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BUDAPEST — Europe is not on the brink of an opioid crisis anytime soon, according to research presented at the 32nd European Congress of Psychiatry (EPA 2024). Deaths from prescription opioid use are nowhere near the level that has been reported in the United States. 

Looking at trends in the medical use and abuse of opioid analgesics over the past two decades, Arnt Schellekens, MD, PhD, professor of psychiatry at Radboud University Medical Center in Nijmegen, the Netherlands, acknowledged that there has been a "slight rise" in opioid prescribing in Europe overall. This rise, however, has not translated into an increased mortality rate in most countries.

Indeed, in a retrospective study published 3 years ago in European Psychiatry, Schellekens and colleagues reported that in 15 of the 19 European countries examined, there was no indication of an opioid crisis comparable to that in the US. The exceptions were the United Kingdom (Scotland, Northern Ireland, and England/Wales) and Ireland, which had high rates of adverse opioid-related outcomes. 

Prescription opioid use in Europe varies widely, Schellekens, who is also scientific director of the Nijmegen Institute for Scientist-Practitioners in Addiction at Radboud University and director of research for the International Collaboration on ADHD and Substance Abuse consortium, told Medscape Medical News. "The healthcare systems are so different." European countries have different problems to address, and the simple injunction to stop using these drugs is "not a solution at all," he added. 

Caution is of course needed when considering opioid use, Schellekens continued. The drugs are associated with a risk for addictive behavior and the development of opioid use disorder. There is generally a good system of care in place across Europe for people who develop opioid-related problems, and this care is reimbursed in the Netherlands, Schellekens said. 

"I'm mainly concerned about the use of synthetic opiates" such as fentanyl and nitazenes, he added. "If they come onto the market, then it might be more of an issue." Data he presented at EPA 2024 indicated that these drugs are increasingly being used in place of other drugs such as morphine, particularly in the Baltic states. The problem with these drugs is that they are riskier in terms of their tendency to cause addiction, complications, and overdose, said Schellekens.

Inappropriate Use 

István Bitter, MD, PhD, DSc, emeritus chair of psychiatry and psychotherapy at Semmelweis University in Budapest, said at EPA 2024 that he was "worried" about the use of certain opioids "not because of the situation in Hungary, but because of the news we are receiving from other countries in Europe." 

A colleague working in Northern Europe told Bitter that the semisynthetic opioid oxycodone was being used to treat people with chronic back pain. But opioids would never be considered for this condition in Hungary, said Bitter. Moreover, prior oxycodone use may play a role in the subsequent misuse of benzodiazepines prescribed in an outpatient setting, Bitter observed. 

A gateway theory of substance misuse has been advanced, said Schellekens. Although addiction to one drug or behavior could theoretically increase a patient's risk for addiction to another substance, this effect does not necessarily arise. "If you switch in a proper way, then there's no need to think that the patient will end up with other problems," said Schellekens.

Prevention Is Key

Psychiatric disorders, pain, and problematic opioid use are associated with one other. The reasons for this association are complex, and researchers suggest that patients must be screened carefully before they are prescribed opioids. 

Despite this association, "do not deny psychiatric patients adequate analgesia," said Schellekens. Patients with a psychiatric comorbidity have been shown to require higher doses of opioids to have an analgesic effect than patients without such a comorbidity do. The former patients thus need a multidisciplinary approach to pain management. 

Current guidance helps clinicians decide when and how quickly to taper opioids in patients who have developed opioid use disorder. Integral to tapering is the use of psychoeducation and psychosocial support. Data also show that incorporating buprenorphine in place of the opioid being misused may help some patients. 

In summary, long-term opioid use for chronic pain has no place in the treatment of patients with psychiatric comorbidity, said Schellekens. "On the other hand, you have people that have already escalated their opiates. And then you should not simply stop it. But get in rapport with your patient, write down a tapering plan and schedule, collaborate to get it done."

Schellekens and Bitter reported no relevant financial relationships. 

Sara Freeman is a freelance medical journalist based in London, England.