Policy analysis
Prescription opioid misuse in the United States and the United Kingdom: Cautionary lessons

https://doi.org/10.1016/j.drugpo.2014.07.009Get rights and content

Abstract

In the United States, opioid analgesics have increasingly been prescribed in the treatment of chronic pain, and this trend has accompanied increasing rates of misuse and overdose. Lawmakers have responded with myriad policies to curb the growing epidemic of opioid misuse, and a global alarm has been sounded among countries wishing to avoid this path. In the United Kingdom, a similar trend of increasing opioid consumption, albeit at lower levels, has been observed without an increase in reported misuse or drug-related deaths. The comparison between these two countries in opioid prescribing and opioid overdose mortality underscores important features of prescribing, culture, and health systems that may be permissive or protective in the development of a public health crisis. As access to opioid medications increases around the world, it becomes vitally important to understand the forces impacting opioid use and misuse. Trends in benzodiazepine and methadone use in the UK as well as structural elements of the National Health Service may serve to buffer opioid-related harms in the face of increasing prescriptions. In addition, the availability and price of heroin, as well as the ease of access to opioid agonist treatment in the UK may limit the growth of the illicit market for prescription opioids. The comparison between the US and the UK in opioid consumption and overdose rates should serve as a call to action for UK physicians and policymakers. Basic, proactive steps in the form of surveillance – of overdoses, marketing practices, prescribers, and patients – and education programs may help avert a public health crisis as opioid prescriptions increase.

Section snippets

Background

In the United States, opioid treatment of chronic pain is the focus of urgent attention due to increasing trends in misuse and non-fatal and fatal overdose among those to whom the opioids are prescribed as well as those who obtain them illicitly. Opioid overdose is now the second leading cause of accidental death in the United States after motor vehicle accidents (Centers For Disease Control and Prevention, 2010). These trends parallel an increase in opioid prescriptions (Hall et al., 2008).

Trends in opioid prescribing

Opioid prescribing for chronic non-cancer pain is increasing in the US and UK. This has occurred in spite of a paucity of evidence regarding the efficacy of opioid therapy for chronic non-cancer pain and a growing literature surrounding its harms (Kalso et al., 2007, Noble et al., 2010, Okie, 2010). Although the US currently consumes more opioids per capita than the UK, both countries have seen increases in opioid consumption over the last two decades (DCAMC, 2012). Notably, the per capita

Opioid misuse in the US and UK

Comparing opioid misuse requires a standard nomenclature. Since the nomenclature is not always consistent in the literature, for the purposes of this review, the term misuse will be used as a general term for behavioral problems – ranging from use other than as prescribed to addiction – that are associated with opioid use (Table 1).

According to national surveys, prescription opioid misuse is second only to cannabis in illicit drug use in the US with approximately 2% of the adult population

Lessons from drug poisoning data

Although the number of opioid prescriptions has increased in both the US and the UK, England and Wales have not seen a concurrent rise in opioid overdose (see Fig. 2). One important methodologic challenge, however, is that surveillance and classification of cause of death are not standardized within or between countries; thus, precise comparison of opioid overdose rates is impossible.

Several important trends have emerged in the analysis of overdose deaths in the US. First, misuse resulting from

Pharmaceutical industry and cultural influences in opioid misuse

Professional guidelines in the UK and US are largely in agreement in terms of recommendations for opioids for pain (Chou, 2009, The British Pain Society, 2010). However, the landscape of opioid treatment differs in these countries with approaches to health care delivery that are unique to their respective cultures and histories.

Pharmaceutical company marketing practices in the US have served to inflate the benefits and obscure the harms of opioids. Notably, Purdue Pharmaceuticals pleaded guilty

Forming opioid policies through regulation, surveillance, and education

Analogous to States, which have a degree of autonomy in public health governance in the US, the devolved administrations of the UK (Scotland, Wales, and North Ireland) differ in meaningful ways with respect to public health priorities, as well as structural aspects of healthcare delivery. Moreover, it is important to acknowledge regional variations in opioid use and opioid-related harms in the US and the UK. Nevertheless, in both the US and the UK there is consistency in their respective

Discussion

The comparison between the US and the UK in opioid consumption and overdose rates should serve as a call to action for UK physicians and policymakers. The trends in decreasing benzodiazepine prescriptions and limited use of methadone for the treatment of chronic pain in the UK as well as structural elements of the National Health Service (NHS) may serve to buffer opioid-related harms in the face of increasing prescriptions. In addition, the availability and price of heroin, as well as the ease

Authors contributions

DW performed the data analysis from national drug poisoning data from the United States and the United Kingdom as well as opioid consumption data compiled by the Drug Control and Access to Medicines Consortium (http://dcamconsortium.net/). DW wrote the first draft of the manuscript based on inter-continental discussions between the authors, and worked with CS, DF, and WB in revising it. All authors approved the final version of the manuscript.

Author information

CS, DF and WB are clinicians and researchers with extensive experience in the area of opioid prescribing. In addition, CS served as the UK Chair of the Consensus Group and Editor of the British Pain Society's and Medical Royal College's guidance entitled “Opioids for Persistent Pain: Good Practice”, and DF has served on the White House Office of National Drug Control Policy (ONDCP), Drug Control Research, Data, and Evaluation Advisory Committee, and the World Health Organization and United

Funding source

Funds from The Office of International Medical Student Education, Yale University School of Medicine, supported this study. Dr. Fiellin is supported by a grant from the National Institutes on Drug Abuse, DA020576-01. Dr. Becker is supported by a Veterans Health Administration Health Services Research & Development Career Development Award (08-276). The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the institutions with which

References (63)

  • A.S. Bohnert et al.

    Association between opioid prescribing patterns and opioid overdose-related deaths

    Journal of the American Medical Association

    (2011)
  • J. Brown et al.

    Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting

    Journal of Opioid Management

    (2011)
  • N. Buscemi et al.

    The efficacy and safety of drug treatments for chronic insomnia in adults: A meta-analysis of RCTs

    Journal of General Internal Medicine

    (2007)
  • CASA (The National Center on Addiction and Substance Abuse at Columbia University)

    “you’ve got drugs!” V: Prescription drug pushers on the Internet [A CASA White Paper]

    (2008, May)
  • Centers For Disease Control and Prevention. Unintentional drug poisoning in the United States....
  • R. Chou

    Clinical Guidelines from the American Pain Society and the American Academy of Pain Medicine on the use of chronic opioid therapy in chronic noncancer pain: What are the key messages for clinical practice?

    Polskie Archiwum Medycyny Wewnetrznej

    (2009)
  • R. Chou et al.

    Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain

    Journal of Pain

    (2009)
  • Care quality commission: Annual report and accounts 2010/2011. www.cqc.org.uk,...
  • Drug Control and Access to Medicines Consortium

    Opioid consumption chart

    (2012)
  • Department of Health

    National Treatment Agency. Statistics from the National Drug Treatment Monitoring System (NDTMS) 1 April 2009–31 March 2010

    (2010)
  • I.A. Dhalla et al.

    Prescribing of opioid analgesics and related mortality before and after the introduction of long-acting oxycodone

    CMAJ: Canadian Medical Association journal

    (2009)
  • C.R. Dormuth et al.

    Effect of a centralized prescription network on inappropriate prescriptions for opioid analgesics and benzodiazepines

    CMAJ: Canadian Medical Association journal

    (2012)
  • Emergency department visits involving nonmedical use of selected prescription drugs – United States, 2004–2008

    MMWR Morbidity and Mortality Weekly Report

    (2010)
  • B. Fischer et al.

    The global diversion of pharmaceutical drugsnon-medical use and diversion of psychotropic prescription drugs in North America: A review of sourcing routes and control measures

    Addiction

    (2010)
  • D.L. Gourlay et al.

    Universal precautions in pain medicine: A rational approach to the treatment of chronic pain

    Pain Medicine

    (2005)
  • T.C. Green et al.

    Revisiting Paulozzi et al.’s “Prescription drug monitoring programs and death rates from drug overdose”

    Pain Medicine

    (2012)
  • T.C. Green et al.

    How does use of a prescription monitoring program change medical practice?

    Pain Medicine

    (2012)
  • A.J. Hall et al.

    Patterns of abuse among unintentional pharmaceutical overdose fatalities

    Journal of the American Medical Association

    (2008)
  • G. Hay et al.

    Estimates of the Prevalence of Opiate Use and/or Crack Cocaine Use, 2009/2010: Sweep 6 report. Home Office Online Report

    (2011)
  • Health and Social Care Information Centre

    Prescribing and primary care: Prescription cost analysis – England

    (2011)
  • International Narcotics Control Board

    Psychotropic Substances: Statistics for 2011; Assessments of Annual Medical and Scientific Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substances of 1971 (E/INCB/2012/3)

    (2011)
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