Increase in opiate prescription in Germany between 2000 and 2010: A study based on insurance data

PMV Research Group at the Department of Child and Adolescent Psychiatry and Psychotherapy, University of Cologne.
Deutsches Ärzteblatt International (Impact Factor: 3.52). 01/2013; 110(4):45-51. DOI: 10.3238/arztebl.2013.0045
Source: PubMed


Insufficient data have been available to date on the prevalence of opioid treatment in Germany, physicians' prescribing habits, and the percentages of cancer patients and non-cancer patients among those receiving opioids for an evaluation of the quality of care and an assessment of possible underuse or misuse.
The data analyzed in this study were derived from the statutory health insurance sample of the AOK health insurance company in the German state of Hesse / ASHIP Hesse for the years 2000-2010. For the purpose of this study, prevalence was defined as the percentage of insurees who received at least one outpatient prescription of an opioid (ATC N02A, excluding codeine, levomethadone and methadone). In order to control for population aging, the prevalence was standardized to the German population on December 31(st) of the preceding year and to the age-structure of the population as it was in 1999. Opioid prescribing for cancer was assumed when a cancer diagnosis was documented in the same year in which the opioid prescription was issued.
The percentage of insurees receiving at least one opioid prescription rose over the period of the study from 3.31% in 2000 to 4.53% in 2010, a relative gain of 37%. Opioids were mostly prescribed to patients with non-cancer pain (2010: about 77% of opioid recipients). The percentage of non-cancer patients receiving long-term opioid treatment has also increased over the period of the study.
As opioids are frequently prescribed for non-cancer pain, it cannot be inferred from the observed increase in opioid prescribing that cancer patients are now receiving better opioid treatment than they were before. Further issues of concern are the observed increases in the prescribing of potent immediate release opioids and in the long-term opioid treatment for non-cancer patients, the benefit of which is currently debated.

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    • "Based on German health insurance data, overall consumption of WHO-step III opioids by patients suffering from CNMP increased from 24.1 million defined daily doses (DDD) in 2000 to 107.6 million in 2010 [4]. Underlying reason for this 4-fold increment is increases in treatment prevalence (from 0.18 to 0.86% of the German population, mainly due to an increased use in CNMP such as back pain), and treatment duration (e.g., the proportion of patients receiving opioids for longer than 90 days increased from 4.3% in 2000 to 7.5% in 2010) [4]. The increasing popularity of WHO-step III opioids for CNMP is frequently explained by their pharmacological interaction with endogenous pain relieving systems (going hand in hand with efficacy in a broad spectrum of painful conditions), the lack of analgesic ceiling effects (i.e., doses can be escalated until either desired or limiting effects are reached), and the absence of a significant toxicity to internal organs; although side effects from these drugs are common, they are usually transient and reversible upon treatment discontinuation in contrast to those observed with quite "
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    ABSTRACT: Objective . To describe physicians’ daily life experience with WHO-step III opioids in the treatment of chronic (low) back pain (CLBP). Methods . Post hoc analysis of data from a cross-sectional online survey with 4.283 Germany physicians. Results . With a reported median use in 17% of affected patients, WHO-step III opioids play a minor role in treatment of CLBP in daily practice associated with a broad spectrum of positive and negative effects. If prescribed, potent opioids were reported to show clinically relevant effects (such as ≥50% pain relief) in approximately 3 of 4 patients (median 72%). Analgesic effects reported are frequently related with adverse events (AEs). Only 20% of patients were reported to remain free of any AE. Most frequently reported AE was constipation (50%), also graded highest for AE-related daily life restrictions (median 46%). Specific AE countermeasures were reported to be necessary in approximately half of patients (median 45%); nevertheless AE-related premature discontinuation rates reported were high (median 22%). Fentanyl/morphine were the most/least prevalently prescribed potent opioids mentioned (median 20 versus 8%). Conclusion . Overall, use of WHO-step III opioids for CLBP is low. AEs, especially constipation, are commonly reported and interfere significantly with analgesic effects in daily practice. Nevertheless, beneficial effects outweigh related AEs in most patients with CLBP.
    Pain Research and Treatment 11/2015; 2015(3):1-8. DOI:10.1155/2015/745048
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    • "Long-term opioid therapy (LTOT) has been defined as daily or near-daily use of opioids for at least 90 days, often for many years or for the rest of the life (von Korff et al., 2008). The prescription rates of opioids for patients with CNCP increased in the last decades in North America and in European countries (Sullivan and Howe, 2013; Schubert et al, 2013; Werber et al., 2015). Although opioid therapy for CNCP was recommended by several national guidelines – based on short-term randomized controlled trials and expert consensus – in some circumstances for CNCP (Cheung et al., 2014; H€ auser et al., 2015), LTOT for CNCP remains controversial. "
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    ABSTRACT: Background: No data are available on the prevalence and predictors of (high-dose) long-term opioid therapy (LTOT) and on abuse/addiction of prescribed opioids by patients with chronic non-cancer pain (CNCP) outside North America and Scandinavia. Methods: We analysed randomly selected claims records of 870,000 persons (10% of insureds) in a large German medical health insurance organization during the fiscal year 2012. Results: The prevalence of LTOT prescriptions (defined by at least one opioid prescription per quarter for at least three consecutive quarters) for CNCP was 1.3% of all insureds. The mean daily dosage of LTOT was 58 (SD 79; minimum 0.3, maximum 2010) mg morphine equivalent/day. The percentage of insureds with high-dose opioid prescriptions (≥100 mg morphine equivalent/day) among LTOT insureds was 15.5%. High-dose LTOT (compared to traditional dose) prescription was associated with younger age, male gender, diagnoses of chronic pain disease, somatoform pain disorder, depression and prescription of anticonvulsants. The pooled 1-year prevalence of abuse/addiction of prescribed opioids (defined by hospital stays because of mental and behavioural disorders due to alcohol, opioids, tranquilizers, multiple substances and intoxications by narcotic agents) was 0.008%. Abuse/addiction of prescribed opioids was associated with younger age, diagnoses of somatoform pain disorder, depression and prescription of tranquilizers. Conclusions: The study found no signals of an 'opioid epidemic' in Germany. However, careful selection of patients with CNCP considered for LTOT and continuous evaluation during LTOT are warranted.
    European journal of pain (London, England) 10/2015; DOI:10.1002/ejp.802 · 2.93 Impact Factor
    • "Europe 24 M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 5 ( DCAMC , 2012 , Ruscitto et al. , 2014 , Zin et al . , 2014 , Schubert et al . , 2013 , Bandieri et al . , 1 2009 , Garcia del et al. , 2008 , Poulsen et al . , 2013 , Fredheim et al . , 2010 , Hawton et al . , 2012 , 2 NHS , 2011"
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    ABSTRACT: A panel of nine experts applied multi-criteria decision analysis (MCDA) to determine the relative overall harm to users and harms to others of street heroin (injected and smoked) and eleven non-medically used prescription opioids. The experts assessed harm scores for each of the 13 opioids on each of 20 harm criteria, weighted the criteria and explored the resulting weighted harm scores for each opioid. Both forms of heroin scored very high: overall harm score of 99 for injected heroin and 72 for smoked heroin on a scale of 0-100. The main feature that distinguishes both forms of street heroin use is that their harm to others is more than five times that of the other eleven opioids. The overall harm score of fentanyl (including injection of fentanyl extracted from patches) and diamorphine (medically prescribed form of heroin) was 54 and 51, respectively, whereas that of orally used opioids ranged from 32 (pethidine) to 11 (codeine-containing pharmaceuticals). Injected street heroin, fentanyl and diamorphine emerged as most harmful to users, with the latter two very low in harm to others. Pethidine, methadone, morphine and oxycodone are also low in harm to others, while moderate in harm to users. We conclude that the overall harms of non-medically used prescription opioids are less than half that of injected street heroin. These data may give a basis for precautionary regulatory measures that should be considered if the rising trend in non-medical use of prescription opioids were to become evident in the UK.
    Regulatory Toxicology and Pharmacology 09/2015; DOI:10.1016/j.yrtph.2015.09.014 · 2.03 Impact Factor
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