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The problem with opioids
The problem with opioids Read this article and complete the quiz to earn 1 iFolio hour
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Opioids, including both illicit and pharmaceutical agents, are the most harmful drugs to human health (see Table 1). Use of opioids increases the risk of overdose, infectious diseases, and the onset of other medical and psychiatric conditions.1 Table 1. Types of illicit and pharmaceutical opioids7
Illicit opioids
Pharmaceutical opioids
Heroin Opium
Alfentanil Buprenorphine Codeine Dextropropoxyphene Fentanyl Hydromorphone Methadone Morphine Oxycodone Pethidine Remifentanil Tapentadol Tramadol
There is increasing global misuse of pharmaceutical opioids resulting in rising accidental deaths.1 Evidence from the United States suggests that while the prevalence of chronic pain has remained stable over the past 15 years, the amount of prescription opioids sold has quadrupled.2 Although opioid use in Australia is not at the epidemic proportions of the United States, similar patterns have also been documented. There has been a four-fold increase in the use of opioids in Australia over the past 25 years (4.6 to 18.0 DDD/1000 pop/ day) and the rates of accidental deaths due to opioids (namely, pharmaceutical opioids) have doubled in Australian adults aged 35 to 44 years over the past decade.3,4 Not all opioid use is considered misuse. There are clear indications for pharmaceutical opioids in individuals with acute and cancerrelated pain. However, evidence to support efficacy in chronic pain is inconclusive.5 The Australian Pain and Opioids in Treatment
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western nurse March – April 2020
(POINT) study demonstrated that opioid use in individuals with chronic pain did not improve workplace functionality and was associated with a high risk of adverse outcomes including abuse, dependence, overdose, and death.6 Despite this, studies have shown that almost 44% of opioid prescriptions in Australia are for chronic pain.7 This suggests there is room for further regulation and a greater emphasis on guidelines for prescribing opioids and nonopioid interventions for the management of chronic pain.
PHARMACEUTICAL OPIOIDS There are 13 different types of opioids available for use in Australia (see Table 1). They act on opioid receptors in the central nervous system and the gastrointestinal (GI) tract to reduce the transmission of pain. They also cause respiratory depression, sedation, and GI complications like constipation, nausea, and vomiting.8 The most commonly prescribed opioids in Australia include codeine (in combination with paracetamol), oxycodone, and tramadol.3 Buprenorphine, morphine, and fentanyl are also common.3 Each type of opioid has a different dose equivalent (compared to morphine) and duration of action. Many opioids are available under different trade names, in variable doses, and as combination agents, meaning there are hundreds of different formulations available.5 Variable
use of multiple opioids, including immediate and/or controlled release formulations, and use of opioids in combination with other psychoactive substances has resulted in many opioid-related deaths.1
CONTRIBUTING FACTORS TO INCREASING USE OF PHARMACEUTICAL OPIOIDS A wide range of explanations have been cited for the increasing use of prescription opioids. They include demographic changes, patient characteristics, and factors related to physician prescribing. Demographic factors include longer cancer survival periods and an ageing population, with increased rates of arthritis.10 Individual risk factors for prescription opioid abuse include; • Obtaining multiple prescriptions from different providers and pharmacies • Daily use of high dose prescription pain relief • History of substance abuse • Current mental illness • Living in rural areas • Low income 9 Some suggest that there is a medical culture towards pain that prevents practitioners from questioning an individual’s experience of pain and equates pain management with compassion for patients.5 Other factors, such
