Portugal approach to OUD; trends in opiate prescribing in youth

There was an important article on Portugal's approach to a huge opiate problem: they decriminalized all drugs there in 2001, and this has been associated with a dramatic drops in overdoses, HIV and hepatitis infections, and drug-related crime (see https://www.theguardian.com/news/2017/dec/05/portugals-radical-drugs-policy-is-working-why-hasnt-the-world-copied-it ).

A few details:
-- The rates of HIV infection in Portugal had become the highest in the European Union. The all-time high was in 2000, with 104.2 cases per million population, decreasing to 4.2 cases per million in 2015 (!!!)
-- Rather than being arrested, people with a personal supply of drugs were given a warning, a small fine, or were told to appear before a local commission composed of a doctor, lawyer, and social worker, with emphasis on treatment/harm reduction/support services
-- “Portugal’s policy rests on three pillars: one, that there’s no such thing as a soft or hard drug, only healthy and unhealthy relationships with drugs; two, that an individual’s unhealthy relationship with drugs often conceals frayed relationships with loved ones, with the world around them, and with themselves; and three, that the eradication of all drugs is an impossible goal”, with the underlying concept of protecting and helping people instead of punishing them

--It should be noted that this change took place in a very conservative country, involved fighting off the “just say no to drugs” campaigns as well as an entrenched philosophy by many that those using drugs should be in jail, and has evolved into a major social change that includes street workers going out and recruiting drug users into programs, supplying clean needles, providing support/counseling

--And, one profound general cultural change in approaching drug use more humanely was a language change on a societal scale, where those taking drugs had previously been referred to as ”drogados” (junkies) now became known as people who use drugs or people with addiction disorders (ie, these people were not marginalized as before). These cultural changes took time, but clearly reflect a much more understanding and helpful approach to opiate use.

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A recent article looked at the trends in outpatient opioid prescribing for adolescents and young adults from 2005 to 2015 (see opioid prescribing adol peds2019 in dropbox or doi.org/10.1542/peds.2018-1578)

Details:

-- retrospective analysis of clinical data across the US of opioid prescribing in ambulatory care settings, including emergency dept (ED) visits when the patient was not admitted, for adolescents (13 to 17 years old) and young adults (18 to 22 years old)

-- datasets:

-- National Hospital Ambulatory Medical Care Survey, data on hospital-based ED visits

-- National Ambulatory Medical Care Survey, data on visits to office-based practices

-- study sample included 47,159 ED visits and 31,271 outpatient clinic visits, reflecting a grand total of 197 million visits to the ED and 801 million visits to an outpatient clinic. No significant difference in numbers of visits by year in either setting

Results:

-- 52 million visits by adolescents and young adults resulted in an opioid prescription: 5.2% of the total visits (5.4%-6.0%)

-- ED: 29.4 million opioid prescriptions (57% of total opiates dispensed)

-- outpatient clinic: 22.7 million opioid prescriptions (44% of total opiates dispensed)

-- rate of opiate prescribing:

-- ED visits: 14.9% (14.4%-15.6%) given opioid prescription

-- adolescents: 10.4% were given opioid prescription

-- young adults: 17.9% were given opioid prescription

-- outpatient clinic visits: 2.8% (2.5%-3.1%) given opioid prescription

-- adolescents: 1.6% were given opioid prescription

-- young adults: 4.2% were given opioid prescription

-- some differences by demographic breakdown: slightly more in urban areas; more in the West and South compared to the Midwest, with the Northeast having the lowest opioid prescription rate; more for those who were self-pay or had private insurance; more for white vs other races; similar amounts for male and female

-- opioid prescription rate trend over time, 2005-2015:

-- ED visits: 4% decreased rate, OR 0.96 (0.95-0.98), which translated to a 5% decrease for adolescents and a 2% decrease for young adults

-- outpatient visits: no statistically significant change

-- opiate prescriptions by outpatient clinic specialty:

-- adolescents: general surgery 10.1% were given an opiate, orthopedics 5.6%, other specialties (GI, heme, vascular medicine) 4.4%, ENT 4.1%, internal medicine 3.2%, family practice 2.0%, OB/GYN 0.9%, pediatrics 0.4%, psychiatry 0.1%

-- young adults: orthopedic surgery 11.5%, other specialties (GI, heme, vascular medicine) 8.4%, general surgery 8.2%, family practice 5.8%, internal medicine 4.5%, ENT for 3.5%, psychiatry 2%, OB/GYN 1.7%, pediatrics 0.8%

-- ED opiate prescriptions, by indication:

-- adolescents:

-- dental disorders: 60%

-- clavicle fracture 47%

-- ankle fracture 38%

-- metacarpal fracture 36%

-- neck sprain 18%

-- ankle sprain 16%

-- contusion of face, scalp, neck 15%

-- abdominal pain 10%

-- acute pharyngitis 9%

-- headache 8%

-- young adults:

-- dental disorders 58%

-- low back pain 38%

-- neck sprain 35%

-- backache 33%

-- cellulitis 31%

-- ankle sprain 27%

-- abdominal pain 20%

-- headache 19%

-- UTI 17%

-- acute pharyngitis 13%

-- trends in specific opioids prescribed, from 2005-2015:

-- hydrocodone (most prescribed): mid 60% down to mid 40%

-- oxycodone: pretty consistently around 15%

-- codeine consistently around 10%, but then jumping to 20% in 2015

-- tramadol: 0% until 2011 then increasing to about 15% annually for the duration

Commentary:

-- a few background statistics:

-- drug overdoses (likely related to opioids) are the leading cause of accidental death, with more than 50,000 US deaths in 2015

-- death rates from opioids have tripled since 1999

-- ED visits associated with opioid prescription have increased 183% from 2004-2011

-- in 2014, more than 460,000 adolescents used pain relievers for nonmedical reasons

-- more than 168,000 became addicted to prescription opioids

-- and, as noted in several previous blogs, young adults and adolescents are at particularly high risk for opioid misuse; and prescription opioids are strongly associated with future long-term opioid use as well as progression to heroin use

-- legitimate prescription opioids given to high school students is associated with a 33% increased risk of future opioid misuse as young adults, and that even those 12^th graders prescribed opiates who had a very low likelihood of future addiction by a validated questionnaire had a three-fold increased risk of opioid misuse later (see http://gmodestmedblogs.blogspot.com/2015/10/prescribed-opioids-and-future.html )

--some impressive findings in this study:

-- high rates of overall opiate prescriptions in this young population, roughly 15% of ED visits as well as 3% of outpatient visits

-- consistent with the blog yesterday (see http://gmodestmedblogs.blogspot.com/2019/05/opiate-scripts-by-dentists-us-vs-england.html ), opioid prescribing overall was highest for dental visits, which as noted in this blog can typically be treated just as well with non-opiate pain meds

-- pretty striking amounts of opiates given for muscle sprains and low back pain

-- and, to me, remarkably large amounts opiates given for UTIs, cellulitis, and pharyngitis

-- This study highlights that we need a fundamental cultural shift from our past opiate prescribing, which largely was fed by the likes of Purdue pharmaceuticals and their pushing pain as the 5^th vital sign (along with fraudulent claims that OxyContin, for example, was non-addicting; and clinicians were dramatically undertreating chronic pain; eg see https://www.nytimes.com/2019/01/15/health/sacklers-purdue-oxycontin-opioids.html and http://www.thepoisonreview.com/2012/12/16/the-money-and-influence-behind-pain-as-a-fifth-vital-sign/ ). In fact, not so long ago, the standard therapy for people with coughs, including young children, was to give a codeine preparation. It worked, and both parents and children slept better. now, of course, this is far from standard-of-care

--and, as commented in previous blogs as well, treating opioid use disorders is a real struggle for patients/clinicians/others. the real issue is avoiding the problem in the first place

-- Limitations of the study include the fact that it was a large data-mining study, with no patient-specific data as to why opiates were the chosen therapy; they did not have longitudinal data on individual opiate use or the long-term effects of that; and the data only was available up through 2015.

So, a few comments based on these 2 articles

-- although there has been significant pressure and some changes in opiate prescribing in the past few years (and these may not be reflected in the above trends until 2016), we clearly have a long way to go

-- it certainly seems reasonable to assume that several of these conditions in adolescents and young adults, a group more predisposed to opiate use disorders later, should just be treated differently. In particular dental disorders (as also articulated in the blog yesterday) but also UTIs, muscle sprains, cellulitis, pharyngitis and headaches should largely be able to be treated with non-opiate medications (and certainly not at the level of prescriptions found in the above study). The goal is to avoid prescribing opiates unless there is a compelling reason to do so.

-- the Portugal approach is pretty dramatic: for those with opioid use disorder, decriminalizing opiates was associated with not just decreases in opiate-related medical problems (e.g. HIV), but over time to a much more positive and productive cultural shift on a societal level, away from stigmatizing and driving those using opiates underground and to less safe situations (ie, providing support vs punishment). it remains shocking, from a public health perspective, that more countries have not adopted this clearly successful and more humane approach....

geoff

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