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The use of opioids, a group of powerful painkillers, for chronic pain has been on the rise in the Netherlands in recent years. Yet, evidence supporting their long-term effectiveness is lacking. Moreover, prolonged use can lead to serious side effects. PhD candidate Lisa Davies explored how Dutch patients experience opioid use and the care surrounding it. Her research highlights a need for better information when opioids are first prescribed, as well as more support in tapering off the medication. Davies defended earlier this month.

Opioids, powerful painkillers like morphine, oxycodone, fentanyl, and tramadol, are commonly used to treat short-term severe pain, such as after surgery or in cancer patients. While it is possible to use opioids safely, they also carry risks. In the United States, opioid addiction has become a major public health issue, with around 82,000 opioid overdose deaths reported in 2022 alone.

Chronic pain

There is no opioid crisis in the Netherlands, but prescriptions for these painkillers have been on the rise in recent years. As of 2020, over one million people were prescribed opioids annually, and the number of hospitalizations and deaths related to these drugs has also increased.

It is important that people understand that physical dependence and tolerance will always occur, no matter the person or their background.

“We are seeing opioids increasingly prescribed for chronic pain, pain that lasts for an extended period,” Davies explains. “In these cases, the pain often does not go away, so patients end up using the medication long term.”

Side effects and dependency

Like other medications, opioids come with side effects. In the short term, these can be unpleasant, including constipation, drowsiness, and dry mouth. Over the long term, however, the effects can become more serious, leading to issues such as tooth decay, a higher risk of falling, and even life-threatening breathing problems.

Moreover, long-term use of opioids inevitably leads to physical dependence, which causes withdrawal symptoms when the medication is stopped, and tolerance, meaning higher doses are needed to achieve the same effect. “That does not necessarily mean someone is addicted,” Davies emphasizes. “But it is important that people understand that physical dependence and tolerance will always occur, no matter the person or their background.”

Long-term use

A survey of 1,605 patients, along with interviews conducted with 50 patients, showed that most patients receive adequate information about opioid use and expected pain relief. However, people are often not sufficiently aware of the benefits and risks associated with long-term use of these medications.

“People receive painkillers for legitimate reasons, like pain after surgery,” says Davies. “But when the pain continues and patients mention this to their doctor, they often get a repeat prescription without any discussion about the side effects and risks of long-term use, or how tapering off the medication works.”

Guidance during tapering

Patients also say they want more support during the tapering process. “People often feel anxious about quitting opioids. Using higher doses can cause severe withdrawal symptoms, like chills and convulsions, that can last for a week. This leads some to give up on tapering. But tapering itself is not dangerous. With proper guidance and support, so patients do not need to do I all by themselves, the chances of successfully quitting improve significantly.”

Role of physician and pharmacist

Patients indicate that they consider the role of both health care providers and pharmacists equally important in providing information. However, right now, this does not always work out well. “Sometimes the doctor says one thing, and the pharmacist says something else,” Davies notes. “It would be better if information is conveyed unambiguously and repeatedly. GPs and pharmacists could use help with this, such as clear guidelines and more attention during training. Simple, straightforward educational materials, like leaflets, would also be helpful.”

A pill isn’t a magic solution. Chronic pain is often complex, and a combination of treatments can be more effective than painkillers alone.

Prevent stigmatization

Davies also thinks it is important to emphasize that patients who were admitted to a treatment program because of their opioid use, reported to rarely experiencing a high when using opioids. They began using the drugs to manage pain and took more and more, in part to manage withdrawal symptoms.

According to Davies, this insight helps prevent stigmatization of these patients. Davies: “They take the medication because they want relief from pain, not to get high. Recognizing this is very important, especially since people with chronic pain often already feel misunderstood.”

Alternatives

More recently, the rise in prescribed opioids in the Netherlands has started to level off. Davies:  “The amounts prescribed also appear to have decreased somewhat. In line with this, the new guidelines for treating chronic pain are more mindful of restraint in prescribing.”

According to Davies, offering alternative treatment options for chronic pain would also be beneficial. “A pill isn’t a magic solution. Chronic pain is often complex, and a combination of treatments can be more effective than painkillers alone. To reduce reliance on opioids, it would help if alternative therapies, like physical therapy, were covered by health insurance.”