Too much or too little opioid use? A comment on Bosetti et al.

Abstract

Opioids have incredible power to make lives better, as well as destroy them. After the latest US opioid overuse crisis reported by the United Nations (UN) in 2017, several other countries started observing their own opioid consumption tendencies in order to better understand current practices, predict future changes and protect their nations if necessary (International Narcotics Control Board, 2017). The report presented by the UN showed the use of opioid in the United States as being the highest of any country in the world, and more than fifty percent higher than Germany, the second country in the rank (International Narcotics Control Board, 2017). When considering a broader extent of the European continent, as Bosetti et al. (2018) did in their longitudinal analysis published in the latest issue of the European Journal of Pain, it is noted that, besides following the US trend on the rise of opioid consumption, there are still substantial differences in opioid consumption within countries. We would like to compliment the authors on the extent of their discussion, which considers not only the policy barriers imposed by governments, but also the social and cultural characteristics of the prescription and use of these drugs. It specifically caught our attention due to similarities regarding the same phenomenon in Brazil. As in Southern Europe, Brazilian regulation is restrictive, and not only in terms of the formulary availability of opioids. In order to prescribe an opioid, Brazilian physicians must go to the local health surveillance agency and sign up as opioid and amphetamine prescribers. Once registered, they are allowed to withdraw a certain amount of prescription pads monthly, which are numbered. Physicians must stamp all the pages while still in the agency, and each sheet can only be used for the prescription of one medicine for a limited 30-day treatment. Added to this bureaucratic barrier is the lack of adequate training on the responsible use of opioids to treat chronic pain. While in training, medical students are discouraged from using strong opioids except for terminal patients, probably due to the fear of possible addiction. The question that remains is as follows: Are Brazilians suffering from chronic pain? The answer is yes. While high opioid usage is undoubtedly a serious problem, low opioid prescribing can also be a threat. According to de Souza et al. (2017), who performed a cross-national survey, chronic pain prevalence was 39% in the Brazilian adult population and 50% of these people classified their chronic pain treatment as inefficient on pain management. So, how are Brazilians managing their pain? As observed by the National Survey on Access, Use and Promotion of Rational Use of Medicines (Pnaum, 2014), around 25% of Brazilian adults reported being under the use of at least one analgesic. The referred analgesics were mostly anilides, salicylic, pyrazolone derivates or nonsteroidal anti-inflammatories. Opioids counted for less than 2% of these medicines and were represented by codeine and tramadol, weak opioids which do not require a special prescription pad. Furthermore, the use of nonanalgesics for chronic pain treatment, such as tricyclic antidepressants, was almost nonexistent, with a few records for migraine treatment Mengue et al. (2016). Further research on the characteristics of opioid consumption and nonopioid pain management is yet to guide us toward a solution. At present, countries with diverse scenarios could join forces and exchange experiences with an emphasis on caring for patients suffering from pain while avoiding the development of new addiction patterns. In the end, we are all working toward the optimization of pain treatment. All authors have no conflicts of interest to declare. ATF conducted data analysis and drafted the manuscript; CMB contributed to drafting the manuscript; TSDP and SSM critically revised the manuscript.