Opioids — will Europe avoid the crisis seen in the United States?

The Stanford-Lancet Commission noted in its report of 2 February 2022 that almost 600,000 people had died already from opioid overdoses in the United States and Canada. It predicted that deaths would increase by a further 1.2 million by the end of 2029.

Understandably, healthcare professionals across Europe were deeply concerned that an epidemic of addiction, hospitalisations and overdoses would overwhelm healthcare systems.

In March 2022, the Lancet (“Opioid Overdose Crisis: Time for Radical Rethink”) noted that in England, opioid prescriptions had risen by 34%, whilst hospitalisations had increased by nearly 50% between 2008 and 2018. 

Concluding that Fentanyl — a synthetic opioid — was particularly dangerous, it called for a fresh, joined up approach to include housing and employment support and consideration of safe “user centres” allied to the wider availability of Naloxone — a tried and effective drug used to reverse the effects of overdoses.

Types of opioids and health risks

Examples of opioids include morphine, tramadol, fentanyl, heroin and methadone. They include compounds extracted from poppy seeds as well as semi-synthetic and synthetic compounds which can interact with opioid receptors in the brain. Not only can opioid use lead to dependency, but it can also lead to breathing difficulties and overdose.

The World Health Organisation (WHO) states that, globally, half a million deaths each year are attributable to drug use — of which 70% are related to opioids. 

Will Europe follow suit?

Whilst the Lancet report of March 2022 points to ostensibly worrying trends in both description and hospitalisations, other research conducted by Professor Humphreys and Others (“Responding to the Opioid crisis in North America and beyond — recommendations of the Stanford-Lancet Commission”), paints a more optimistic picture.

Their research, whilst noting an increasing trend in the prescription of opioids, found no evidence of a “substantial” increase in opioid adversities in European countries — whether measured by dependency, hospitalisation or overdose deaths — the one exception being Scotland.

They found significant differences between the US and European healthcare systems, identified as follows:

• For the most part, in Europe, the population does not have to choose between care which is “appropriate” (at often high cost) as opposed to cheaper care — for example the prescription of opioids to manage pain but not treat the underlying cause.
• That European healthcare is more centralised than the US with GPs central to healthcare, acting as “important gatekeepers” to specialist care and thereby minimising the risks of over-prescription.
• Evidence-based addiction care is more widely available in Europe than the US.

Scotland

Figures released by Public Health Scotland showed almost 1,200 drug-related deaths in 2018 with opioids implicated in 77% of cases. Of that number, 41% had been prescribed an opioid substitute — an increase from 21% in 2009.

Research led by Van-Amsterdam J et al (“Opioid overdose deaths between Scotland and England/Wales — implications for European opioid policies”) was published in European Addiction Research in 2021. The researchers found the main drivers to be a combination of a population having a higher involvement in opioid use, notably methadone, and more “poly-drug use” — with benzodiazepine heavily implicated.

Comment

The conclusions drawn by the researchers are based on the fundamental differences between the healthcare systems of the US compared to Europe — most notably over the provision of appropriate and not “cheapest” care. 

Scotland’s position remains distinct and different to the rest of Europe. Here, the Scottish Government announced a “National Mission” in January 2021 to reduce Scotland’s ‘unacceptable drug death rates’.

Viewed in the round, there are grounds for optimism that Europe will not be overwhelmed by a crisis, which it is estimated will cost over a million lives in the United States and Canada by the end of this decade.