Europe has much to do to improve the quality of and access to safe pain management – Authors' reply

Abstract

We agree with Patrice Forget and Winfried Hauser that opioid pain medication prescribing has increased substantially in almost all countries in Europe. However, we disagree that this is associated with a substantial increase in opioid-related mortality. Most European countries have stable opioid-related mortality rates, with only slight increases in some countries, primarily in those with an already low opioid-related mortality rate.1Pierce M van Amsterdam J Kalkman GA Schellekens A van den Brink W Is Europe facing an opioid crisis like the United States? An analysis of opioid use and related adverse effects in 19 European countries between 2010 and 2018.Eur Psychiatry. 2021; 64: e47Crossref PubMed Scopus (25) Google Scholar The only exception is the British Isles, especially Scotland.2van Amsterdam J van den Brink W Pierce M Explaining the differences in opioid overdose deaths between Scotland and England/Wales: implications for European opioid policies.Eur Addict Res. 2021; 27: 399-412Crossref PubMed Scopus (13) Google Scholar Thus, the general picture for Europe is that there has been a large increase in opioid pain medication prescribing without a serious, let alone alarming, increase in opioid-related mortality. However, this does not mean that current levels of opioid prescribing are optimal. In fact, opioid prescribing is decreasing in many European countries.3Häuser W Buchser E Finn DP et al.Is Europe also facing an opioid crisis?—A survey of European Pain Federation chapters.Eur J Pain. 2021; 25: 1760-1769Crossref PubMed Scopus (31) Google Scholar This decrease is probably a correction in the right direction, but caution is needed to ensure that unrealistic fears for opioids (opioid phobia) do not lead to suboptimal pain management and unnecessary suffering,3Häuser W Buchser E Finn DP et al.Is Europe also facing an opioid crisis?—A survey of European Pain Federation chapters.Eur J Pain. 2021; 25: 1760-1769Crossref PubMed Scopus (31) Google Scholar, 4Kalkman GA Kramers C van Dongen RT van den Brink W Schellekens A Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study.Lancet Public Health. 2019; 4: e498-e505Summary Full Text Full Text PDF PubMed Scopus (99) Google Scholar which could cause patients to reach out to the illegal opioid market for pain relief, as was the case in the USA. Forget and Hauser state that Europe should improve the quality of pain management. The underlying assumption is that variation in opioid prescribing and mortality rates across Europe reflect a serious variation in the quality of pain management. However, data on optimal opioid prescribing rates do not exist. Variation in opioid prescribing also relates to cultural factors and availability of alternative pain management strategies. Data on patients’ preferences and satisfaction regarding pain management are needed to know in which European countries pain management could be improved and how.5Foy R Leaman B McCrorie C et al.Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics.BMJ Open. 2016; 6e010276 Crossref Scopus (64) Google Scholar WvdB reports personal fees for consultation from Camurus. All other authors declare no competing interests. Europe has much to do to improve the quality of and access to safe pain managementWe have read with interest the debate surrounding opioid use in the USA and related deaths. We also welcomed the different perspectives of Gerard A Kalkman and colleagues,1 concluding that universal health care and addiction care in Europe contributes greatly to preventing an opioid epidemic of US proportions. If we agree with many points, we respectfully disagree that this prevention is homogeneously helping to prevent such a crisis development. The authors mentioned only the opioid crisis in Scotland and, after studying it themselves, acknowledge that it cannot be fully explained, which also means that the opioid crisis remains far from being resolved. Full-Text PDF