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The World Health Organization &#40;WHO&#41; considers that a country&#39;s mean opioid consumption is a good indicator of the quality of the clinical management of pain&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The available information on the use of opioids in Spain has been scarce to date&#46; Studies on the use of drugs express the consumption of drugs in daily defined doses &#40;DDD&#41; per 1000 inhabitants and day &#40;DID&#41;&#46; DDD is the maintenance dosage established by the World Health Organization for an active ingredient in the primary indication for a specified administration route in adults&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results of the interesting study by Ruiz-Lopez and Alonso-Babarro<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> on opioid consumption between 2004 and 2014 in Madrid &#40;Spain&#41;&#44; published in this issue of <span class="elsevierStyleItalic">Revista Cl&#237;nica Espa&#241;ola&#44;</span> and those of a recent report &#40;13 March 2019&#41; from the Spanish Ministry of Health that analyzed data on the national level between 2010 and 2017<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> help to determine the present situation in Spain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Firstly&#44; both studies have shown significant growth in the overall use of opioids&#44; which has tripled in the Community of Madrid during 2004&#8211;2014 &#40;the overall DID increased from 2&#46;7 to 8&#46;1&#41; and doubled in Spain between 2010 and 2017 &#40;the overall DID increased from 9&#46;9 to 17&#46;4&#41;&#44; although Spanish consumption was still much lower than that of North America and northern European countries&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Secondly&#44; the studies have shown a change in the pattern of consumption for the various drug groups&#46; Step II opioids are still of the most prescribed&#44; with almost 71&#37; of the overall opioid consumption in 2017 and a significant increase in the use of tramadol &#40;especially in combination with paracetamol&#41; and a simultaneous reduction in the use of codeine&#44; which in 2017 represented only 7&#37; of the market share&#46; In terms of major or step III opioids&#44; the most widely used were fentanyl &#40;14&#46;4&#37; of the total opioids in 2017&#41; and buprenorphine &#40;4&#46;4&#37;&#41;&#44; although their prescription progressively declined during 2010&#8211;2017 due to the significant increase in the consumption of new-generation drugs &#40;introduced in Spain in 2010&#41;&#44; such as tapentadol and oxycodone-naloxone&#44; which currently represent 4&#46;3&#37; and 3&#46;3&#37; of the total prescribed opioids&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Morphine consumption in Spain is residual&#44; and its use did not reach 2&#37; of the overall prescriptions&#44; being restricted almost entirely to the hospital and palliative care setting&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The reasons for the increase in opioid consumption are numerous and include cultural changes in the society&#44; a lower pain tolerance&#44; sociodemographic and healthcare factors&#44; increased survival of patients with oncologic and nononcologic conditions with chronic diseases&#44; increased use of opioids in chronic nononcologic pain&#44; increased sensitivity and training of healthcare practitioners in pain management &#40;which has helped overcome the paradigm of morphine phobia&#41;&#44; the development of new active ingredients other than morphine that provide advantages in terms of use and adverse effects and&#44; possibly&#44; increased accessibility provided by the widespread use in Spain of electronic prescriptions&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In terms of the usage patterns&#44; there is a noteworthy lack of morphine use&#44; which is the opioid of choice in most clinical practice guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> This fact is probably related to the advantages in terms of the use and adverse effects provided by the new synthetic opioids such as fentanyl&#44; which&#44; in its transdermal form&#44; can be employed for patients with nausea and&#47;or upper gastrointestinal tract symptoms &#40;which are common with advanced neoplasia&#41;&#46; Fentanyl can also be administered on a 72-h basis&#44; thereby avoiding reminding patients with cancer about their cancer&#46; Another factor to consider in the change in opioid usage patterns is the recent development in Spain of palliative care units&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The WHO&#44; in its 2002 definition of palliative care&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> recommends early intervention in the care of patients who are candidates for palliative care&#44; which should be performed based more on the patient&#39;s psychological&#44; physical&#44; emotional&#44; social and spiritual needs than on the vital prognosis&#46; The present objective is to start comprehensive and multidisciplinary care in earlier phases concomitantly with other active treatments against oncologic and nononcologic disease&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">This situation increases the number of patients who are candidates for opioid treatment and extends the duration of their use&#44; which encourages improper usage conditions&#46; This is especially true for chronic nononcologic pain&#44; in which despite the opioids&#8217; demonstrated efficacy in controlling pain during the first 3<span class="elsevierStyleHsp" style=""></span>months of treatment&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> the rates of severe adverse effects in longer treatments is very high &#40;7&#46;5&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> Opioids have also started to be employed in unaccepted indications such as fibromyalgia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the past decade&#44; there has been an exponential increase in opioid consumption&#44; especially in the US&#44; Canada and&#44; to a lesser extent&#44; Europe&#44; with the number of deaths due to analgesic opioid overdosing quadrupling in the US &#40;16&#44;651 in 2010&#41; and Europe &#40;6800 in 2014&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> Therefore&#44; the abuse and misuse of this drug group has become a public health problem in North America&#46; In Europe&#44; this situation has become a reason for concern because&#44; although the sociocultural and healthcare context is different&#44; the neurobiological substrate for developing these behaviors is common&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Opioid-induced aberrant behaviors &#40;OIABs&#41; can include chemical coping&#44; addiction or other opioid-related conditions such as pseudoaddiction&#44; dependence&#44; tolerance&#44; hyperalgesia and criminal intent&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> The term chemical coping has been recently defined by an expert consensus as &#8220;the use of opioids to cope with emotional distress&#44; characterized by inappropriate and&#47;or excessive opioid use&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Chemical coping in its most severe form becomes an addiction characterized by behavior that includes one or more of the following&#58; loss of control over the use of the drug&#44; compulsive use&#44; continued use despite damage and compulsive need&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">All patients undergoing treatment with opioids can develop OIABs&#44; from chemical coping to addiction&#59; practitioners should therefore be familiar with detecting and addressing these behaviors&#46; It is therefore important to identify the risk factors for developing these behaviors such as alcohol and drug abuse&#44; tobacco use&#44; young age&#44; good functional status&#44; lower scores on the Edmonton Symptom Assessment System scale &#40;a validated reference instrument for assessing the symptoms of patients with advanced cancer&#41;&#44; high doses of morphine&#44; concomitant use of benzodiazepines and other sedatives&#44; psychiatric or psychological comorbidity and a history of sexual abuse&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">If we cannot detect these behaviors early on&#44; we will be increasing the patient&#39;s suffering and risk of adverse effects and ineffectively managing their pain&#46; N&#250;&#241;ez-Olarte et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> recently published the results of a clinical audit of their &#8220;early palliative care&#8221; activity in 100 patients with advanced cancer undergoing long-term opioid treatment&#44; in which 19&#46;2&#37; of the patients presented aberrant behaviors&#44; and 7&#46;7&#37; presented addiction&#46; These data are merely indicative of an emerging phenomenon in Spain&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Our reflections do not question the undoubtedly beneficial role of opioids in controlling pain and should not lead to a decreased use for fear of expanding aberrant behaviors&#44; but rather we attempt to promote appropriate and judicious consumption of this group of drugs&#46; In any case&#44; we need to improve our still highly limited understanding of OIABs to implement more appropriate follow-up and treatment strategies for the individual profile of each patient with severe pain&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez-L&#243;pez A&#44; Medrano FJ&#46; Hacia un uso juicioso de los opioides en Espa&#241;a&#46; Rev Clin Esp&#46; 2019&#46; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.rce.2019.03.012">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;rce&#46;2019&#46;03&#46;012</span></p>"
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October 2019 Towards the judicious use of opioids in Spain
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Vol. 219. Issue 7.
Pages 398-400 (October 2019)
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Vol. 219. Issue 7.
Pages 398-400 (October 2019)
Editorial
DOI: 10.1016/j.rceng.2019.03.026
Towards the judicious use of opioids in Spain
Hacia un uso juicioso de los opioides en España
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A. Fernández-Lópeza,b,◊, F.J. Medranoc,d,e,f,◊,
Corresponding author
medrano@cica.es

Corresponding author.
a Servicio de Medicina Interna, Equipo de soporte domiciliario, Hospital Universitario Virgen del Rocío, Sevilla, Spain
b Dirección del Plan Andaluz de Cuidados Paliativos, Sevilla, Spain
c Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, Spain
d Instituto de Biomedicina de Sevilla, Sevilla, Spain
e Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain
f Departamento de Medicina, Universidad de Sevilla, Sevilla, Spain
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