Opioid prescription patterns in Germany and the global opioid epidemic: Systematic review of available evidence

Abstract

Introduction Opioids are one of the most important and effective drug classes in pain medicine with a key role in most medical fields. The increase of opioid prescription over time has led to higher numbers of prescription opioid misuse, abuse and opioid-related deaths in most developed OECD (Organisation for Economic Co-operation and Development) countries around the world. Whilst reliable data on the prevalence of opioid treatment is accessible for many countries, data on Germany specifically is still scarce. Considering Germany being the largest country in the European Union, the lack of evidence-based strategies from long-term studies is crucial. The aim of this work is to review and summarise relevant published literature on the prevalence of opioid prescription in Germany to adequately inform health policy strategies. Methods A systematic review of the epidemiology of opioid prescription in Germany was conducted, searching PubMed and Web of Science. Eligibility criteria were defined prior to conducting the search. Literature concerning Germany, published in English and German was included and the search was replicated by three independent researchers. Two levels of screening were employed. Disagreement was resolved by face-to-face discussion, leading to a consensus judgement. Results Our electronic search yielded 735 articles. Reviewing titles and abstracts yielded 19 relevant articles. Three authors examined each article’s full text more closely and determined that twelve papers should be included. Of the twelve identified studies—with publication dates ranging from 1985 to 2016—six were retrospective cross-sectional studies and six were retrospective repeated-measures cross-sectional studies. Sample sizes ranged from 92,842 to ≈ 11,000,000 participants. Data sources of included studies showed vast heterogeneity. The reviewed literature suggested an increase in the number of patients with opioid prescriptions and defined daily doses of opioids per recipient in Germany over time. The majority of opioid prescriptions was used for patients with non-cancer pain. Opioid use was more common in older people, women and in the north of Germany. Fentanyl was shown to be the most prescribed strong opioid in outpatient settings in Germany, despite not being the first-line choice for chronic pain conditions. All data published before 2000—but none of the more recent studies—suggested an insufficient treatment of pain using opioids. There were no signs for a current opioid epidemic in Germany. Conclusions Despite some limitations of the review and the heterogeneity of studies, it can be stated that the number of opioid prescriptions overall as well as the number of people receiving opioid treatment have increased over time. Most prescriptions were found to be for strong opioids and patients with non-cancer pain. Even though patterns of opioid prescription follow trends observed in other developed countries, there are...

Ranking the Harm of Psychoactive Drugs Including Prescription Analgesics to Users and Others–A Perspective of German Addiction Medicine Experts

“…It is interesting to note that opioid analgesics were not within the top ranks of harmful drugs. This could perhaps be related to the fact that an "opioid epidemic" (such as that in the USA, Canada and Australia), is yet not apparent in Germany or in Western Europe (35)(36)(37)(38). The relatively low harm rankings of prescription opioids in our study stand in stark contrast to the high level of stigmatization of illicit opioids.…”

The Trends in Opioid Use in Castile and Leon, Spain: A Population-Based Registry Analysis of Dispensations in 2015 to 2018

“…The nontherapeutic use of opioid analgesics has increased in the last 15 years, to the point where it is now perceived as a serious public health concern [1]. An increase in the number of cases of misuse, abuse, and death in most developed countries has been noted and attributed to the increase in opioid prescriptions [2], even considering disparities between world regions (the medical and nonmedical use of opioids have increased to a lower degree in Europe and Australia compared to Canada and the USA [3][4][5]). Whatever way we look at it, the problem is real: in Canada, between 2016 and 2017, accidental deaths due to the misuse of fentanyl or fentanyl analogues increased by 81% [2]; in the USA, in 2017, 11.4 million people aged 12 years or older misused prescription opioids and 47,600 people died from opioid overdose [6].…”

“…An increase in the number of cases of misuse, abuse, and death in most developed countries has been noted and attributed to the increase in opioid prescriptions [2], even considering disparities between world regions (the medical and nonmedical use of opioids have increased to a lower degree in Europe and Australia compared to Canada and the USA [3][4][5]). Whatever way we look at it, the problem is real: in Canada, between 2016 and 2017, accidental deaths due to the misuse of fentanyl or fentanyl analogues increased by 81% [2]; in the USA, in 2017, 11.4 million people aged 12 years or older misused prescription opioids and 47,600 people died from opioid overdose [6]. Clinicians, researchers, policy-makers, and drug developers from all over the world are aware of the problem: in October 2017, the USA declared the opioid epidemic a national public health emergency [7], according to data showing that opioids are the eighth most common cause of premature death [2].…”

“…Whatever way we look at it, the problem is real: in Canada, between 2016 and 2017, accidental deaths due to the misuse of fentanyl or fentanyl analogues increased by 81% [2]; in the USA, in 2017, 11.4 million people aged 12 years or older misused prescription opioids and 47,600 people died from opioid overdose [6]. Clinicians, researchers, policy-makers, and drug developers from all over the world are aware of the problem: in October 2017, the USA declared the opioid epidemic a national public health emergency [7], according to data showing that opioids are the eighth most common cause of premature death [2].…”

<p>Regional Differences in Opioid Prescribing in Germany – Results of an Analysis of Health Insurance Data of 57 Million Adult People</p>

“…Opioids are essential drugs in the treatment of acute and chronic pain conditions. [1][2][3] Over the last decades, rising opioid use has been reported especially for chronic non-cancer pain conditions 4,5 although in these indications opioid treatment was only associated with small improvements compared with placebo according to a recent meta-analysis. 6 Since the 1990s, opioid use increased substantially in North America but also in Europe including Germany.…”