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Introduction
• A rise in global opioid consumption has led to an increase in negative
consequences associated with prescription opioids
• Opioid analgesic dependence (OAD) has become a global concern but is
poorly documented in Europe
• Populations who misuse over-the-counter (OTC) or prescription only
(POM) opioid analgesics are at risk of developing OAD
• More guidance is required to aid healthcare professionals in the clinical
management of OAD
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Opioid analgesic consumption is increasing on a global
Canadians are the
second largest per capita
consumers of narcotics
and prescription opioids
scale outside of Europe
Opioids were involved in 43% of all
drug overdose deaths in the US in
2010. They were responsible for
more than twice the number of
deaths from heroin and cocaine
combined
Prescription opioids
are the most abused
opioids in Brazil
Non-medical use of
pharmaceutical opioids
doubled between 2007
and 2010 in Australia
Source: INCB report 2012; INCB statistics for 2011, 2012; CM Jones et al. 2013; I Giraudon et
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al. 2013; A Roxburgh et al. 2013. Canadian
Centre on Substance Abuse, Prescription Drugs
http://www.ccsa.ca/Eng/topics/Prescription-Drugs/Pages/default.aspx
The size of the OAD problem in Europe is
poorly defined
An estimated 455,000
people dependent on
prescription opioids in
2013
The true extent of
non-medical uses of
OTC and POM
medications is
unknown: treatment
seekers often cite
OTC/ POM meds as
their drug of choice
17 European countries
reported 10% or more
of first-time opioid
patients entering
specialised treatment
were using opioid
medications other
than heroin
Source: H Alho ISAM 2013; European Monitoring Centre for Drugs and Drug Addic6on.
3 developments. 2014. L Weich et al. 2015
European Drug Report: Trends and
People dependent on opioid analgesics
are different from those dependent on
heroin
Illicit heroin
dependence
OAD
OAD populations may result from:
1. Iatrogenic dependence on prescription only (POM) or over the
counter (OTC) opioid analgesic preparations following treatment for
pain
2. Dependence on illegally acquired/ diverted POM and OTC analgesic
preparations
Source: RGCP 2013 Addiction to medicines Factsheet 4
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6 factors highlight individual OAD risk; personal
family history of dependence is strongest predictor
Personal/ family history
of dependence
Genetic
predisposition
Drug
exposure
Risk
factors
Brain reward
mechanism
alteration
Frequent
prescription
analgesic use, low
pain threshold
Psychological
profile
Source: J Højsted et al. 2007; TJ Ives et al. 2006; MJ Edlund et al. 2007; J
Elander et al. 2014;
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Physical, psychological and social
consequences highlight the importance
of treating OAD
Physical
Psychological
Social
• Vary with opioid
intoxication,
overdose or
withdrawal
• Mood instability
• Loss of employment
• Agitation
• Marital & family
breakdown
• Long term effects:1
• Depression
• Anxiety
• Endocrine
changes
• Hyperalgesia
• Immunological
effects
• Sleep disorders
• Loss of friendships
• Loss of interest in
regular activities
• Financial problems
Source: British Pain Society. Opioids for persistent pain: Good practice. 2010
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Challenges for addiction specialists
in OAD management
• How to help a patient
address their opioid
misuse without
diminishing their pain
control
• How to accommodate
and treat patients that
do not fit the traditional
model of treating street
drug users
Challenges
• Understanding how
these new patients’
needs relate to the
needs of existing
patients
• How to develop
effective and
collaborative joint
working methodologies
with local pain services
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An integrated treatment plan,
multidisciplinary team with adjunctive
therapy is recommended
Team Planning
Adjunctive & psychosocial
therapies
Primary care
physicians
Pain
Integrated
specialists treatment
Mental health
specialists
• Plan psychological and
social support depending
on need
Addiction
specialists
• Consider social problems:
unstable housing, lack of
employment
• Mutual aid services and
support groups might be
useful
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Specific Management Tool
OAD Treatment Algorithm
Treatment
assessment
Treatment
selection
Treatment
monitoring
Recovery from
dependence
• Dependence on opioid analgesics
requires specific management which
is supported by international
guidelines and a body of evidence
• A decision-tool may be useful in OAD
management
• There is an opportunity to improve
outcomes in OAD by making clear
choices in management
• Future work should define better
outcomes in OAD with different
interventions
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