Dr. Wolter criticizes that the key recommendations of the guidelines do not adequately cover measures to filter out patients in whom the use of opioid analgesics is contraindicated because of previous addictions or who require special precautionary measures for that reason.
The long version of the guidelines contains the recommendations to take a psychosocial history (including addiction history) and to rely on participative decision-making when deciding on the indication for opioid treatment (1). Discontinuation of opioid analgesics if treatment targets are not met as well as gradual discontinuation of opioid treatment when patients misuse the prescribed opioid analgesics despite supportive treatment by an addiction specialist are actually key recommendations of the guideline. Furthermore, the long version of the guidelines contains recommendations regarding the management of patients with current substance abuse and regarding opioid withdrawal (1). Therefore, the authors of the guidelines believe that the addiction medicine aspects are adequately covered in the guideline.
There is no evidence to support an “opioid epidemic” in Germany. In the United States, opioid prescriptions climbed sharply by 400 percent between 2000 and 2010, accompanied by a rise in the numbers of opioid-associated hospital admissions and deaths (2). In Germany, long-term prescriptions of opioid analgesics for non-cancer pain increased by 23 percent during the same period (1). An expert group established by the Federal Government of Germany analyzed data from various sources (surveys of pharmacists and addiction recovery centers, health insurance data, Federal Criminal Police Office data) and found no evidence of tilidine or tramadol abuse in any significant numbers (3).
Case series of German pain centers revealed no problem behavior with regard to the way patients on long-term opioid treatment took their medication (1). Thus, no evidence is available to support the claim that one third of the patients receiving opioid analgesics for the treatment of non-cancer pain suffer from an “opioid use disorder”.
In line with Dr. Wolter’s concerns, the recommendations of the guidelines are intended to prevent an “opioid epidemic“ from happening in Germany.
Footnotes
Conflict of interest statement
PD Dr. Häuser owns mutual stock funds that may contain pharmaceutical company stock. He has been paid for serving on an advisory board for Daiichi Sankyo. He has received lecture honoraria from the Abbott, Janssen-Cilag, MSD, Sharp & Dohme, and Pfizer companies.
References
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