Last month, the research round-up provided you with an overview of articles looking at statin prescribing practice. This month, we will look at issues around opioid prescribing. The first article looks at the mortality of people prescribed opioid agonist therapy in Scotland. The second article looks at whether England is facing an opioid epidemic and the final paper looks at how opioid prescribing can be affected by online education.
Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011–20: a national retrospective cohort study
This retrospective cohort study, published in the journal Lancet Public Health online sought to identify mortality amongst people prescribed opioid agonist therapy in Scotland between the years 2011 and 2020. The article starts by covering the scale of drug related deaths in Scotland and outlines that in this part of the UK, drug-related deaths are 3.7 times higher than the rest of the UK as a whole and higher than most internationally available country figures indicating a particular problem in Scotland.
The study aimed to investigate whether opioid agonist therapy was protective against drug-related deaths and to look at this effect over time. The study encompassed all individuals identified in Scotland between 2011 and 2020 who had been prescribed opioid agonist drugs on at least one occasion. The researchers then calculated drug related mortality rates and a regressional statistical analysis to estimate trends over time. In total, 46 453 individuals were identified as having been prescribed opioid agonist therapy.
The findings suggest that drug-related deaths increased over the time period studied, and that deaths were 3.5 times higher for those not receiving opioid agonists compared to those who were. They acknowledge that confounding variables suggest the risk is just as high on therapy as off due to the complicated nature of opioid misuse. They suggest that, although opioid agonist therapy does proffer some protection, on its own it is an insufficient strategy to combat drug-related deaths and that other interventions such as take home naloxone, drug consumption rooms, drug checking services and alternatives to street drugs must be considered as a multi-strand approach to combating this increasing problem.
Is England facing an opioid epidemic?
This article, published in the British Journal of Pain, sought to explore whether England is facing an opioid epidemic similar in proportion and scale to that seen in the USA. This was done through public health and epidemiological methods and definitions contextualised to opioid misuse and mortality in England.
The article begins by outlining the high-profile nature of the opioid scandal of the USA in the 21st century. It states that figures from 2019 suggest that then, the UK had the highest rate of opioid consumption in the world and that since 1993 the rate of drug-related deaths has increased by 388% in England and Wales.
Public health definitions are then explored in the context of the epidemic: ‘The occurrence of more cases of disease, injury or other health condition than expected in a given area or among a specific group of persons during a particular period’ and relate this to opioid overdose and death, which led to the USA declaring in 2017 that this constituted a public health emergency. The article explores three areas that were distinct about the US opioid crisis and review these from an England perspective.
The first area was opioid prescribing and deaths. The authors describe the US position, where widespread over-prescribing led to a death rate of 20.7 per 100 000 people in 2020. The death rate in England is lower; however, there are higher than expected rates of morbidity and mortality from opioid prescribing including a 49% increase in opioid-related hospitalisations between 2008 and 2018, but could not identify if the source for these was legal or not.
The second area was street heroin. In the US, the move in 2010 from prescribed drugs to street drugs including heroin was notable. In England, however, statistics on heroin-related deaths are not distinguishable from other opioid-related deaths meaning interpretations are not possible in a comparison. What has been seen in England since 2013 is an increase in availability and supply of heroin and a corresponding, but not correlated, increase in opioid-related death over the same period.
The third area was the use of synthetic opioids such as fentanyl. In the USA, this third wave of the crisis was noted in 2013 when identified deaths due to use of synthetic opioids was identified as an increasing problem. This may be due, in part, to the increased potency of these drugs as well as increased availability. In the US in 2021, the recorded related death rate was 21.4 per 100 000, which is significant in comparison to the death rate in England the same year of 0.223 per 100 000. There has been an increase in these deaths in England year on year, but establishing whether these were from prescribed or illicit sources was not possible. The rise here is concerning and requires close monitoring.
The authors conclude that England has experienced a dramatic rise in opioid prescribing and has seen a concurrent rise in opioid-related deaths and with people misusing opioids seeking treatment in recent years. They acknowledge that England rates in no way have reached those of the US opioid crisis and, therefore, cannot be defined as an opioid epidemic. They suggest that England is facing a chronic pain emergency and that access to and development of services for chronic pain sufferers is needed to manage pain and addiction.
Online education for safer opioid prescribing in hospitals—lessons learnt from the Opioid Use Change (OUCh) project
This article, published by the Oxford University Press in the Postgraduate Journal as open access sought to explore online education for safer opioid prescribing in hospitals. The article starts by outlining the prescribing of opioid medication in UK hospitals and the use of NICE guidelines for doing so. They outline the areas where prescribing occurs and the risks of prescribing including side effects and adverse effects.
They acknowledge the lack of specific training in opioid prescribing and de-prescribing with a known problem of lack of knowledge among many junior and senior prescribers. They then contextualise this to their own geographical areas of the north east of England and describe the development and evaluation of their project. This is a brief online educational tool for safer opioid prescribing named Opioid Use Change.
They describe the 5-minute professionally made video, which contain evidence-based information on the benefits and short- and long-term risks, as well as reduction and de-prescribing. The video contains a real-life patient story. Prior to watching the video, the participants completed a short knowledge-based quiz, which would be repeated after viewing the video. This video was shown to participants and a mixed methods evaluation conducted. Feedback from the users consisted of an initial evaluation of impact on behaviour and understanding around opioid prescribing completed online.
Responses were 106, which included 98 junior doctors and eight nurse prescribers/ward pharmacists. All responses were anonymised beyond job role and took around 15 minutes to complete. Feedback was positive and showed that knowledge of side effects significantly increased, but also contacts with ward pharmacists and the acute pain team increased. Junior doctors highlighted that the undergraduate curriculum did little to prepare them for prescription addiction and that pharmacy and senior support was needed to support any changes in longer-term, high-dose opioids.
The authors conclude that the short online education intervention was associated with an improved knowledge of safe opioid prescribing and could be incorporated within wider opioid education in UK healthcare. The video can be accessed here: https://www.youtube.com/watch?v=hnqGvUlf3ic.
Conclusion
Opioid prescribing and de-prescribing is often a complicated and problem fraught area for prescribers at all job roles and levels of experience. Monitoring of prescribing and of other opioid use is essential, and prescribing using guidelines and prescribing appropriately is vital as is management of short- and long-term side effects and risks. Continuing education and evaluation of opioid prescribing practice can be useful for all prescribers.