Recent data show that more than 40% of adults in England have at least one long-term medical condition (NHS Digital, 2019a; Pharmaceutical Journal, 2019a). With many living with multiple long-term conditions and complex care needs, opioid prescribing is high, despite the rate not having increased since 2016 (Pharmaceutical Journal, 2019b). Concerns related to this volume of opioid prescription are being raised on several fronts.
Drug misuse poisoning
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 and 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).
It was also noted that hospital admissions for drug misuse poisoning in England are fives times higher in areas of high deprivation compared with areas of low deprivation (Burns, 2019), and 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, the review from 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. Worryingly, it also acknowledged that more than half a million patients in England were being continuously prescribed an opioid for 3 years or more, despite a lack of evidence regarding 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 (Pharmaceutical Journal, 2019b). A 2018 study showed that high opioid doses were associated with increased use of healthcare services, as well as increased morbidity and mortality (Mordecai et al, 2018).
While the initial high dose may be justified with prescribers attempting to effectively resolve the chronic pain of their patients, if patients do not understand what they have been prescribed, how long they should be taking it and the risks of continuing on such a high dose, they may continue on a high-dose formulation for long periods of time (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 or not they would benefit from continuing their medication, the appropriate dose and what support they need, quite possibly from a multidisciplinary team (Pharmaceutical Journal, 2019b).
Holistic pain management
A central aim for the NHS at present is addressing the over-reliance on pharmacological interventions and on medications such as opioids to relieve pain. Social prescribing of non-pharmacological interventions, such as exercise-based programmes, must be a more routine approach. Where necessary, this should, of course, be complemented by medication, but perhaps pharmacological interventions should be reserved for acute pain rather than being seen as a lifelong solution (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 also a normal part of life, illness and injury, and is the body's way of alerting us to a root cause that requires addressing.
As well as an overall cultural shift away from overmedicalisation, perhaps we also need to shift towards the normalcy of pain and the acknowledgement that some conditions will be accompanied at times by some level pain. Attempting to rid ourselves of pain completely will lead us instead towards the norm of dependence and a misuse of drugs, as well as an inability to hear important messages being delivered by our bodies, which are hardwired to let us know what is truly happening when we fall ill.