Monitoring Opioids in Europe: The Need for Shared Definitions and Measuring Drivers of Opioid Use and Related Harms

Abstract

The past 20 years, the USA is facing a serious opioid crisis initiated by an increase in prescription opioid use. Europe has also seen an increase in prescription opioid use, but the extent of related harm is still largely unknown. Given the impact of the US opioid epidemic, it is important to closely monitor signs of emerging opioid-related problems to guarantee early warnings and timely actions. Shared and meaningful definitions for opioid use and related harms, and relevant information about specific drivers for opioid use and related problems are needed for an adequate policy response. In this commentary, we discuss these definitions, the need to know more about the specific drivers for increased opioid use, its related harm, and proposals for strategies to move forward. Policy recommendations include making a distinction between licit and illicit opioids when monitoring and reporting on opioid-related harm, and using oral morphine equivalents to quantify prescription opioid use in a clinically relevant and comparable manner. A major topic of further research is exploring unique and universal drivers of prescription opioid (mis)use across Europe, in particular the role of opioid diversion.

Real-world patterns of opioid therapy initiation in Spain, 2012–2018: A population-based, retrospective cohort study with 957,080 patients and 1,509,488 initiations

“…Many studies have addressed the use of prescription opioids in Europe and have raised concerns about increasing trends and concerning patterns of use. However, there is a great heterogeneity between studies in the operational definitions and the nature of data employed, and there is a lack of granular, high quality epidemiological data on opioid use that is required to implement policy responses at national or regional level and to make accurate comparisons ( Kalkman et al, 2022 ). Also, contextual information is important (such as, for instance, indication of use) to interpret the use of a drug in a specific setting, and comparison between settings without that information should be made with caution.…”

Management of Co-Occurring SUD and Chronic Pain

“…More recently, it has been recognized that the real prevalence of OUD is much higher, with various estimates ranging from 3.2 to 27%, with most of these estimates falling in the 20-25% range [17]. Though the level of prescription opioid use, and opioid-related deaths in most European countries and worldwide is still much lower than that of the US, as noted above Europe has seen a steady increase in prescription opioid use over the past 15 years, mainly due to increased tramadol, fentanyl, and oxycodone prescriptions; there are calls for proactive investigation into these trends and their potential subsequent harms [11].…”

“…Potency is certainly a key factor in this equation, and it is important that medical providers have a solid understanding of the relative potencies and basic pharmacologic properties of various opioid medications. Ranging from opioid partial agonists such as tramadol to high potency full agonists such as fentanyl, these potencies are classified by the World Health Organization on their "Analgesic Ladder" [11]. Of note, opioids with the highest potency also have the greatest addiction liability and highest risk of overdose death.…”

“…In this context, management of chronic pain in the US has undergone systematic re-examination to elucidate best practices for patient safety and treatment effectiveness [8]. Elsewhere in the world, countries are attempting to learn from the mistakes of the US and prevent or mitigate major prescription opioid-related public health problems [11]. As providers are regularly tasked to straddle the intersecting realms of chronic pain disorders, substance use and mental health disorders, treatment approaches must emphasize evidence-based, compassionate, inclusive, patient-centered, safe, and sustainable interventions.…”

Individuals Dying of Overdoses Related to Pharmaceutical Opioids Differ from Individuals Dying of Overdoses Related to Other Substances: A Population-Based Register Study

“…In the previous two decades, the use of pharmaceutical opioids (PO) has increased substantially, especially in North America, but also to a lower degree in some European countries [1,2]. This is of great public health concern, as increased PO access and use have subsequently been associated with increases in opioid use disorders and associated overdose deaths [1,[3][4][5][6][7][8].…”