Abstract
In an era of ‘fake news’, communicating factual public health messages is pertinent. The opioid crisis in the USA has affected entire communities, with 192 lives lost every day, 1 and misinformation was cited as a contributing factor. 2 In England, the prescription of opioids has increased by 127% since 1998. 3 Opioid deaths in England and Wales are at an all-time high, with 2263 deaths involving an opioid in 2020. 4 Clear information and messages are required on the indication, benefits and safety of opioids, as well as alternatives to inform patients and guide shared decision making in clinical practice. This commentary discusses the need for a collaborative and coordinated data-driven approach to getting the right messages to the right people at the right time to avert a UK opioid crisis.
The ‘right’ messages
Important public health messages to avert a UK opioid crisis.
The second message is that opioids are effective in the short term for acute pain while providing limited benefits for some people with chronic pain. Opioids are essential medicines and play an important role in treating cancer pain, during palliative care and managing acute (e.g. postoperative or trauma) pain. Conversely, opioids are neither beneficial nor safe for most people with chronic non-cancer pain,6 where pain can persist for months, years or even decades. Most clinical trials on the effects of opioids are conducted over short durations, using placebo comparators (rather than paracetamol, physical or psychological therapies), and exclude people at high risk of serious adverse events – limiting the generalisability to clinical practice. 7 Chronic pain management aims to improve people’s quality of life and daily function. Paradoxically, opioids do the opposite in people with chronic pain; they increase the severity of pain, negatively impact quality of life and reduce one’s ability to function. 8,9
Common types of opioids by their origin of discovery (class), alphabetically ordered.
The complete list of 233 opioid drugs is available at the Oxford Catalogue of Opioids (https://www.catalogueofopioids.net/). 10
Finally, the public should be privy to the legal and life-threatening consequences of driving while taking prescription opioids. In the UK, driving has been illegal if taking more than 220 mg of morphine or equivalent (i.e. blood limits of 80 µg/L of morphine and 500 µg/L of methadone) since 2015. 18 A high-quality case–control study (5300 cases) found that drivers taking low doses of opioids (20–49 mg/day of morphine equivalents) had a 21% increased odds of road trauma; those receiving moderate doses (50–99 mg/day) had a 29% increased odds and those prescribed high doses (>100 mg/day) had a 42% increased odds of road trauma. 19 Prescribers should speak with their patients taking prescription opioids about how this law may affect their pain management strategy.
Public health recommendations
We recognise that there is a large body of research on public health messaging – the theory and process of health communication and behaviour change – which is beyond the scope of this commentary. Building trust between healthcare professionals and patients is at the heart of medicine. Trust influences how we respond to public health messages. 20 Nurses and doctors are the most trusted profession in Britain, closely followed by academics (professors) and scientists. 21 Therefore, nurses, doctors, academics and scientists have an important role in delivering clear, simple and consistent messages using the best available evidence to people with pain.
National organisations also play a significant role in educating the public. In September 2019, Public Health England (PHE) released a report on medicines associated with dependence, including opioids. 22 They found that 5.6 million people in England were dispensed at least one opioid in 2017–2018. 23 Between 2015 and 2018, the number of people taking opioids decreased (3.9%). However, half of all people prescribed opioids in March 2018 continuously took opioids for at least 12 months, and this long-term use of opioids had increased since April 2016. The PHE report provided recommendations, including increasing the availability of prescribing data, enhancing clinical guidance, improving information for patients and carers, and improving patient support. In October 2015, a similar report had been published by the British Medical Association (BMA), which also concluded with three key policy recommendations: (1) a national helpline for people prescribed drugs of dependence; (2) an increase in specialist support services; and (3) revised guidelines on the safe prescribing, management and withdrawal of prescription drugs. 24 None of the BMA’s 2015 recommendations were actioned. Thus, urgent action is needed to implement such important recommendations, which should be coordinated and systematically employed so that people with pain are not left behind.
A coordinated data-driven approach
Across England, general practitioners, Clinical Commissioning Groups and specialist centres are working to reduce the volume of opioid prescribing and improve the management of people with chronic pain. 25 –27 However, this is not standard practice across the country, and patients in low-resource areas who are taking opioids may fall through the cracks. There may also be variations in how services are run, and there are minimal data on the benefits, harms and cost-effectiveness of such services.
The publication of chronic pain guidelines by NICE in April 2021, 28 the plan to reduce overprescribing by the Department of Health and Social Care, 29 and the aim of NHS England and NHS Improvement to reduce high-dose opioid prescribing by 50% by March 2024 30 will likely increase initiatives to de-prescribe people on opioids. Yet resources for managing people taking opioids remain limited. Therefore, collaborative and coordinated efforts are needed to roll out an evidence-based pain strategy that accounts for all patients in the UK, and which avoids relying on simple de-prescribing as the sole outcome metric. Patients who have developed prescribed opioid dependence following inappropriate long-term opioid prescribing often require psychological support to wean and stop their opioids, with enforced opioid tapers found to be unhelpful and dangerous. 31 A data-driven approach using an open national registry of opioid safety initiatives to collect standardised patient outcome measures would allow for real-time evaluations and best practices to be established.
Conclusions
Mixed public health messages about the opioid crisis may be inevitable in a time of information overload. Clear public health messages that reach the public are needed to prevent a rise in the number of people on long-term and high doses of opioids. The four key messages we describe here should be transmitted to prescribers, such that new patients presenting with chronic pain should not have opioids initiated. When a patient’s acute pain, treated with opioids, becomes chronic, a tapering plan is discussed and implemented. Moving forward, public organisations and individuals, including nurses, doctors and scientists, should work together to get the right messages, to the right people, at the right time.
Declarations
Competing Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SA is the President-Elect of the Pain Medicine Section of the Royal Society of Medicine. GCR is an Associate Editor of BMJ Evidence Based Medicine. GCR received funding from the NHS National Institute for Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation, and the Rotary Foundation to study for a Doctor of Philosophy at the University of Oxford (2017-2020). JQ declares no competing interests.