Europe's silent opioid epidemic
As opiate addiction continues to grip the United States – killing more than 100 people per day in 2016 – researchers are trying to get a handle on the scale of the problem in Europe.
The US is grappling with a major crisis driven by dependency on opioid painkillers such as fentanyl. These highly addictive prescription drugs are chemical cousins of heroin, morphine and methadone.
Strong opiates are tightly controlled in Europe but several EU countries allow over-the-counter sales of a milder pain medication: codeine. While less dangerous than heroin or fentanyl, codeine is turned into morphine in the liver and can still be toxic in high doses.
'It's a hidden addiction,' said Dr. Michael Bergin of Waterford Institute of Technology, Ireland. 'Codeine abuse affects people with diverse profiles, from children to older people across all social classes.'
Some are children who got hooked on cough medicine that contains codeine – although these products are not recommend for children. Others are heroin and morphine addicts who use codeine as an occasional substitute for harder opiates.
'But we have also identified middle-aged respectable women who became addicted to codeine having used it for pain relief or, in some cases, anxiety,' Dr. Bergin explained.
Globally, demand for codeine is high and rising – up by approximately 27% over the last decade, although precise data on codeine use is hard to come by. Information on sales is deemed by companies to be commercially sensitive and, as the painkiller is often paid for directly by consumers rather than reimbursed by a medicines payment scheme, there is no central database tracking how many people are using it, nor how much they are buying.
One project, CODEMISUSED, set out to understand how widespread codeine abuse is by interviewing users, pharmacists and doctors. It found that access to the drug varies widelyacross Europe, with pharmacists in some countries requiring a doctor's prescription before they can dispense it.
In other jurisdictions, codeine is sold on demand. Several countries allow over-the-counter sales but apply limits to how much can be purchased and provide pharmacists with guidelines on how to limit abuse. Online sales have also grown strongly, according to researchers, with patients obtaining the drug without needing to engage with health professionals at all.
An online survey of 450 codeine users found high levels of craving among regular users. The research, conducted by King's College London, UK, and Waterford Institute of Technology, found 20% of respondents were dependent on codeine.
In-depth interviews by the Waterford-based research team found codeine addicts sometimes combine the drug with alcohol and other drugs. Users said they turn to over-the-counter codeine at the first sign of pain, anxiety or stress, some referring to it as 'my helper' and 'companion'. However, several interviewees were surprised to learn that a relatively accessible product was addictive and a member of the opiate family.
For community pharmacists, codeine abuse is a real challenge. The drug has legitimate uses, making it difficult to refuse a customer who may be taking codeine appropriately. 'Codeine addicts speak about what they call pharmacy hopping or pharmacy tourism,' said Dr. Bergin. 'They would go from one pharmacy to another, sometimes buying 40 or 50 boxes in a single day.'
Dr. Pádraig McGuinness, superintendent pharmacist of the CARA Pharmacy group, who worked with CODEMISUSED, said a brief intervention – warning the patient of the risks of opiate addiction – can be more effective than flatly refusing to sell it. 'The customer may simply go down the street or to a different town with a different story,' he said.
One solution examined by the project could be to implement an online tracking system similar to one introduced in South Africa, which allows pharmacists to share data on codeine purchasers and cap sales to any individual at 4 grams per month.
CODEMISUSED, which finished last year, published an extensive review of best practices and innovative approaches to balancing access to codeine with reducing the risk of addiction. These include manufacturing formulations of codeine that are less easily converted to the stronger opioid injectable deso-morphine, public information campaigns, tighter surveillance of codeine sales, training for pharmacists to help them identify codeine dependency, and responsible prescribing practices where prescriptions are required.
Doctors also play a crucial role in recommending codeine and in identifying dependency. As health professionals with long-standing relationships with patients, they are well-placed to tackle addiction but are also in the difficult position of having to refuse or moderate the use of painkillers for people in their own community.
Better training could help them play a more decisive role. A survey of almost 400 medical professionals carried out by CODEMISUSED found that 77% of doctors routinely reviewed patients prescribed codeine, but only 21% said they were confident in identifying codeine dependence. Three-quarters said more instruction on alternative pain management options would be valuable.
The role of educating general practitioners (GPs) in managing addiction is the focus of a separate project, BEAMED. Through a collaboration between Ireland and Canada, researchers are testing a specialised training programme used in Canada in a European context.
'GPs are well placed to identify and treat mental health and substance use problems,' said Dr. Walter Cullen, professor of urban general practice at University College Dublin (UCD), Ireland.
'Improving the identification and treatment of addiction-related issues through education and training is a global challenge. The lessons from this programme (in Canada) will be examined to inform future developments in the EU.'
Across Europe, family doctors have a growing role in addiction, ranging from the provision of methadone for opioid users to managing other addictions such as alcohol and nicotine.
The British Columbia Centre on Substance Use has developed an addiction medicine fellowship which equips health professionals to lead state-of-the-art addiction services. By borrowing from this model, services in Ireland and other EU countries can be improved, according to Dr. Jan Klimas who works at the University of British Columbia in Canada and UCD.
'By applying proper training, evidence-based tools and resources, the pool of addiction specialists will increase,' he said. 'This will help to identify drug use earlier, preventing its escalation to substance use disorders and reducing the number of patients in need of treatment.'