Opioid use grows in Brazil and inappropriate prescription leads patients to addiction

The inappropriate prescription of opioid analgesics for pain control and the increase in patients dependent on these narcotics have worried doctors and raised fears that Brazil could face an “epidemic” of abuse of these substances such as those registered in the United States in recent years. years old.

Some studies have already pointed out this risk. In 2019, a Fiocruz drug survey showed that 4.4 million Brazilians had already made illegal use (without a prescription) of an opiate — or 2.9% of the population. The number is three times higher than the use of crack, experienced by 0.9% of the population throughout their lives.

Another 2018 study, published in the American Journal of Public Health, raised the alarm for the increase in legal use of these drugs. In six years, the sale of prescription painkillers based on opium grew 465%, according to data from Anvisa (National Health Surveillance Agency).

Codeine, considered a mild opioid and generally indicated for moderate pain, accounts for more than 90% of prescriptions.

In the opinion of doctors, the consumption of these drugs increased in the Covid-19 pandemic, but the Brazilian numbers are not yet closed. In the US, overdose deaths, mostly from opioids, passed the 100,000 mark between April 2020 and April 2021, up 28.6% from the same period before.

at the request of Sheet, Anvisa compiled data on the use of opioids until June 2021. In total, in 2020, 21,785,015 packages of narcotic analgesics were sold. In the first six months of 2021, there were 14,469,642.

So, roughly speaking, if the amount used in the second half reflects the first, the year will have closed with a rise of around 33% compared to 2020.

For some types of narcotic pain relievers, the increase is already clear. In the case of codeine phosphate (associated with substances such as paracetamol), there was a 52% increase (from 824,020 packages to 1,255,298).

The use of methadone and oxycodone, for example, in the first half of 2021 alone was already 29% higher than in the whole of 2020 — 699,520 cases against 543,081. The sale of oxycodone in Brazil is controlled in the same way as antibiotics (red stripe). Methadone has a black stripe.

Doctors who specialize in pain management and who work in hospital emergencies report an increase in patients who come to them who are already dependent on opioid analgesics, such as codeine, requesting new prescriptions.

“Many people are irresponsibly receiving opioids for lack of diagnosis and correct treatment”, says anesthesiologist Silvia Tahamtani, a specialist in pain and palliative care at ICESP (Cancer Institute of the State of São Paulo).

At the private clinic where she treats non-cancer patients, she says that, of every ten patients with symptoms of opioid dependence, eight had no indication to have started using the medication. If they can’t get their prescription renewed, they start changing doctors.

“We call it ‘doctor shopping’. He goes to a doctor, he goes to the other and in each one he says he lost the prescription, that the dog ate, that the rain got wet and he needs a new prescription”, says doctor Angela Sousa , also an anesthesiologist and pain specialist at ICESP.

In general, the prescription is considered inappropriate when the pain can be controlled by other drugs and therapies or because the patient already had some predisposition to dependence. In Brazil, 4 out of 10 people suffer from some chronic pain – which persists for more than three months.

A common example, according to her, is the treatment of low back pain, one of the most frequent in the Brazilian population.

“Sometimes, it’s a muscle pain, because the person works seated for a long time, because they exert excessive effort or because they are obese. They should be doing physical exercises, stretching, but they want medicine to be pain free.”

Migraine or headache, often caused by tension, and fibromyalgia are other conditions where opioid pain relievers have been frequently prescribed.

“These patients should be doing rehabilitation, physical exercise, trigger point infiltration [pequenos nódulos localizados na fibra muscular]taking care of mental health, or using other medications, but not opioids”, reinforces Sousa.

Some Brazilian hospitals have also detected abuse in the indication of these substances in emergency rooms and are creating programs to avoid deviations and educate health professionals about the prescription of opioids, in addition to adopting protocols to identify patients at risk of dependence.

UnitedHealth Group Brazil, for example, launched in November last year a protocol for headache treatment. Among other objectives, the program aims to reduce the prescription of opioids in emergencies in hospitals in the network, which currently varies between 5% and 30%.

“We often see opioids being wrongly prescribed to patients with this condition,” said neurologist Marcelo Calderaro on the “Doctor’s Conversation” podcast, from the site to Medscape, which specializes in medical education and information.

According to him, there is confusion about the treatment of acute pain associated with diseases such as renal lithiasis. [cólica renal]in which the use of opioids is indicated, and pain associated with a chronic disease, such as migraine.

Psychiatrist Lisia von Diemen, a professor at UFRGS (Federal University of Rio Grande do Sul), says that in the last three years there has been an increase in consulting requests for suspected opioid abuse in hospitals. In 2016, the average was one every three months, while from 2018 onwards it went to one case per week.

The situation has also led physicians to seek advice from regional boards of medicine on what to do in situations where patients routinely seek emergency care asking for narcotic pain relievers.

“What is the threshold for medical connivance to prescribe the medication requested, when it claims to be the only one that effectively improves their pain, but that notoriously characterizes dependence or abuse on the part of patients in the face of such a substance?”, asked a doctor to the Medical Council of Mato Grosso do Sul.

The counselor replied that “if the patient’s dependence or abuse is clinically explicit, the physician, when administering the opioid analgesic, is automatically colluding, when there is no clinical indication for its use”.

According to the WHO (World Health Organization), the treatment of pain must respect an escalation (steps of the analgesic ladder), which includes analgesics, anti-inflammatory drugs, adjuvant drugs and opioids (weak and strong).

According to Sousa, the strategy is common for patients to go to the emergency room and exaggerate the intensity of pain to get stronger opioids. “He says he has unbearable pain. It is not always easy for the ER doctor to assess the profile of this patient. Sometimes it takes us two, three days to understand that it is a difficult case, to separate what is pain and what is it’s addiction.”

She recounts, for example, the case of a patient who had already had his spine operated on eight times and became dependent on opioids, when, in fact, he had no indication to have started on medication. “He was a person with a personality disorder. He needs to be under the care of a psychiatrist.”

According to Tahamtani, hospitalized patients are also at risk of dependence on opioid painkillers, but in this case, they are the best treatment to control cancer pain.

The difference, he explains, is that in these situations, addiction can be circumvented through clinical protocols and other tools. “Addiction is a disease that needs to be treated in a multidisciplinary way, with help, for example, from a psychiatrist.”

During the pandemic, the doctor noted that cancer patients resorted more to opioids due to worsening mental health. “There was isolation, stress, fear of death by Covid. Fear is a factor of lack of control, triggers more pain and more consumption”, she says.

After undergoing surgery to remove cancer from the rectum in early 2021, waiter Marcelo, 49, from São Paulo, started using methadone, practically identical in its properties to morphine, acting on the same receptors and with the same effects.

In the seven months he was hospitalized and using the medication in his vein, his body developed tolerance to the opiate. He says he started to need more frequent dosages to feel the same relief. Before cancer, Marcelo was addicted to cocaine and crack for 20 years.

The waiter says he even fought at the hospital over more methadone. “When it was time to take the medication, I would go to the nursing station to pressure. There was a time when I took it every six hours. Then it was every four hours.”

As soon as he felt the medicine entering the vein, he says he felt “a good breeze”, which can be described as muscle relaxation, a feeling of well-being that mixes numbness and euphoria. Already the lack of the substance produces withdrawal symptoms: tachycardia, hypertension, sweating, diarrhea, chills, muscle pain and insomnia.

After discharge, Marcelo started using oral methadone and, with the help of the hospital pain team, managed to extend the intervals between doses. He currently uses the medication once a day. “But I can’t go a day without her. I’ve tried, but I get so nervous, I can’t sleep.”

Understand what opioids are and the risks

• Medicines derived from the poppy — a plant that is also the basis for the production of opium. They stimulate receptors in the brain and provide powerful pain relief.
• In addition, they reduce the anxiety and depression that often accompany episodes of intense pain.
• They also produce a feeling of euphoria, are highly addictive and can lead to overdose deaths and other harm. Therefore, there is a danger that they will be used irregularly.