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Why hasn’t what is being observed in the USA on opioid addiction been seen here. Could it?

Asked q on twitter yesterday in prep for a research interview I am doing next week for a researcher from Princeton

Very helpful set of responses

Put here in full. Not especially sorted or ordered. Use as you  need to
Why hasn’t what is being observed in the USA on opioid addiction been seen here. Could it?

1. Continuity of record, via GP
2. Expectation* of prescribers, patients & pharmacists that repeat scripts – even privately initiated- default to NHS
3. Patients not seen* as customers
4. Seeing your own* expert generalist (aka GP) regularly (*we’ll soon lose these)
5. no DTCA in UK
6. We’ve not been subjected to intense industry-led ‘pain = fifth vital sign’ campaign. This thread is quite insightful. Look at the graph…..https://twitter.com/COSMakin/status/1213785366119014400?s=09
7. I suspect the lack of a direct financial incentive for prescribing more expensive therapies has played a role.
8. from my viewpoint, as a hospital prescriber of opiates, we use modified release less often than the states, and rarely send patients home with strong opiates. Was shocked to hear US colleague go home with 4 weeks oxycotin post casearean, we usually give none!
9. The big issue with modified release is that they are the 3rd largest risk factor for persistent post operative opioid use. The Australians have banned them for post surgical pain, and the US ‘s FDA have essentially done so too. We should too.
10. I would say Private health care system plays a part. In the UK there isn’t a necessity to satisfy the customer as they do in the US. I also think re-addiction could be a factor as ex addicts are easily prescribed opioids in the US but it’s avoided in the UK.
11. You can buy eg Cocodamol Over The Counter (OTC) albeit dose of codeine is lower than prescription-strength, but there’s a warning on packet exterior not to use for more than (three days?) & seek medical assistance if pain persists, so people will go to see GP/ER as it’s £free.
12. in UK, most people are more likely to take opioids short-term, go to doctor & get underlying cause treated, whereas in US there’s temptation/necessity to defer $$$ treatment & get by with $ pain meds, so they take them longer and are more likely to get addicted?
13. The harm is not equally distributed. It is happening in areas of deprivation where (risky) dependency forming medications are prescribed more frequently and/or for longer (see PHE and lots of evidence prior). Whilst opioid dosages are being reduced in some areas…….we still risk creating another great health inequality iatrogenically. At same time unilateral deprescribing risks the therapeutic relationship and risks pushing patients to street meds of dubious quantity. ….Therefore best not to start prescribing. See RCGP’s Secure Environments Group’s Safer Prescribing in Prisons for traffic light risk assessment as valid outside prisons as in https://rcgp.org.uk/policy/rcgp-policy-areas/prison-medicine.aspx…
14. I’d only add how difficult it can be to get a prescription in England…..for almost anything. Particularly in primary care. Which is much stronger in UK than US. Hard to imagine pill factories in UK. But may be some unmet need..
15. E.g. of packaging here in UK: “* Can cause addiction * For three days use only” http://lloydspharmacy.com/en/lloydspharmacy-co-codamol-8mg-500mg-tablets-32-tablets…
16. I suppose in UK, most people are more likely to take opioids short-term, go to doctor & get underlying cause treated, whereas in US there’s temptation/necessity to defer $$$ treatment & get by with $ pain meds, so they take them longer and are more likely to get addicted?
17. You can buy eg Cocodamol Over The Counter (OTC) albeit dose of codeine is lower than prescription-strength, but there’s a warning on packet exterior not to use for more than (three days?) & seek medical assistance if pain persists, so people will go to see GP/ER as it’s £free.
18. Mix of: Fentanyl, different access/financial relationship pharma-doctors, history of easy access to opioid prescriptions shapes patient expectations. Easier licit access = more available for diversion. If you need more,
19. If you supply addicts with monitored Pharma grade methadone and Pharma grade opioids and keep them steadily supplied, you’ll be fine. If they can’t access then the illegal market will supply, with cheap and deadly Fentanyl you’ll have more dead bodies than us
20. The biggest difference is that we think we have an opioid epidemic but we don’t—we have a Fentanyl poisoning epidemic. Cartenafil etc are many times stronger, and being brought in illegally. When doctors cut patients off legal pharmaceuticals here, patients get illegal ones
21. And then patients die because the illegal ones are 20 times stronger. Post-surgery new patients can be safely prescribed and tapered down. Addicts will never stop, so we need the safest harm reduction possible, which is Pharma made —because illegal injectables DO kill patients
22. In the u.k we now know about rescription opioid addiction and are doing something about it. There was a piece in the Evening standard last year about the prescribing of Opiods and the dangers.
23. Easy access – online pharmacies. Online prescibers
24. Pain management systems
25. Labels and warnings
26. Knowledge: When Crack users were being sold “pow” and were told it was Methamphetamine they started to buy crack elsewhere. When Meth hit the US people didn’t know what they were getting into. We tend to be able to warn people of the dangers before things take off over here….
27. Availability and quality are also a factor. We see things like Krokodil in Russia which is due to not having consistent supply of quality heroin. In the US supply varies, opioids are available and consistent so are far better option for an addict.
28. From what I’ve seen in Canada which has the same problem, and it shocked me when I arrived, GP training and access to psychological support are the main differences I see. GP training in the UK has a significant focus on psychosocial aspects of illness and the hidden agenda, 1/ From Michael Balint’s work. So UK GPs are more ready to recognize that the presentation of illness may have a deeper or comorbid psychological component. In Canada I find there is a strong focus on Emergency Room Medicine by GPs many of whom work also in ER and bring the same 2/ Approaches focusing often on the superficial presentation of illness and the obvious complaints. Even if the psychological aspects are recognized there is little to no resource for high quality counselling and what does exist is psychology for which there are long waits. 3/ Unlike the UK GPs don’t employ counsellors as the billing system wouldn’t remunerate them. The billing system drives a lot of clinical activity directly/indirectly e.g. many patients with a diagnosis of asthma / COPD who haven’t had spirometry bc GPs don’t have spirometers 4/
29. its here but not reported. Youngish people becoming older, distressed by pain on cocktails of opiates, gabapentoids, SSRI and TCA antidepressants and need something more now. Usually been to secondary care services and counselling not helped. Using cannabis and now cannaboid oils at home. Although worse now wont reduce prescribing. How many deaths have their repeat prescription charts examined for unsuspected causes like QT issues? We do not scrutinise for causes of death enough as noone wants postmortems and inquests.
30. IMO You understand this is partly a result if a generation of GP education moving from paternaliatic to shared decision making at the expense of knowledge and letting patients make decisions interplaying with Incompetent national guidance and management from pain clinics?

21.  And there are still too many people on long term opioids where other pain management strategies would be safer and more effective. The reason it’s escalated less than US is they’re not on oxycontin)

Thanks to
@nicholasalevy @JIDMMatheson @doctorsdilemma @AmyMcNTweets @jpraft @DrAnneMurphy @SimonGilbody @Louise243 @EllieHoul @DrCJohn @MccabeCJM @pmw777 @Louise243 @RandomDaveR @pmeiersheffield @janewilcock @RCGPSecureEnvi1  @cleverestcookie

 

Articles
Opioids – The Opioid Timebomb: Are they doing us more harm than good? A special Evening Standard investigation opioids.standard.co.uk https://opioids.standard.co.uk/

Nick Hopkinson review of American overdose

Nick Hopkinson: American overdose

LSE article Why has the US opioid crisis not spread to the UK? Thank the NHS https://blogs.lse.ac.uk/usappblog/2018/02/26/why-has-the-us-opioid-crisis-not-spread-to-the-uk-thank-the-nhs/

Curtis et al – was the key open prescribing data analysis. Note the OME trends https://www.thelancet.com/journals/lanplh/article/PIIS2215-0366(18)30471-1/fulltext

 

this in perioperative use of short term opioids is good  https://www.rcpjournals.org/content/clinmedicine/19/6/441

 

this is good from Cathy Stannard – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590089/

 

Tracing the US opioid crisis to its roots – understanding how the opioid epidemic arose in the United States could help predict how it might spread to other countries’ – https://t.co/NEYEKvMBhE?amp=1

 

Fifth vital sign https://amp.theguardian.com/us-news/2018/mar/30/enduring-pain-how-a-1996-opioid-policy-change-had-long-lasting-effects

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