NHS Opioid prescriptions – a litigation time bomb?
Posted on 28th March 2018
Opioid addiction has been highlighted in the news following a study by the Public Health Research Consortium, which found that the proportion of patients being prescribed opioid painkillers by GPs has doubled in 15 years.
Data held by NHS Digital for 2017 shows 23.8 million opioid painkillers were prescribed to patients across the country compared to 10 million in 2007.
Dr Luke Mordecai, from University College London Hospitals, said communities that are poor or have a large elderly population often have higher prescribing rates. “We also have to remember that GPs are often under pressure and patients demand they get given these strong painkillers,” he added.
There are fears that the UK might see a similar explosion in opioid use to that seen in the USA. Incredibly, drug overdose is now the leading cause of accidental death in the USA – higher than firearm deaths or breast cancer.
During 2016, more than 63,600 overdose deaths in the United States, including 42,249 that involved an opioid (66.4%). That’s an average of 115 opioid overdose deaths each day.
Prescriptions of opioid-based painkillers by doctors in the USA more than doubled between 1992 and 2012. Studies suggest that people who become addicted to the painkillers sometimes turn to heroin.
The White House stated on November 20, 2017, that in 2015 alone the opioid epidemic cost the United States an estimated $504 billion. The US accounts for 5% of the world’s population and 80% of global opioid use.
So is this problem on the rise in other countries? Peter Raiser, deputy CEO of the German Centre for Addiction, told German media this week that he did not see it as likely that Germany was on the verge its own opioid crisis.
Raiser acknowledged that between 200,000 and 300,000 Germans are estimated to be dependent on opioids, but said that “there are two central factors that differentiate Germany from the US.”
“The first factor is that there are much higher requirements here for prescribing opioids. While they are a useful prescription against tumours for people who suffer from cancer, they should never be prescribed for chronic pains, like back pains”. The second factor he named was a greater awareness among German doctors about when patients are becoming dependant on painkillers and what can be done to wean them off the drugs.
So what are the factors leading to the rise of opioid use in the UK?
A study published in the British Journal of General Practice, found that over a 43-month period between 2010 and 2014 there was a significant rise in opioid prescribing. There was a 30% rise in Tramadol prescriptions in that period. It also revealed a north-south divide with nine out of ten of the highest prescribing areas located in the north of England.
Many academic papers are advising that opioids should be reserved for patients coping with cancer pain and short-lived acute pain. However, the widespread prescribing of opioids for people with long-term pain is apparently not adequately supported by evidence because opioids have not been shown to be effective in most chronic pain beyond modest, short-term effects.
There is a strong correlation between chronic pain and socio-economic deprivation, therefore the extent to which the chronic pain might be a symptom of other problems is a significant factor. Despite the risks and evidence that they do not work, the study found that many GPs prescribed opioids because they thought it was unethical to refuse their patients painkillers. I wonder whether they may also be mindful of a complaint or an unpleasant confrontation with an angry, perhaps addicted patient.
Having said that, there is said to be not enough capacity in the specialist pain service to treat these patients with as few as one in five people with problematic pain having access to specialist pain services, and that only 40% of those services offer best practice in the form of multidisciplinary team assessment and treatment.
I have acted in the past for a patient who sustained brain damage due to long term use of benzodiazepines (15 years or so). Another study by the British Journal of General Practice suggests that just under 300,000 patients nationwide are taking benzodiazepines or Z-drugs (zolpidem, zopiclone, and zaleplon, commonly known as Z-drugs) for longer than recommended.
The BNF recommends that benzodiazepines should be prescribed in short courses only and for no longer than four weeks, due to the high risk of dependency, potential adverse neurological and cognitive outcomes and difficulty in withdrawing.
The scale of the problem and the possibility that we could see a US style increase is very worrying. As well as the legitimate market the USA is seeing a huge rise in drugs from so called “pill mills”, local back street drug factories as well as imports of black market drugs such as Fentanyl and Xanax allegedly being smuggled in from Chinese factories.
Litigation with regards to these types of claims has been rare – perhaps due to embarrassment or shame on the part of the affected patient or the belief that they are entirely to blame for their situation.
I would anticipate that we may well see a rise in claims involving opioid prescriptions and perhaps other potentially harmful drugs as public awareness rises on the back of media coverage.