Use of opioids for chronic nonmalignant pain.
What is the Norwegian
experience?
Based on several papers from
National Competence Center for Complex Symptom Disorders
& Norwegian Institute of Public Health
Supported by
Norwegian Directorate of Health
Research Council of Norway
Central Norway Regional Health Authority
St. Olav´s University Hospital
1
Time Magazine:
The New Drug Crisis: Addiction By Prescription
Illustrasjon fra Time Magazin
fjernet
Se link:
http://content.time.com/time/magazine/
article/0,9171,2015763,00.html
2
27.000 unintended death in 2007
IS- 2077
Bruk av opioider i behandling av
langvarige ikke-kreftrelaterte smerter
Bruk av opioider i behandling av
langvarige ikke-kreftrelaterte
smerter
[Undertittel]
3
Foto fjernet
4
Methods for the studies
• The Norwegian prescription database (NPD)
• All prescriptions from all Norwegian pharmacies since 2004
•
Separated those who use it against cancer pain: palliative reimbursement code
•
Separate those who use it for acute pain by various advanced syntaxes
• Linkage between NPD - Survey of Nord-Trøndelag (HUNT)
•
Weaknesses: We don’t know much about those receiving opioids.
Are they taking it?
•
Strength: NPD includes all persons in Norway prescribed opioids and receive it in
paharmacies
5
Bargraf fjernet
Viser at forbruket av svake opioider er
høyt i Norge og Sverige sammenliknet med
Nederland, Tyskland, Danmark, Finland
og Island
6
Total opioid consumption in Norway
Bargraf fjernet
7
Norwegian Institute of public health.
2014.
Defined Daily Doses were not suitable: Morphine 100 mg, Tramadol 150 mg
Oral Morphine Equivalent Defined Daily Dose (OMEQ) reflects
clinical use better than DDD
Svendsen et al: Palliative Medicine 2011
Bargraf fjernet
Relationship between
the Nordic countries'
consumption become
quite different
The increase in total opioid
consumption becomes much
larger and more realistic
8
DDD/day/1000 inhabitants
OMEQ/day/1000 inhabitants
OMEQ = Oral Morphine Equivalent
2004
16.7
500
2008
17.8
610
% increase
6.7
23.6
What is the prevalence of persons prescribed opioids in Norway?
Fredheim et. al Eur J Pain. 2010; 14: 289
10% (470,638 Norwegians) were dispensed opioids in 2007
What is the fraction using opioids persistently without having cancer?
0,3% (13.220) due to cancer
7% (362 391) received less than 50 DDD / year – used it for acute pain
2% (95 027) received more than 50 DDD / year
1% persistent opioid users
9
What is the prevalence of persistent opioid use?
What kind of doses are they using?
Svendsen et al: Eur J Pain 2012
Illustrasjon
fjernet
10
Strict definition
6547 persons
(0.14%)
>50 mg oral morphine equi.-
Intermediary def.
20679 persons
(0.43%)
>25 mg oral morphine equi.
Wide definition
45141 persons
(0.94%)
>12 mg oral morphine-equi.
Use of opioids at least ½ of
the days during one year
To what extent do they in addition
receive other addictive drugs?
Figur er fjernet
Se:
Mellbye et al:
Acta Anaesth Scand 2012
11
How much do opioid consumption
increase for chronic use? 10% from 2004-07
2004
Non-Cancer
DDD
N
DDD
Short acting strong
880 183
9242
762 567
Long acting strong
1 425 376
5122
1 561 655
Short acting weak
21 639 613
409 622
22 547 197
Long acting weak
710 836
11 236
1,289 119
Patches
300 340
1609
538 250
Fredheim et al. Eur J Pain. 2010
12
2007
To what extent will new users of short-acting weak opioids
develop chronic use? Skurtveit et al: Pain 2011
Illustrasjon er fjernet
2005:
2005-2008:
2008:
13
0,3% persistent users
> 365 DDD/år
>365 DDD/år + > 100 DDD/år med benzo +
> 3 leger
How many new intended long time
users are still on opioids 5 y. later?
24% of the study cohort who were still alive
Fredheim et al. Pain 2012
Bargraf er fjernet
Mellbye et al.
Acta Anaesthesiol
Scand. 2015
Of those who were still on opioids:
21% decreased their annual opioid dose by 25% or more
21% kept a stable dose (± 24%)
34% more than doubled their opioid dose
14
To which extent do persons having
chronic pain use opioids?
From linkage between prescription base and HUNT Survey (46.000):
Fredheim et al. Pain 2013
Of 14,477 people who reported chronic nonmalignant pain:
3% used opioids persistently
12% used opioids occasionally.
85% did not use opioids at all.
• Of those reporting severe or very severe chronic pain:
2680 did not use opioids. 304 used opioids.
15
To what extent have persons taking out
opioids from pharmacies chronic pain?
Fredheim et al. Pain 2013
From linkage between prescription base and HUNT Survey:
• Almost 100% reported chronic pain
• Three quarters of people using opioids persistently reported strong or
very strong pain in spite of the medication
16
How many have probable problemaic
opioid use? Fredheim et al Acta Anaesthesiol Scand. 2009
• 6500 persons are using >50 mg oral morphine equi.- daily
• Of those: 2000 are using >=8 tablets codeine paracetamol daily
Foto av avisartikkel er fjernet
Mona Grim Nordman: 2000 nordmenn har et Paralginproblem Artikkel i VG 1. desember 2009 side 16]
17
Use of opioids for chronic nonmalignant pain in Norway. Summary
•
•
•
•
•
•
•
•
18
10% use opioids every year.
8% use it against acute pain.
1% use it against chronic pain.
60% of these co-medicating with benzodiazepines and/or z-hypnotics?
Problematic
About 0,1% have a definite problematic opioid use
An increasing trend (10% 2004-2007) is now declining
Few person use it without having pain?
The chances that codeine-use should provide addiction, is small
(~ 0.1%)
What is new in the new guideline?
• It is warned against combining with other addictive, also z-hypnotics
• Recommend monotherapy (not more than one opioid, no other
addictive drug) and argue against “break through pain-treatment”
• It is no longer recommended long-acting rather than short-acting
• It set an upper limit of 300 mg oral morphine equivalents
19
Bruk av opioider i behandling av
langvarige ikke-kreftrelaterte smerter
The study group
Olav Fredheim
Svetlana Skurtveit
Harald Breivik
Tormod Landmark
Milada Mahic
Kristian Svendsen
Andreas Mellbye
Line Pedersen
Arve Nordbø
Pål Romundstad
Ola Dale
20
How many receive an opioid with reimbursement for chronic non-malignant pain?
L. Pedersen Tidsskr Nor Laegeforen. 2012
• 1,9 % of the population (90 731) received an analgesic with
reimbursement
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Følgende informasjon var gitt:
Medikament
Pregabalin:
Gabapentin:
Amitryptiline:
NSAIDs:
Paracetamol:
Opioids:
21
Antall personer
8112
16507
20654
25864
33242
6875