Recently released data from the Health Survey for England 2018 have shown that more than 40% of adults in England have at least one long-term medical condition (NHS Digital, 2019a; The Pharmaceutical Journal, 2019a). However, with many now living with multiple long-term conditions and complex care needs, opioid prescribing is high, and several issues and concerns related to this volume of opioid prescription are being raised.
Drug misuse poisoning
There appear to be high rates of hospital admissions for drug misuse poisoning in areas with high levels of opioid prescription (Burns, 2019). Although local authority spokespeople claim there is no solid evidence linking these two factors, the picture is a worrying one and the patterns being observed cannot be ignored.
According to new figures from NHS Digital, more than half of all hospital admissions for drug misuse poisoning are related to opioids other than heroin, such as codeine or morphine (NHS Digital, 2019b). In England, 18 053 people were admitted to hospital for poisoning resulting from drug misuse, and the primary diagnosis in 9486 of these cases was poisoning from opioids other than heroin (Burns, 2019).
Furthermore, three local authorities with the highest rates of drug poisoning were also among those with the highest levels of opioid prescribing (Burns, 2019). The authorities in order of highest admissions are St Helens (95 admissions per 100 000), Middlesbrough (91 per 100 000) and Blackpool (80 per 100 000). However, spokespeople from the Clinical Commissioning Group (CCG) in relevant regions confirmed to The Pharmaceutical Journal that steps are being taken to understand and reduce the high volume of opioids being prescribed and consumed (Burns, 2019).
It was also noted that hospital admissions for drug misuse poisoning are fives times higher in England's high deprivation areas compared with areas of low deprivation (Burns, 2019). A previous review from Public Health England (PHE) (2019) reported that prescribing of opioids was 1.6 times higher in the most deprived areas compared with the least deprived (Robinson, 2019).
In August 2019, figures from the Office for National Statistics (2019) showed that 4359 deaths in England and Wales in 2018 were related to drug poisoning. Following this, analysis by The Pharmaceutical Journal highlighted the alarming fact that this is a 46% increase since 2008, and a 17% increase since the previous year (Burns, 2019).
Opioid dependence
In September 2019, a review from Public Health England (PHE) (2019) noted that from 2017 to 2018, 5.6 million people received and had dispensed one or more prescriptions for an opioid pain medication. It also worryingly acknowledged that more than half a million patients in England were being continuously prescribed an opioid for three years or more, despite a lack of evidence for their long-term efficacy (Robinson, 2019).
According to the review, despite evidence that prescribing opioid pain medicines for longer than 90 days was associated with opioid overdose and dependence, approximately 540 000 people were prescribed opioids continuously for 36 months or more (PHE, 2019; Robinson, 2019). Higher initial doses, as well as prior mental health issues, were associated with long-term use of opioids and dependence (PHE, 2019).
Opioid prescribing
Aside from the ineffectiveness of long-term prescribing of opioids, it has also been shown that many patients are on high-dose formulations (The Pharmaceutical Journal, 2019b). A 2018 study showed high opioid doses were associated with increased use of healthcare services, and increased morbidity and mortality (Mordecai et al, 2018).
It is certain that well-meaning prescribers issue high-dose prescriptions in an effort to effectively reduce chronic pain for their patients; however, the problem often lies in the lack of information and communication that accompanies these initial prescriptions (The Pharmaceutical Journal, 2019b). While the initial high dose may be justified, if patients do not understand what they have been prescribed, how long they should be taking it, and the risks of continuing on a high dose, they may continue on a high-dose formulation for long periods of time (The Pharmaceutical Journal, 2019b).
In addition to informing patients, this information also needs to be communicated clearly to primary care in the discharge information, and patients should be regularly reviewed to determine whether they would benefit from continuing their medication or not, the appropriate dose, and what support they need, quite possibly from a multidisciplinary team (The Pharmaceutical Journal, 2019b).
‘Approximately 540 000 people were prescribed opioids continuously for 36 months or more’
While opioid prescriptions were long on the rise, increasing by 22% between 2007 and 2015, this rate has begun to stabilise, declining by 2% in 2016-2017 (The Pharmaceutical Journal, 2019b). However, opioid use still remains alarmingly high and overprescribing persists despite evidence that long-term use is not appropriate for most people (PHE, 2019). For example, the PHE (2019) review importantly highlights that long-term use of opioids is not effective for chronic (non-cancer) pain.
Holistic pain management
A central issue that is rightly the focal healthcare aim for many at present is addressing the overreliance on pharmacological interventions and medications such as opioids to relieve pain. Social prescribing of non-pharmacological interventions such as exercise-based programmes must be a more routine approach, complemented by medication where necessary, but perhaps reserved for acute pain rather than seen as a lifelong solution (The Pharmaceutical Journal, 2019b).
It must be acknowledged that while pain is uncomfortable and some pain is so acute that it absolutely requires pharmacological management, pain is a normal part of life, illness and injury, and is the body's way of alerting us to a root cause that requires addressing.
Perhaps in addition to an overall cultural shift in healthcare and prescribing moving away from overmedicalisation, we also need to shift towards the normalcy of a bit of pain, and the acknowledgement that some conditions will be accompanied at times by pain. Attempting to rid ourselves of pain completely at all times will lead us instead towards the norm of dependence and a misuse of drugs, as well as an inability to listen to our bodies, which intuitively know best how to communicate to us what is wrong.