Careful prescription of addictive painkillers still necessary

19 September 2019

Although the use of opioid painkillers in the Netherlands has risen over the past ten years, it is nowhere near the degree to which they are used in the United States, say Arnt Schellekens and his colleagues in an article published in The Lancet Public Health.
  
There are currently many lawsuits being filed in the United States. The prosecutors state that pharmaceutical companies have for many years been putting strong opioid painkillers such as oxycodone on the market too aggressively. Physicians were encouraged to prescribe more, and marketing continued unabated despite the risks of addiction being known. This led to an unprecedented ‘addiction crisis’ among patients and citizens in the USA. According to STAT News – an American medical news website – 48,000 Americans died of opioids in 2017, largely due to painkillers. Since 2009, more civilians in Oklahoma are said to have died from opioid use than from traffic accidents.
 
Nearly a billion dollars in fines
This year has already seen various settlements and fines being issued. Earlier this year, Purdue Pharma, the producer of oxycodone, reached a settlement of 270 million dollars with the state of Oklahoma. Not much later, Teva followed with 85 million, and pharmaceutical Endo recently joined the list of settlements with 10 million dollars. Latest news: pharmaceutical company Johnson & Johnson, who chose a lawsuit over a settlement, has been sentenced to a fine of 572 million dollars. And Purdue Pharma now seems to be preparing to settle for around 12 billion (!) dollars, according to a report by the Dutch network NOS (article in Dutch).
Developments in the USA often follow in Europe with a slight delay, and the Netherlands is no exception. “Due to a combination of circumstances, prescriptions of opiates are getting out of control. Large-scale addiction problems are lurking”, general practitioner Jos van Bemmel wrote almost two years ago in Medisch Contact (article in Dutch). Last year, the Dutch newspaper de Volkskrant (article in Dutch) headlined: “Physicians say use of addictive painkillers is getting out of control”.
 
Situation in the Netherlands
Given that context, the article by Arnt Schellekens and several Dutch colleagues, which was recently published in The Lancet Public Health, is very informative. Schellekens, psychiatrist at Radboud university medical center, collected data on the number of people in the Netherlands who were prescribed opioids or opiates and the number of hospital admissions related to intoxication following their use. He also looked at the number of people treated for opioid addiction and how many died from opioid use. To this end, the researchers used data from Statistics Netherlands (Centraal Bureau voor de Statistiek, CBS), the Drug Information Project (Genees- en hulpmiddelen Informatie Project, GIP), the Dutch National Health Care Institute (Zorginstituut Nederland, ZN), the Dutch National Hospital Care Basic Registration (Landelijke Basisregistratie Ziekenhuiszorg, LBZ) and the National Alcohol and Drugs Information System (Landelijk Alcohol en Drugs Informatie Systeem, LADIS). With this data, an accurate overview of the developments in the period from 2008 to 2017 could be formed.
 
The numbers tell their story
Is the use of opiates increasing? “It certainly is”, says Schellekens. “In that period, it went from over 4,000 to almost 7,500 per 100,000 inhabitants, which means the number nearly doubled. The main factor in this increase are the oxycodone users, who increased from 574 to 2568 per 100,000 inhabitants. Hospital admissions related to opioid intoxication increased from an average of 2.5 to 7.8 people per 100,000. If we exclude heroin addictions in order to get a clear picture of the addictions to painkillers, we can see the number rising from over 3 to almost 6 per 100,000 people in that timeframe. The number of people who died from opioid use remained the same in the years from 2008 to 2014. But after 2014, that increased from an average of 0.21 to 0.65 per 100,000 people in 2017.”
 
Differences in healthcare
To paint as accurate a picture of the situation as possible, Schellekens and his colleagues consistently separated data on the traditional opioids (heroin, methadone, etc.) and prescription opioids (oxycodone, fentanyl, etc.). Schellekens: “We can indeed observe a relatively large increase in opioid use. But this increase is not in proportion with the relatively limited increase in problems associated with that opioid use, such as an increased mortality rates, hospital admissions and treatment of addictions. That is a clear difference with the American situation and this difference can largely be attributed to the differences in the healthcare system in the Netherlands. Due to the approach of general practitioners and pharmacists, nearly automatic increases of doses are much less common, for example.”
 
Proper use
Based on the data, the conclusion must be that the problems here did not get out of control as much as elsewhere in the world. “That conclusion is supported by the fact that we see that the increase in opioid use, which started in 2010, was only followed by a slight increase in mortality rates from prescription opioids in 2017. In other countries, such as the USA, those two trends run completely parallel, and the increase in mortality rates is a clear trend, which continues even despite the decrease in the number of opioid prescriptions.”
The fact that the Netherlands is not struggling with an opioid epidemic does not mean that the subject does not require any attention. On the contrary. Schellekens: “Good guidelines for prescribing opioid painkillers to restrain further increase in use are necessary. Also because these drugs must remain available for those who really need them.”
 
Publication in The Lancet Public Health 
Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study
Gerard Arnoldus Kalkman, Cornelis Kramers, Robert T van Dongen, Wim van den Brink, Arnt Schellekens