More than five million Britons are prescribed opioid painkillers every year, and new analysis by the York Health Economics Consortium reveals that unnecessary prescribing of these highly addictive medicines is costing the NHS £240 million annually – and the wider economy more than £1 billion a year. There is also a grim human toll, with 40 people a week dying from opioid-related deaths, and the Faculty of Pain Medicine warning that opioid use – and not necessarily misuse – increases the risk of an adverse drug event by 250%.
Postcode lottery in prescribing
Investigators at the York Health Economics Consortium, based at the University of York, also identified a dangerous postcode lottery around prescribing, which suggests that a patient’s postcode, rather than their pain, may play a part in whether or not they are offered prescription opioids. That is why experts are calling for a rethink of the way pain is treated, in order to help tackle one of Britain’s biggest hidden health crises.
In a paper published in the Journal of Community Medicine & Public Health, titled Next-Generation Mild-to-Moderate Pain Management Pathway: A Strategy for Reversing the Opioid Crisis, co-author and pharmacist Mark Burdon warns: “Some of the current analgesic pathways may facilitate earlier escalation to opioids than is necessary and could lead to dependency.”
Risks of long-term opioid use
Opioids – a family of painkillers that includes codeine, morphine, oxycodone and tramadol – can be highly effective for short-term pain, and they are routinely used in cancer and palliative end-of-life care. However, their long-term use is associated with dependence, tolerance and a range of serious health risks.
Dr Nisa Aslam, also a co-author, says: “These medicines are highly addictive and dependency can develop in a relatively short time. Studies show that using opioids for three months or more carries a high risk of addiction, particularly if there is a history of poor mental health or misuse of alcohol or other substances.”
Researchers at the University of Bristol, who analysed data from 148 studies involving more than 4.3 million patients, estimate that one in three people taking opioids for more than three months exhibited “signs and symptoms of dependence”. NHS data shows that in England alone, more than a million people were prescribed opioids for more than three months in 2021, and prescriptions more than doubled between 1998 and 2018 – despite the well-documented risk of dependence and addiction.
Withdrawal and the scale of the problem
Mark explains: “While we have made a lot of progress around the use of opioid painkillers, we cannot escape the fact that in 2019 the UK held the unenviable record of having the highest rates of opioid use in the world, and we are still living with the fallout of that opioid epidemic. That cannot and should not continue.”
Dr Aslam adds: “Dependency and addiction can lead to some very unpleasant side effects when patients try to come off opioids. These include shivers, sweating, body aches, widespread and/or increased pain, diarrhoea, sleep disturbance, nausea, vomiting, agitation, palpitations, abdominal cramps and increased blood pressure, breathing and heart rate. This is why withdrawal from opioids should be carefully tapered, with the dose reduced over many weeks or months.”
Pain is a huge and growing problem for Britons. The British Pain Society estimates that 10 million Brits experience it almost every day. Real-world research for Combogesic found that two out of five people (41%) experience pain on a daily basis, with the vast majority (84%) reporting mild-to-moderate discomfort. A study of pain in general practice found that among patients presenting with a pain problem, around one-third (37%) were experiencing acute pain – where “acute” reflects duration of up to three months, not severity.
Pain is also on the increase, as a result of an ageing population, sedentary lifestyles and rising rates of obesity. Statistical modelling by the Government Office for Science estimates that by 2050, 60% of men, 50% of women and 25% of children under 16 will be obese. Extra weight puts added pressure on the musculoskeletal system, and multiple studies confirm a strong association between obesity and joint and back pain. Obesity has also been linked to fibromyalgia, and studies have found that people who are obese report more severe pain.
Call for updated treatment pathways
Dr Janine David, GP and another co-author of the paper, says: “It’s common for patients to develop a tolerance to opioids and require ever-increasing doses to achieve the same level of symptom relief they experienced initially. In some cases, patients develop hyperalgesia and become more sensitive to pain.”
Despite these red flags, the new paper argues that current pain management pathways are failing patients because they suggest escalating to opioids before all non-opioid options have been explored. The authors believe treatment pathways should be updated to recommend the use of a fixed-dose combination of paracetamol at 500mg and 150mg of ibuprofen per dosage – such as Combogesic – before opioid medicines are considered.
Clinical trials confirm that the unique 3.3:1 ratio of paracetamol to ibuprofen used in Combogesic is 80% more effective than paracetamol alone and 30% more effective than ibuprofen alone. A study in the Journal of Pain Research concluded: “The fixed-dose combination of acetaminophen [paracetamol] and ibuprofen provided greater and more rapid analgesia than comparable doses of either agent alone.”
Worryingly, many may not even realise they are taking an opioid painkiller. Codeine, for instance, is an opioid found in co-codamol – one of the UK’s most widely prescribed painkillers. Mark says: “To give you an idea of the scale of the problem, just over 15 million packs of co-codamol are dispensed every year in England alone, only slightly fewer than paracetamol.”
Codeine can also be found in a number of over-the-counter painkillers, often in combination with paracetamol, ibuprofen or caffeine, although this is not always obvious, so it’s important to check ingredients. Researchers at the University of Oxford have identified 83 different over-the-counter medicines containing the opioid sold in the UK. Between April 2013 and March 2019, 4.75 billion dosage units of codeine were sold in over-the-counter medicines – an average of 72 units per UK resident.
Mark says: “The prescribing patterns and economic data documented in the York Health Economics Consortium report are alarming and should come as a wake-up call to healthcare professionals, prescribers and every arm of the NHS which has a stake in improved pain management.”
Dr Aslam adds: “There is everything to gain from encouraging wider use of the proven fixed-dose combination of paracetamol and ibuprofen that is used in Combogesic. All the evidence suggests that incorporating this clinically proven strategy for mild-to-moderate pain could help to address the UK’s ongoing opioid problem.”
