VALENCIA, Spain — After watching the opioid epidemic hit the United States, spill into Canada and now Australia, all eyes are on Europe: Could the Continent be next?

The statistics look alarming. In the Netherlands, oxycodone prescriptions doubled in only three years, while opioid prescriptions in the U.K. spiked by 127 percent between 1998 and 2016.

Europe certainly has an issue with opioids — the No. 1 drug-related killer on the Continent. They were involved in more than 80 percent of the 8,200 drug-related deaths recorded in 2017. But the situation is playing out differently than the one in the U.S., which recorded around 70,000 opioid-related deaths in 2017, and where the epidemic has claimed almost 400,000 lives in the past two decades.

Bart Morlion, president of the European Pain Federation (EFIC), says the far tighter regulation of opioid prescriptions in Europe plays a big role, including in the stricter controls over how drug companies advertise to patients and doctors. And in many European countries, especially in the south, people are more wary of painkillers.

Europe's environment "is completely different from the U.S.," Morlion told POLITICO.

"We are prepared if the tsunami comes to Europe in the next years" — SED President Juan Antonio Micó

Spain is a good case in point. The country saw opioid consumption increase by nearly 84 percent between 2008 and 2015. But people aren't flocking to emergency rooms or dying from overdoses due to their opioid prescriptions.

Some doctors are nonetheless ringing alarm bells that the country — and Europe — cannot be complacent.

“There are these differences that make us more protective than in the U.S.," said Aina Perelló Bratescu, a family doctor in Catalonia who studies opioid prescriptions in the region. "But it's not good to feel like there's no danger and everything is OK."

Of particular concern is Spain's spike in prescriptions for rapid release fentanyl, which doubled from 2010 to 2016. These drugs — often administered by a nasal spray or chewing tablets — are 50 to 100 times stronger than morphine. This worrying trend prompted the Spanish health ministry to update its prescription guidelines and convene a working group to discuss the issue.

'This is another country'



Experts in Spain are quick to point out how different the environment is from the U.S.

Víctor Mayoral, the secretary of the Spanish Society of Pain (SED) and a pain doctor in Catalonia, said practices like doctor-shopping — going from doctor to doctor to get more prescriptions — simply aren't possible in Spain thanks to the national rollout of electronic prescriptions five years ago.

Another big difference, according to Mayoral, is that the country is constantly on alert for prescription abuse. For example, on the local level in Catalonia, when someone is prescribed a "high dose" of an opioid (more than 90 milligrams of morphine, for example) he and the regional department of health pharmacists investigate the prescription, sometimes literally meeting at his house to discuss whether the prescription for a patient is accurate.

Spain has also taken steps to avoid conflict-of-interest problems that have drawn attention in the U.S. For example, Spain forbids pharma reps from taking doctors out for meals more than €60.

In addition, Spain adheres to an EU law that says pharma companies cannot provide doctors with drug samples.

Meanwhile, advertising standards vary greatly between the two continents. Pharma companies can advertise for aspirin and paracetamol in Spain. But opioids?

"The problem is that each time you feel the effect less. You need more doses, and more frequently" — Flora, an arthritis sufferer

“No, no, no,” Mayoral said.

And the doctors insist these measures are shoring up the country against a U.S.-style opioid epidemic.

"We are prepared if the tsunami comes to Europe in the next years," said SED President Juan Antonio Micó, talking on the sidelines of a recent event in Valencia. "But at this present moment, I don’t think it’s possible in Europe."

'A ticking time bomb'



Some patients disagree.

"I think it is only a matter of time ... that the problem of opioids in Spain is unleashed so much that it is impossible to silence it much more," said one patient, Flora, age 44.

Flora has degenerative arthritis. After other pain relievers became ineffective, her doctors had her try opioids. She started with moderate ones like tramadol, but once that stopped working, her general practitioner, in coordination with her neurosurgeon, moved her on to more intense opioids.

Quickly, those became less and less effective. "The problem is that each time you feel the effect less," she said. "You need more doses, and more frequently."

At some point, she was faced with a hard choice: She could either decrease her pain, or move her finger.

Flora was becoming increasingly tolerant to the fentanyl patches she was taking, and if she wanted to stop feeling pain, she would need more. More fentanyl, though, would leave her physically unable to move.

This is when she knew she was dependent.

"I couldn't go without them, but when I took them I couldn't do anything at all," said Flora, who used a different name for this article.

Perelló, the doctor, said it's sometimes difficult to tell whether opioids such as fentanyl patches are "over-prescribed." When there's a patient in serious pain, how does a doctor choose the right balance between relieving a patient's pain and creating an addict?

Rapid release fentanyl, though, is easier to judge because it's supposed to be used only for cancer patients, she said. In a 2018 regional study of 43,000 patients given strong opioids in Catalonia, the Catalan Health Service found 43 percent of the rapid release fentanyl prescriptions were for non-oncological pain. Another 20 percent were given high doses of opioids.

When asked about these numbers, a spokesperson for Spain’s pharma association Farmaindustria responded that companies can only promote medicines like rapid release fentanyl for their indicated use — in other words, they're staying within their legal guidelines.

"When the pain comes so strong it relaxes me and takes away the pain, but at what price?" — Hasan, patient on pain medication

But these numbers, Perelló said, are still worrying.

“We are giving it to them like there is no danger," she said.

Mostly commonly, Perelló said, she sees older women with chronic pain given fentanyl patches. It might help address their pain, but they are also left unable to move in their apartments.

Perelló said she also sees younger people who are prescribed the drugs over a long period of time — and the doctors are "making addicts."

56-year-old Hasan is one of them. He was injured in an accident as a construction worker at the age of 32, and began with a host of pain relievers to tackle the pain. Then, 12 years ago, he went to a pain clinic and was prescribed a high dose of fentanyl.

That kind of dosage is "for terminal cancer patients who will die, which is not my case," Hasan said. The drugs made him feel "doped all day."

Hasan's general practitioner realized he was a "ticking time bomb," but couldn't take Hasan off high potency opioids right away.

Hasan has whittled down his dose of Actiq — a fentanyl drug taken like a lollipop. Years of the drugs have worn away the roof of his mouth. He is still trying to decrease his intake.

The increase in prescription rates do worry those in Europe.

"When the pain comes so strong it relaxes me and takes away the pain," Hasan said, "but at what price?"

Lessons across Europe



Europe's approach to controlling legal prescriptions stands in contrast to the U.S. There, the "first wave" of the opioid epidemic began when people became addicted to legal prescription opioids like oxycodone, morphine and fentanyl. When patients built up a tolerance to the drugs, they were able to go doctor shopping to get more prescriptions and feed a growing addiction.

People then turned to the black market for illicit opioids like heroin or the many forms of synthetic fentanyl that made up the second and third waves of the opioid epidemic in the States.

By contrast, Fernando Ribas de Pina, an intervention specialist at the drug rehabilitation group Proyecto Hombre in Valencia, said he has not had a single person enter his center with an addiction to prescription opioids. Rather, typical addiction issues have more to do with alcohol and cocaine.

The increase in prescription rates do worry those in Europe.

"We are concerned because to the extent there is more fentanyl moving through society, the possibility of abusing it, of improper use, obviously increases," Ribas de Pina said, with printed news articles about the U.S. opioid epidemic laid out on a conference table in front of him.

“I think this analysis must be done in every single country” — Bart Morlion, president of the European Pain Federation

But by comparison, he said, there is "no significant sample" of that kind of illicit opioid abuse in the country.

Neither Flora or Hasan, for example, said they have ever turned to the black market to purchase illegal opioids.

Still, it's also clear that Europe lacks a complete picture of the problem, as there isn't any standardized data examining prescription opioids — and their abuse — around Europe. And it seems that in some countries, illicit opioid abuse is a bigger cause for concern. Estonia, for example, has a much longer history of opioid abuse, but most of this appears to be with synthetic fentanyl.



EFIC's Morlion points to specific measures his native Belgium has taken that he thinks should be adopted across the bloc. For example, the Belgian health ministry did an analysis to see which doctors were prescribing opioids too much.

“I think this analysis must be done in every single country,” EFIC's Morlion said.

But individual doctors need to be aware of the risks prescribing opioids, Perelló warned: "We are more calm than we should be."

Arnau Busquets Guàrdia contributed reporting.

UPDATE: This version includes a response from Farmaindustria and clarifies that the survey on fentanyl prescriptions was conducted by the Catalan Health Service.

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