The use of strong opioids has skyrocketed over the past two decades.
More people now die from an overdose of prescription drugs than from heroin.
Opioid victims are a different group than those who die from heroin poisoning. They are more often women over 50 who are better off financially. Many have long-term pain.
Is the threshold for prescribing these medicines in this country too low?
Researchers are now trying to find an answer to that.
Trust in doctors
– I had a lot of faith in the doctors who said that these medicines would help me. And they really did, says Marion Jakobsen.
She had damage to the nerve fibers in her neck after an operation for neck prolapse.
– I had constant pain that went down the nerves in both arms. Eventually I lost all feeling, especially in my right arm. Eventually the pain also went down the legs. They felt like jelly and I completely lost control of them.
The pain was all-consuming, says Jakobsen.
They disappeared when she got opioids in 2010.
But she lost herself these years, she believes.
– I couldn’t quite take in what happened. I misunderstood a lot. And I slept most of the day.
Only in 2019 was she able to cut out these drugs, after a hard fight.
Is it the start of an epidemic?
“One of the worst public health scandals” ever. This is how the journal The Lancet described the opioid epidemic in the USA and Canada in a leading position in 2022.
These countries have had a very liberal practice in prescribing opioids for pain. It has led to around 600,000 overdose deaths in the last 20 years.
Now several people are worried that we may be on the way to a similar epidemic in Norway.
A sixfold increase
There may be cause for concern.
In Norway, from 2004 to 2021, there has been a lower threshold for prescribing these medicines for patients with long-term pain.
The use of weaker opioids, such as codeine and tramadol, has been stable over the same time period.
But there has been a sixfold increase in the use of oxycodone.
Large research project
The increase is greatest among those who already use a lot of strong opioids, say Ingvild Odsbu and Svetlana Skurtveit. They are both researching addictive drugs at the Norwegian Institute of Public Health.
Skurtveit is now leading a large research project called POINT (Preventing an opioid epidemic in Norway: Focusing on treatment of chronic pain).
Together with a number of research institutions and user organisations, they will find out how the use of these medicines is developing in Norway.
Opioids at the state’s expense
One of the reasons for the increase may be that from 2008 it became possible for patients with long-term pain to get opioids on a blue prescription. That is, at the state’s expense.
It is the blue prescription that worries researchers the most. These patients receive much higher doses than those who collect the medicines on a white prescription. And they often get them for a very long time.
Of those who received opioids on a blue prescription in 2009, almost half continued with the treatment nine years later.
Risk of addiction
It has not been documented that opioids have a pain-relieving effect when used over a long period of time.
On the contrary, there is a risk of becoming addicted and an increased risk of overdoses.
Around 60,000 people in Norway have what the researchers call persistent use of opioids.
Of these, 24 percent are in the blue receptor category for long-term pain. 63 percent have persistent opioid use on a white prescription.
This is also a group that researchers worry about.
GPs were allowed to write prescriptions
In 2016, GPs were given the opportunity to prescribe opioids to patients with long-term pain. Previously, only pain clinics could do this.
Some of the explanation for the increased use may also lie here, according to the researchers.
But the increase in oxycodone in Norway has been steady since 2004. It is therefore about something more than GPs being able to issue blue prescriptions, Skurtveit and Odsbu believe.
In a time crunch
It is challenging for GPs to find good relief that is not drugs. This is what Marte Kvittum Tangen, head of the Norwegian Association for General Medicine, told Aftenposten recently.
It demands more from the patients. It is time-consuming and often more difficult to implement, she explains.
Marion Jakobsen will not criticize the GPs.
– They only want to help the patients who really need it. But they are constantly pressed for time. It probably slips out a bit for that reason.
Jakobsen was prescribed opioids by the specialist health service after a neck prolapse. Her GP at the time continued to prescribe what the hospital had given her for pain relief.
Begins in the hospitals
An American study shows that patients are often prescribed opioids after surgery or for an acute pain problem. They receive the prescription from the specialist health service.
But it is the GPs in the primary healthcare service who have to deal with the long-term consequences.
This can also be a challenge in Norway, the researchers believe.
There were alternatives
Marion Jakobsen finally said herself that enough was enough.
After over nine years as an addict, she decided she couldn’t go on living like this anymore. She wanted to stop the medication, but felt that the doctors had no alternatives for her.
Then she herself searched for knowledge about other pain relief. She decided to get off the medication.
Marion Jakobsen found out that there is something called spinal cord stimulation.
She went to the doctor and asked him to investigate if there could be something for her. He thought it was interesting and submitted an application to the hospital.
Strong abstinence
She was initially refused, but did not give up.
When she finally got to the hospital, they recommended she try something called TENS. It is a handheld device with small electrodes that are attached to the skin to relieve pain.
– This device worked very well for two years, she says.
It was during this period that Jakobsen seriously decided to get rid of the medication.
– I stepped down within two months. But when I had taken off the last morphine patch, I almost went on the wall.
Then the GP asked her to come in for an interview. He asked her to try to hold out for two more days. If it wasn’t better then, they should find an alternative together.
After the two days, the abstinence was over.
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– If my GP hadn’t asked me to have that conversation, I might have put another plaster on and postponed the whole thing. But my doctor was a fantastic support, says Jakobsen.
Got a new life
After two years, the TENS machine no longer relieved her pain.
Now she has had a so-called SCS implant operated on.
This is an electronic spinal cord stimulation where an electrode is placed into the body. With the help of a weak current, it can relieve long-term pain.
It is particularly patients with nerve pain in the back and neck who benefit from such a device, Oslo University Hospital writes on its website.
– I have been given a new life. I have returned, says Jakobsen.
Little knowledge of alternatives
There are many alternatives to medicines for most people who suffer from long-term pain, Jakobsen believes.
She is happy that she has a GP who is responsive and positive about trying out alternative treatment methods.
As deputy leader of the Association for Chronic Pain Patients, she knows that it is not always like that. Many GPs do not have much knowledge about alternatives.
– I understand that some therefore prescribe these medicines. They do not know what to do and are distressed to see their patients in so much pain.
Do not undertreat pain
Opioids have a very important role in the treatment of pain. They are absolutely necessary after major operations and with cancer at the end of life.
It is therefore very important that we do not end up in a situation where we undertreat pain, says Petter Christian Borchgrevink.
He is a senior physician and professor at St. Olav’s Hospital at NTNU.
– It will be very negative if the GPs simply say no to giving the patient opioids that can help them with the acute pain, he believes.
Patients with long-term pain should not usually have opioids, Borchgrevink points out.
He has been involved in creating a treatment plan, called NOMED, for GPs. It should help them away from the prescription block.
NOMED for GPs
You can read about all the 17 factors mentioned in NOMED that prolong and intensify pain at smernettverk.no and nhi.no.
The questionnaire, which doctors, psychologists and physiotherapists have collaborated on, has been entered into the Norwegian electronic medical handbook. It is a tool that most GPs have access to.
A survey among 70 GPs who have been trained in using the system shows that they want to use it.
Petter Christian Borchgrevink hopes that they can get a research project done on the effect, even if it is complicated to set up a good study on this.
Amplifies and prolongs pain
The program includes a questionnaire that will help the GPs to address factors that cause long-term pain not to go away and the pain to become stronger, says Borchgrevink.
– It can be, for example, sleep problems, loneliness, poor physical condition, depression, anxiety, worries about work and NAV, health anxiety and brooding.
Long-term pain can affect the relationship with those closest to the patients. Many pain patients struggle with a bad relationship with their loved ones. Many have also had bad experiences in childhood and youth, says Borchgrevink.
– Many of these have been traumatized. This particularly applies to women.
Some need to be referred to a psychologist. For others, it can be very good just to talk to the GP, he believes.
– This is actually something that GPs can help patients with pain with, instead of prescribing opioids, says Borchgrevink.
No crisis in Norway
There is not an opioid crisis in Norway today, Borchgrevink believes.
– The Norwegian authorities are good at taking control. And they do not go in reverse, as the health authorities do in the US and Canada. There, many doctors no longer dare to prescribe these drugs.
We need more research before we introduce a more restrictive policy in this area in Norway, says Borchgrevink.
– And it must not affect those patients who need opioids.
