The opiate crisis is still in full swing in North America, but what about in the Netherlands?

Here too, opiate use increased at an alarming rate from the end of the last century. And with that, fears of ‘American conditions’ also grew. But that doomsday scenario seems averted.

In The Lancet Last week, experts were very clear: the American opiate epidemic is very much alive and threatens – without intervention – even to assume pandemic proportions. The scientists draw attention to a major, but by no means new, problem: the American opiate crisis has its origins in the 1990s, when the pharmaceutical industry almost aggressively encouraged the low-threshold use of opiates, falsely claiming that some opiates were by no means addictive, did not shy away from them. It led to an explosive increase in the use of opiates. Millions of North Americans became addicted, and nearly 600,000 people in the US and Canada have died from opioid overdoses since 1999.

Growing problem

And the problem is still growing, researchers say The Lancet† With more than 76,000 North American deaths from opiate overdose, 2020 was the deadliest year since the start of the opiate crisis. And the total number of deaths in North America from opioid overdose is expected to double to 1.2 million before 2030. Moreover, the researchers emphasize, the opiate crisis is no longer a typical American problem. In more and more countries, opiates are prescribed more freely and their use – just like the (addiction) problems that this entails – is increasing. And so the opiate epidemic – to use epidemiological terms for a moment – ​​is beginning to take on pandemic proportions.

The Netherlands

The use of opiates has also increased considerably in the Netherlands since the end of the last century, says Dr. Mette Heringa, pharmacist-researcher at SIR Institute for Pharmacy Practice and Policy† “That was the result of an accumulation of factors. At that time, for example, new opiates came onto the market that were – unjustly, as it turned out later – presented by pharmaceutical companies as being less addictive and therefore a safer alternative to morphine. In addition, the culture surrounding pain also changed: it was felt that patients should not have pain and pain was measured and treated more actively in hospitals. Finally, during the same period it also became clear that less strong painkillers (NSAIDs) in the elderly relatively often led to stomach bleeding and cardiovascular disease, and doctors were therefore urged to be careful when prescribing them. It had a shifting effect: the less strong painkillers were regularly exchanged for opiates.” All this together led to a fivefold increase in the use of opiates in the Netherlands between 2010 and 2020. For example, in 2018 about 1 in 30 Dutch people was prescribed an opiate.

These are impressive figures, but that means that opiate use is still 4 to 5 times lower than in the US. “That’s partly because our health care system is structured differently, but also partly because pharmaceutical companies in the US are allowed to target consumers directly with their advertisements, which is not allowed in Europe,” says Heringa. “Finally, it is also the case that in terms of opiate use, we lagged behind North America somewhat, and as a result, at a slightly earlier stage, we also gained insight into the problems that arose in America due to opiates and were then able to intervene earlier.” But although American situations could be averted, things sometimes went badly wrong in the Netherlands in individual cases. “There is an increase in people who end up in hospital with an opiate overdose,” says Heringa. “Fortunately, we are not seeing the opiate-driven social disruption seen in the US, which arose as the illicit use of opiates – and with it the risk of overdose – increased.”

Flattened

The figures now tentatively suggest that the use of opiates in the Netherlands is leveling off somewhat. “And it may even decrease somewhat – although measuring opiate use in times of corona is somewhat difficult,” Heringa notes. The flattening or decrease is undoubtedly due to a bit of awareness. “In recent years you have seen that there is a lot of attention for opiate use. It is also increasingly being agreed at regional level to be more cautious about prescribing opiates, for example around operations.” They are fairly simple ways to limit the number of new opiate users. However, it is a lot more difficult to tackle existing use. “You cannot tell a patient today that he or she has to stop tomorrow. That requires that you reduce use, perhaps find alternatives and also provide good guidance to the patient.”

TATTOO

Although the leveling figures are optimistic, the problematic use of opiates has not yet been resolved. In order to get a better grip on it and to better help people with an opioid addiction, the research project was therefore launched in 2019. TATTOO †Tackling And Preventing The Opioid Epidemic) started with a subsidy from NWO. The research project – in which scientists from various universities, healthcare institutions and professional and patient associations join forces – will run for five years and has different perspectives. “For example, Radboudumc is conducting research into how best to reduce opiate use in the event of addiction,” says Heringa, member of the TAPTOE research team. “And Utrecht University is looking at how an addiction develops from a patient perspective, while Leiden University is conducting research into alternative painkillers (for example, a combination of existing painkillers).

The goal of TAPTOE is clear: to prevent ‘American situations’ without patients suffering unnecessary pain. Although the research project is still in full swing, Heringa is optimistic that it will succeed. “But it remains to be vigilant.” Because there will always be patients or situations that require opiates and therefore it is impossible to completely ban them. It means that doctors need to make careful considerations when considering prescribing opiates. The same applies if they consider phasing out an opiate user. “You don’t want to push someone into illegality,” Heringa notes. “And so it remains a balancing act: looking for the right drug in the right dose for the right patient and with the right guidance. And in that respect, there is certainly still something to gain in the Netherlands.”