Tackling rising numbers of opioid prescriptions users
Authors: Gerard Arnoldus Kalkman, Cornelis Kramers, Robert T van Dongen, Wim van den Brink, Arnt Schellekens
Journal: The Lancet Public Health (2020)

We thank Peter Groot and Jim van Os for their comments1Groot PC van Os J Tackling rising numbers of opioid prescription users.Lancet Public Health. 2020; 5: e16Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar on our Article.2Kalkman GA Kramers C van Dongen RT van den Brink W Schellekens A Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study.Lancet Public Health. 2019; 4: e498-e505Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar We agree with Groot and van Os that the implementation of safe prescribing guidelines will only curb the increase in chronic prescription opioid use, while offering no solution for patients currently using opioids who wish to discontinue.1Groot PC van Os J Tackling rising numbers of opioid prescription users.Lancet Public Health. 2020; 5: e16Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Since there were more than 200 000 chronic opioid users in the Netherlands in 2017,3Schepens MHJ Leusink M de Vries SE et al.Toename in extramuraal opioïdgebruik in Nederland.Ned Tijdschr Geneeskd. 2019; 163D3854PubMed Google Scholar guidelines on how to effectively discontinue chronic opioid use are needed. Gradual tapering of opioid dosages is often needed when discontinuing chronic opioid use to mitigate withdrawal symptoms, especially in patients on a chronic high dose.4Dowell D Haegerich TM Chou R CDC guideline for prescribing opioids for chronic pain—United States, 2016.JAMA. 2016; 315: 1624-1645Crossref PubMed Scopus (1791) Google Scholar Groot and van Os suggest tapering strips as a practical solution for opioid tapering.1Groot PC van Os J Tackling rising numbers of opioid prescription users.Lancet Public Health. 2020; 5: e16Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Although an interesting and potentially effective strategy, there is no evidence for increased effectiveness of opioid-tapering strips over conventional opioid-tapering methods using existing drug formulations. Added complexity arises due to differences in starting dosages, required tapering speeds, and combinations of different opioids and dosage forms. Moreover, not all patients will be able to fully discontinue their use due to insufficient analgesia. Importantly, factors such as patient buy-in, psychosocial support, and maximisation of non-opioid pain therapies are potentially more important for the success rate of tapering attempts.5Dowell D Haegerich TM Changing the conversation about opioid tapering.Ann Intern Med. 2017; 167: 208-209Crossref PubMed Scopus (13) Google Scholar Additionally, tapering strips are likely to increase costs compared with use of existing drug formulations. Although the use of opioid-tapering strips sounds attractive, research into its effectiveness—in terms of cost and otherwise—is needed before it can be recommended. Potential indications might be patients with previous failed tapering attempts, who require ultra-slow tapering or ultra-small dosages that are currently unavailable. Therefore, we emphasise the importance of a multidisciplinary approach to tapering, including psychosocial support, due to the complexity of the combination of chronic pain, addictive behaviours, and comorbid psychiatric disorders in patients with long-term opioid use and chronic pain.6van Rijswijk SM van Beek M Schoof GM Schene AH Steegers M Schellekens AF Iatrogenic opioid use disorder, chronic pain and psychiatric comorbidity: a systematic review.Gen Hosp Psychiatry. 2019; 59: 37-50Crossref PubMed Scopus (13) Google Scholar WvdB reports personal fees from Takeda, Mundipharma, Indivior, and Opiant Pharmaceuticals. All other authors declare no competing interests. Tackling rising numbers of opioid prescriptions usersIn The Lancet Public Health, Gerard Kalkman and colleagues have made a much-needed inventory of the rising number of opioid prescription medication users in the Netherlands.1 We fully agree with their call for the implementation of safe opioid prescribing guidelines. However, improved and reduced prescribing of opioid painkillers can only solve part of the problem, because these measures will not help patients who are already using opioids and are struggling to come off them. Full-Text PDF Open AccessTrends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database studyPrescription opioid use increased substantially between 2008 and 2017, and several proxies for misuse show a parallel increasing trend. Although the Netherlands is far from the opioid epidemic faced by the USA, safe opioid prescribing guidelines should be implemented to prevent further escalation and to keep opioid painkillers available for those in need. Full-Text PDF Open Access