Letter to the Director
Reflections on the “opioid crisis”: Prevention is better than cure
Reflexiones sobre la «crisis de los opioides»: más vale prevenir que curar
A. Alcántara Montero
, A. González Curado
Corresponding author
Unidad del Dolor, Hospital Don Benito-Villanueva de la Serena, Don Benito, Badajoz, Spain
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This is predominantly in the lingula and possibly left lower lobe. Further consolidation is seen in the perihilar region on the right side with a more distal wedge area of opacification in the right upper lobe. There appears to be some volume loss in the right upper lobe. There are no pleural effusions. Appearances would be in keeping with an infective process.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "G. Skalley, S. Rodríguez-Villar" "autores" => array:2 [ 0 => array:2 [ "nombre" => "G." "apellidos" => "Skalley" ] 1 => array:2 [ "nombre" => "S." 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Alcántara Montero, A. González Curado" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Alcántara Montero" "email" => array:1 [ 0 => "a.alcantara.montero@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "A." "apellidos" => "González Curado" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad del Dolor, Hospital Don Benito-Villanueva de la Serena, Don Benito, Badajoz, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reflexiones sobre la «crisis de los opioides»: más vale prevenir que curar" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The so-called “opioid epidemic” currently raging in the United States has become an important public health debate. Opioid overdose caused the death of more than 33,000 Americans in 2015, and almost half of these were due to prescription drugs. Opioid-related deaths have quadrupled since 1999—an alarming upward trend.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Opioid use disorder is a chronic disease characterised by a problematic pattern of consumption that has a significant effect on the patient's health, and is often accompanied by pathological anxiety. This disorder involves compulsive, prolonged self-administration of these drugs for no medical purpose or, if opioids are prescribed to treat a disease, they are used at rate that far exceeds the therapeutic dose.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In other words, an addictive use of the drug for non-medical purposes, usually as a result of previous clinical use. Individuals that develop this disorder have usually passed through several preliminary stages: prescriptive (lawful) use, suspension of treatment, symptoms of dependence and tolerance, access to new substances, management of addictive symptoms, etc. Pathological opioid consumption therefore, which starts with medical treatment, is perpetuated due to poor follow-up, with many patients resorting to opioids to alleviate either their withdrawal symptoms or their psychological problems. Previous opioid use together with inadequate medical follow-up is also aggravated by the patient's personality.</p><p id="par0015" class="elsevierStylePara elsevierViewall">All this, therefore, begs the question: where do these individuals obtain opioids? We know that opioids and other psychotropic drugs can be obtained either through legal (prescription) or illegal channels. Studies have shown that some patients are as reluctant to report the misuse of these and other prescribed medications as they are to admit to the illicit use of opioids; some even go so far as to feign symptoms to obtain them. With regard to illegal channels, potential opioid users will first search for the drugs through the means at their disposal—nowadays, predominantly social networks and Internet search engines.</p><p id="par0020" class="elsevierStylePara elsevierViewall">But, what can we do about this crisis? Being a multifactorial problem, it requires a multifactorial approach. The US Food and Drug Administration (FDA), has implemented a series of measures to halt the spread of this epidemic, one of these being the creation and promotion of oral abuse deterrent formulations (ADF). These new technologies are intended to make it more difficult for users to manipulate the formulation by separating the opioid from its excipient and either snorting or injecting the pure drug. The aim is to greatly increase the instant “high” that the consumer experiences, and is strongly associated with the development of addiction.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The FDA also recently approved monthly buprenorphine injections for the treatment of moderate to severe opioid use disorder. The treatment, indicated for patients who have received a stable dose of buprenorphine for at least 7 days, reduces withdrawal symptoms and the desire to use these drugs. It also decreases the pleasurable effects of other opioids, making continued opioid abuse less attractive, and halving the risk of death from all causes.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Along with pharmacological treatment with buprenorphine, to which methadone or naltrexone are added, it is important to draw up a comprehensive plan that includes counselling and psychosocial support, in order to accelerate recovery from the disorder. Another important aspect is early detection. This can be achieved by monitoring at-risk patients, such as those taking opioids for chronic non-cancer pain, using clinical controls and urinalysis to detect inadequate consumption of these substances.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However, the most important factor is prevention, and this is where clinicians make a vital contribution. A key aspect of prevention is adequate training in the administration of opioids for chronic non-cancer pain (CNCP), and careful follow-up of all patients receiving this therapy. In this respect, several recent clinical guidelines now make specific practical recommendations on the proper use of these drugs in CNCP. These recommendations were, in fact, published some years ago in this very journal,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> so we must ask ourselves the obvious question: why have they not been followed in the years leading up to this crisis?</p><p id="par0030" class="elsevierStylePara elsevierViewall">For reasons of patient safety and public health, it is essential to provide clinicians with a set of rules for the responsible prescription of opioids, notwithstanding the importance of giving patients clearer information on such treatments. This does not mean that we should be wary of opioids, but that they must be used responsibly, in accordance with their indications, and with the corresponding follow-up when they are withdrawn.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,5</span></a> These drugs should only be prescribed after a detailed evaluation of the patient's medical situation, once the diagnosis has been confirmed and the risk-benefit ratio carefully evaluated. Patients at high risk of medication misuse should continue to be treated appropriately, and should receive opioids for their pain if required, albeit with a well structured strategy. The treatment protocol could include the patient's informed consent or a written or verbal therapeutic agreement indicating the risks and benefits of opioid therapy, explaining what is expected of the patient, educating him or her on the use of the drug, and specifying the actions that would be considered unacceptable. Other measures should also be introduced, such as more frequent clinical visits, prescribing fewer units per prescription, verifying compliance and, if indicated, providing motivational advice. Once the treatment has been started, patients at high risk of drug abuse can be referred to units specialising in addictive behaviours, thus optimising chronic pain management and the use of opioids in those patients who need this type of therapy.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Alcántara Montero A, González Curado A. Reflexiones sobre la «crisis de los opioides»: más vale prevenir que curar. Rev Esp Anestesiol Reanim. 2018;65:413–414.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharmaceutical overdose deaths United States, 2010" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.M. Jones" 1 => "K.A. Mack" 2 => "L.J. 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