En la última década, países como EEUU han sufrido una epidemia de adicción a opioides sin precedentes, que ha provocado la muerte por sobredosis a miles de ciudadanos y una oleada de demandas contra las farmacéuticas que los vendían sin escrúpulo. En España los expertos llaman a la tranquilidad, ya que la prescripción médica está muy controlada, así como los cauces administrativos con los que contamos, lo que nos sitúa a años luz de estos países.
Los opioides son los fármacos analgésicos más potentes con los que contamos en la actualidad y se utilizan para tratar episodios de dolor agudo y, generalmente, corto. Se prescriben fundamentalmente en pacientes oncológicos, por los dolores relativos a la enfermedad y los tratamientos e intervenciones que se derivan de ella. Su acción analgésica se produce gracias a su interacción con los receptores opioides de las neuronas del sistema nervioso central. El riesgo de adicción es la principal limitación de uso de estos analgésicos, de ahí que suelan reservarse para tratamientos de corta duración en dolor muy agudo o esencialmente para aliviar el dolor en pacientes terminales y oncológicos.
El estreñimiento inducido por opioides (EIO) es el efecto adverso más común en los pacientes que siguen un tratamiento analgésico con opioides. Los analgésicos opioides ejercen sus efectos de manera predominante a nivel del sistema nervioso central, aunque también actúan a nivel periférico sobre el sistema nervioso entérico del tracto gastrointestinal, lo que altera la motilidad intestinal conduciendo a un tránsito gastrointestinal más lento, una reducción de las secreciones y un aumento del tono de los esfínteres, produciendo el estreñimiento, según explica el doctor Joan Santamaría, jefe sección Medicina Interna del Hospital General de Palma de Mallorca y responsable de la unidad de Medicina Paliativa del Sector sanitario de Ponent de Mallorca.
Crisis de los opioides en EEUU
A día de hoy, la epidemia de opiáceos de EEUU persiste y según las cifras, en 2017 fallecieron 24.000 pacientes por sobredosis de opioides recetados. Según las conclusiones extraídas en la Jornada Opioides 2019 llevada a cabo por el Grupo de Trabajo de Opioides de la Sociedad Española del Dolor (SED), las muertes por sobredosis en EEUU están asociadas, en su mayoría, al uso de fentanilo ilegal o heroína. Otra de las conclusiones es que, aunque en Europa ha aumentado considerablemente el uso de opioides prescritos, continuamos muy lejos de las cifras de EEUU y en España existe una baja prevalencia de dependencia opioide, estipulada en un 5%, relacionada con altas dosis de opioides y la asociación con benzodiazepinas. De hecho, según explican desde el Grupo de Trabajo de Dolor de la Sociedad Española de Médicos Generales y de Familia (SEMG), actualmente, a diferencia de EEUU o Canadá, en nuestro país no podemos decir que haya un problema de abuso o prescripción inadecuada de este tipo de opioides.
Aquí, los médicos controlan
En base a los datos de la Encuesta Edades 2017-2018 (Encuesta sobre Alcohol y Drogas en España), el 14,5 por ciento de la población española ha consumido opioides en alguna ocasión. De ellos, el 95,7 por ciento de las personas que han consumido opiáceos señalan que lo han hecho por prescripción directa de su médico. Los casos de personas que se hacen con estos fármacos de manera irregular son residuales, y la gente que los ha tomado fuera del período indicado por su médico ni siquiera llega al 10 por ciento, sumando aquellos que lo han tomado por un período más prolongado que el previsto o en dosis más altas o aquellos que pudieran tener algún tipo de adicción, que representan un 1,5 por ciento del total de la población. Aunque es cierto que se ha observado un aumento en el consumo de estos analgésicos en los últimos años, los expertos lo achacan al envejecimiento de la población, que se traduce en más dolor y, por consiguiente, en un aumento del uso de estos fármacos.
Los expertos coinciden en que existe un gran control en la prescripción de opioides en la práctica clínica, ya que en la prescripción de cualquier opioide existe un doble sistema de control: el que establecen nuestros médicos, con su prescripción adecuada al código deontológico; y el que ejerce la Administración con la limitación de prescripción crónica a tres meses. Todo lo cual hace que los casos de adicción sean muy poco frecuentes, fácilmente detectables y tratados dentro de nuestro mismo sistema. En la prescripción, además del tipo de opioide, su dosis y su duración, hay que valorar otros aspectos. Además, explican desde la SEMG, existen herramientas como el OPIOID RISK TOOL, desarrollado específicamente para pacientes con dolor, que permiten valorar el riesgo de adicción a opioides antes de iniciar un tratamiento, y otras como SOAPP-R y COMM, que nos permiten valorar si pacientes en tratamiento crónico con estos medicamentos están desarrollando conductas aberrantes.
Otro escenario es el de su utilización fuera de indicación, es decir, en pacientes con dolor no oncológico. En este caso, desde la Sociedad Española del Dolor, al igual que otros organismos científicos europeos y mundiales hacen un llamamiento a la prescripción responsable, ya que en los pacientes con dolor crónico no oncológico se debe tener muy claro el balance riesgo/beneficio de su utilización y conocer y evitar los riesgos de su uso, especialmente el riesgo de adicción
Tramadol/paracetamol y fentanilo
Es cierto que en España hemos asistido a un aumento del consumo de opioides, especialmente debido a la asociación tramadol/paracetamol, que es un opioide menor con muy bajo riesgo de adicción y habitualmente utilizado en dosis bajas y potenciado con su asociación al paracetamol. Según los expertos, es lógico que en una población cada vez más envejecida como la española, donde la población con dolor crónico se va incrementando progresivamente, entre otros motivos por el aumento de la patología degenerativa, el consumo de analgésicos aumente y especialmente con tratamientos aprobados para uso crónico. Paralelamente al aumento del consumo de tramadol/paracetamol, también ha existido un aumento del consumo de fentanilo, un analgésico con una potencia mayor a la morfina pero que se prescribe en dosis más pequeñas. Este es ya un opioide mayor, y aunque en el último informe de la AEMPS no se detalla exactamente qué tipo de fentanilo es aquel por el que han saltado las alarmas en nuestro país, por la cronología se sabe que en gran parte se trata de fentanilo de liberación transmucosa, que se caracteriza por su alta biodisponibilidad y rápida absorción y por ser potencialmente más adictivo. Según ponía de manifiesto Ana Henche, responsable de la unidad de conductas adictivas de Toledo en el XXIII Congreso Nacional de la Sociedad Española de Farmacéuticos de Atención Primaria (Sefap), el uso del fentanilo transmucoso para otro tipo de dolores diferentes al indicado en su ficha técnica puede generar “una dependencia física muy fuerte” en los pacientes, que cada vez requieren dosis más altas, lo que puede acabar en última instancia en “una sobredosis incluso con resultado de muerte”. Ana Henche manifestaba que “los opioides no se deben utilizar de entrada porque no están indicados para ningún tipo de dolor como primera línea de tratamiento”, y solo en caso de dolores moderados o severos. “Ahora, el tramadol se utiliza para todo, y donde antes se pautaban ibuprofeno o paracetamol ahora se receta muchas veces el tramadol, un opiáceo que sobre todo en dolor crónico no oncológico se utiliza en dosis muy altas y durante mucho tiempo, con lo cual el potencial adictivo es importante”.
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