More than half a million people in England have taken prescribed opioid painkillers for three years or more, Public Health England (PHE) has said.
In a major new report into dependence on – and withdrawal from – prescription medicines, PHE found 23% of people prescribed opioids in March 2018 had been taking them continuously for 36 months or more, equating to around 540,000 patients in total. A further 3% (approximately 80,000 people) had a continuous prescription for 35 months.
Opioid painkillers, which come from the same family as heroin, can be highly addictive. They are prescribed for a wide variety of reasons, from pain relief after an operation to the management of severe period pain. The length of time a person takes opioids for is a significant risk factor for addiction.
A worrying trend emerging from the PHE report is that dependence on prescription medicines (opioids included) is strongly linked to deprivation.
The prescribing rate of opioids for individuals in the most economically deprived areas of England was approximately 1.6 times the rate for those in the least deprived, the report found. Those living in the most deprived areas were also more likely to be on a prescription for a year or more.
The opioid crisis in the US – where 130 people are dying every day from opioid overdoses – is well documented, but the potential scale of the problem in the UK is not fully known.
It was hoped the latest report from PHE would provide more clarity on the issue. However, the health body caveated that while long-term prescribing is “likely to result in dependence or withdrawal problems”, it is not possible to put an exact figure on the prevalence of dependence and withdrawal from the current data.
Opioid painkillers work by stopping pain signals from travelling along the nerves to the brain. They can come in multiple forms, including tablets, syrups and as solutions for injection. While more potent opioids such as morphine and strong codeine are only available on prescription, lower strength opioids are available from pharmacies over-the-counter.
Tolerance to opioids can build up, meaning patients or recreational users sometimes take high doses to get the same effects or to avoid withdrawal symptoms, which can include nervous tremors, anxiety, sleep disorders, vomiting and diarrhoea.
Opioid prescriptions in England rose from the mid-1990s to 24 million in 2016, before starting to fall again. A total of 5.6 million people in England received a prescription for opioid pain medicine between 2017 and 2018.
Despite decreasing rates in prescribing over time, the report from PHE flagged worrying trends among the population, including an increase in prescribing among every age group. The oldest age group had around nine times the prescribing rate of the youngest age group.
Jane, 48, from Oxford, developed an addiction to the opioid drug tramadol when she was prescribed it by a GP to ease chronic back pain in her early thirties. “The GP made no mention of the downsides of tramadol,” she tells HuffPost UK.
She moved house into a rental property and temporally registered with a second GP, who continued to refill prescriptions of tramadol as she requested them. It wasn’t until Jane moved house again that a third GP explained the risks of the drug she’d been taking.
“Once I realised I was addicted, I then realised what it had done to me: huge mood swings, weight gain, gut problems.”
“The third GP refused to prescribe tramadol and explained that it was ‘medicinal heroin’ and that it was designed to be taken for a very short period or as palliative treatment,” she says.
“My reaction was both shock that this had happened but also panic that something that managed my pain was being taken away.”
On that visit, Jane realised she had developed a dependance on the drug and was experiencing withdrawal symptoms. “Once I realised that I was addicted, I then realised what it had done to me: huge mood swings, weight gain, gut problems. It made me very stressed as I wanted to come off the drugs immediately,” she says.
It took her two months working alongside the third GP to transition off the painkiller.
There are wide-ranging and complex issues surrounding the prescribing of opioids, says Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners (RCGP).
“GPs don’t want to prescribe medication long-term unless it is essential and most patients don’t want to be taking medication long-term, but there will always be some patients for whom medication is the only thing that helps with distressing conditions such as chronic pain.”
She said GPs need to be able to give patients better access to alternative therapies in the community, and called for more high-quality research into alternatives to drug therapies, as well as around dependence and withdrawal.
When it comes to the bigger picture, prescriptions are only part of the problem. Both men and women previously told HuffPost UK they developed opioid addictions after being prescribed painkillers, then began using the drug – bought over-the-counter – beyond the recommended dosage recreationally.
Mike, 37, who preferred not to share his surname, was initially given a prescription for codeine by his GP in 2008 while recovering from a broken hand. What followed was a nine-year struggle with addiction, which was fed by purchasing multiple over-the-counter codeine-based products – such as co-codamol – and mixing them.
“At the time I didn’t realise I had an underlying anxiety issue. Codeine made me feel less anxious. It made me feel really calm and like my head went warm. It’s a really nice feeling,” Mike, who is from Manchester, said.
Over time, his misuse became more frequent, to the point where he lost his driving licence, relationships with friends and family, and almost lost his job. “It can ruin lives,” he said.
The PHE report also looked at prescribing patterns of benzodiazepines (mainly prescribed for anxiety and insomnia), Z-drugs (for insomnia), gabapentinoids (neuropathic pain), and antidepressants (for depression).
Professor Paul Cosford, Emeritus Medical Director at PHE, said: “This report shows that while the vast majority of new prescriptions for these medicines are for short term use, within clinical guidelines, it also highlights significant numbers have been taking these medicines for a long time.
“It is vital that clinical guidelines for prescribing are followed and regular reviews with patients take place to address this.”
PHE has created an action plan to address the problem, focusing on education and treatment. Recommendations, developed with medical colleges, the NHS and patients who have experienced long-term problems, include: giving doctors insight on prescribing behaviour in their local area; updating clinical guidance for medicines associated with dependence and withdrawal; and providing guidance on how to support people who are addicted.
The Medicines and Healthcare Products Regulatory Agency (MHRA) will also ensure packaging on opioid medications carry a warning that informs patients about the risk of addiction.
Rosanna O’Connor, director of Alcohol, Drugs, Tobacco and Justice at PHE, said: “We know that GPs in some of the more deprived areas are under great pressure but, as this review highlights, more needs to be done to educate and support patients, as well as looking closely at prescribing practice and what alternative treatments are available locally.
“While the scale and nature of opioid prescribing does not reflect the so-called crisis in North America, the NHS needs to take action now to protect patients.”