treatment of cancer pain. However the study has identified that they are now being prescribed more frequently for other sorts of pain. The authors of the report note that opioids can produce withdrawal symptoms if their use is stopped.
The report identified and discussed trends in the prescription of opioid painkillers for any non cancer related pain such as chronic pain, as well as trends in opioid related deaths. It also carried recommendations for policy changes, which they say will reduce the number of these deaths in North America.
Type of Report
The report was compiled by the authors, all lecturers and researchers at the University of Toronto and was not peer reviewed. The article studied data presently held and trends were extrapolated from that data, meaning that it was systematic in its review of the data and no opinions were put forward but recommendations were included.
The editorial stated the facts and any trends drawn from those facts in relation to opioid use. Prescribing practices and trends in death and harm were discussed leading to recommendations which the authors believe will cause a drop in the numbers of deaths and harm related incidents. The main focus of the investigation was North America but other countries were given limited consideration too.
When the report was published it caused the media to run headlines such as “'Disaster' looms over addiction to painkillers,” as reported by The Independent. The paper goes on to report that the report’s recommendations ‘do highlight important areas for future policy discussions in England’. These talks are scheduled according to The Independent which states that Public Health Minister Anne Milton has said that “experts will convene next month to discuss new evidence from recent studies on addiction to prescription medicines”.
The media did not discuss this editorial alone they also used information, in the form of a report called ‘Addiction to Medicine’ from the National Treatment Agency for Substance Misuse. This is a special health authority within the NHS with the role of reporting on drug addiction in England.
The report, published in May 2011 researched problems with over the counter and prescription medicines and the support given to people with these problems. The Daily Mail and the Independent both chose to report the increase in ‘prescribing of opioid analgesics by GPs from 228 million items in 1991 to 1.38bn items in 2009’ as the main point from this report. A finding which fully supports the findings in the editorial.
What was in the Editorial?
The editorial identified that the number of deaths in the US involving opioid painkillers increased more than three fold from 1999 to 2007. The actual figures were 4,000 in 1999 more than 14,000 in 2007. This type of increase was not limited to the US. Other countries recorded similar increases too. It was also identified that the majority of deaths were unintentional and most common in young people.
The UK is one of the other countries addressing the issue opioid painkillers and the report commented that the former chair of the House of Commons All Party Parliamentary Group on Drug Misuse had concerns that the UK may see a similar spike in opioid-related deaths within the next decade. The editorial also had a reference to a 2010 BMJ article which had investigated opioid deaths in England and Wales between 2005 and 2009. That report said that methadone and codeine related deaths nearly doubled in that time.
Discussions expressing increased concern that some of the opioid related deaths were avoidable was included in the editorial. It was believed that these deaths could be prevented if the government provided adequate regulation of drug companies. It was also stated that doctors should consider more evidence-based prescribing practices. These findings led the authors to present the following wide ranging recommendations, which address the patients, doctors and drug companies:
- Regulate the drug companies and change their working practices. Stop paying bonuses linked to the amount of drugs sold and do not let drug companies give coupons for free prescriptions to new patients which may be used for potentially addictive medication.
- Physicians dealing with patients with drug addiction problems should register prescriptions to allow drug users behaviours to be monitored.
- All doctors and pharmacists to access a yet to be developed database before prescribing or dispensing opioid painkillers. A check can be carried out to track the patient’s prescription drug history.
- Ensure that doctors are given more education, clarifying the risks of opioid painkillers when used for non cancer related pain and possible interactions between other drugs, toxicities and if there are any suitable non opioid available on the market such as analgesics.
- Teach the public about the dangers of mixing opioids with other drugs or alcohol.
- Urge further academic rigorous research to be carried out with the aim of measuring the rate of pain relief produced by opioids compared to other forms of pain killer.
The editorial also asserted that any long term benefits from using opioids do not match the risks taken by using them long term for many patients. The researchers explain that opioids must be available to those who need them. That is those in pain caused by cancer. In these cases the benefits do outweigh the risks. For other patients though, the researchers suggest that doctors err on the side of caution when deciding to prescribe opioids because any long term benefits have yet to be fully researched or is not supported by evidence.
Written to address the changing trends in opioid related deaths and incidents of harm this editorial used all the data which was readily available and identified trends from which the authors formed recommendations. It is possible to consider the recommendations as opinion-based because they came from the authors’ review of trends drawn from the data. However, without further research and investigation they appear rational and feasible. It is not known if a full systematic review would have drawn any other findings or recommendations. Identifying whether all the available data was studied is a limitation of the editorial.
The report showed areas of concern which are ready for decisions to be considered about the future direct to take. The UK’s prescription and dispensing policies may benefit from some rigorous scrutiny to avoid the problem escalating. Avoiding unnecessary opioid related deaths or incidents can be managed. Long term chronic pain sufferers should be discussing issues with their GPs and building up their knowledge of the subject to help make informed decisions. It is hoped that the doctors are already making informed decisions, however it appears that maybe all are not.
Many of the recommendations in the editorial are US based and not relevant to the UK because the workings of the drug industry in both countries are very different. In the UK no marketing of prescription drugs directly to the public is allowed, drug manufacturers can only advertise directly to health professionals. It is clear that drug companies could be better regulated in the US from an opioid prescription and dispensing point of view. One recommendation relevant to both societies was that more effective research should take place into the pain killing properties of opioids compared to other analgesics and pain killers for non cancer related pain.