For a number of years, North America has seen an ‘epidemic’ of abuse, overdoses and death associated with opioids. To a lesser extent, the use of opioids in Europe has increased dramatically in recent years, for the treatment of chronic pain syndrome among other things. Although it falls within the category of improving pain management, this increasing use of opioids raises the question of the risks associated with their abuse. The emphasis is therefore on preventing dependence and abuse and on the importance of the rational use of opioids.
In recent years, Europe has seen increasing consumption of opioids. This increasing consumption has not yet reached the levels reported in the United States and Canada. However the figures from the Organisation for Economic Cooperation and Development (OECD) published in May 2019 show that Belgium has the third highest daily consumption of opioids in Europe per million inhabitants, after Germany and Austria.
The Netherlands saw a large increase in the number of opioid prescriptions between 2005 and 2015. Medical prescriptions of powerful opioids there have increased sixfold. The largest increase in opioid consumption (moderate to powerful) concerned oxycodone and tramadol.
In France, the National Agency for the Safety of Medicine and Health Products (ANSM) noted that prescriptions of strong opioids increased by around 150% between 2006 and 2017. In 2017, the most-consumed opioid analgesics in France were, in decreasing order: tramadol, codeine (in combination), morphine, oxycodone and fentanyl.
In Belgium, the National Institute for Health and Disability Insurance (l’Institut national d'assurance maladie-invalidité – INAMI) analysed the consumption of five opioids (tramadol, tilidine, oxycodone, fentanyl and piritramide), which represent around 80% of the total usage of all reimbursable opioids. Between 2006 and 2017, the number of patients who had consumed at least one of these five opioids rose by 88% to 1,104,485 insured persons or around 10% of all Belgians.
In December 2018, INAMI organised a consensus meeting to assess opioid usage practices in the treatment of chronic pain and to put forward recommendations for rational opioid use. Among other things, the experts discussed adverse effects associated with their chronic use, for example hyperalgesia and the syndromes of habituation and dependence. It was proposed that the more powerful a product is, the faster and more short-lived its effect, the greater the risk of dependence. Thus, the risk that opioids will be inappropriately used is five to six times higher in the case of short-acting opioids. It therefore follows that the use of short-acting opioids, and above all ultra-short-acting opioids, should be closely monitored. Preventing dependence and abuse partly comes down to the choice of opioid: if possible, favour an opioid with a slow, prolonged effect, at the lowest effective dose and for as short a period as possible.
The committee of experts assembled by INAMI also raised the existence of diagnostic and assessment instruments that make it possible to identify patients at high risk of opioid misuse or abuse (NPC_Canada, CDC 2016, ASCO 2016)*. Moreover, the experts emphasised the fact that effective communication between health professionals, but also with the patient and their family, was essential in order to be able to promote appropriate use of analgesics, monitor abusive use and prevent medical nomadism.
The committee concluded that as with all medicinal products, therapeutic prudence should be exercised in the indication and selection of opioids and in patient monitoring. Opioids have only a limited place in the multimodal treatment of certain chronic pain syndromes. Even then, they are rarely the first choice. At the time of writing, scientific evidence is limited concerning their added value in long-term treatments (over three months). The complete jury report is available on the INAMI website (Consensus meetings – Jury reports).
The Belgian Centre for pharmaceutical and therapeutic information (Centre belge d’information pharmacothérapeutique – CBIP) has reiterated the place of opioids in the treatment of non-cancer-related pain and the very limited role that opioids play in the chronic pains of osteoarthritis (with a reminder of the conclusions of the KCE on the subject). The CBIP has also drawn the attention of healthcare professionals to the risks associated with the use of preparations combining opioids (such as codeine) with paracetamol or a non-steroidal anti-inflammatory drug (NSAID). This type of fixed combinations can contribute to trivialising the use of opioids.
In 2018, the FAMHP issued communications on opioids. Firstly on the appropriate use of fentanyl, in order to minimise the risk of abuse, addiction or accidental overdose and then on the serious risks associated with the concomitant use of opioids and benzodiazepines. Due to the risks of sedation, respiratory depression and potentially fatal coma, the concomitant prescription of opioids and benzodiazepines should be reserved for patients for whom the therapeutic alternatives are inadequate.
Given the worrying data on the increasing use of opioids (associated with an often underestimated risk of psychological habituation) and the abuse and misuse issues that can result from it, the FAMHP would like to reiterate the importance of rational use of these substances.
For the attention of patients
The FAMHP would like to remind you of the importance of using opioid medicinal products at the prescribed dose and only for the maximum period recommended by your doctor. Do not take opioid painkillers from an unsealed box, or which have not been prescribed to you personally, without medical advice.
If you are worried about the risks of habituation or dependence, or if you think that you may be suffering from these issues, do not hesitate to talk to your doctor or pharmacist about it.
* NPC Canada = Canada’s National Contact Point for the Organisation for Economic Co-operation and Development (OECD)
CDC = Centers for Disease Control and Prevention (USA)
ASCO = American Society of Clinical Oncology