This nationwide study revealed a considerable decrease in opioid consumption, as measured by the number of opioid prescriptions filled, from 2016 to 2021 in a cohort of > 7 million people. This trend is in line with global efforts to prevent overprescription of opioids and subsequent misuse. The observed decrease is primarily attributable to a reduction in the number of individuals obtaining a prescription for tramadol, whereas the utilisation of strong opioids appears to have remained relatively stable. However, the distribution of opioid prescriptions in Austria differs from global patterns. The consumption of tramadol is predominant in terms of the number of filled prescriptions. This pattern diverges from the typical consumption patterns observed in high-income countries and aligns more closely with those of middle/low-income countries [10]. The observed prevalence of tramadol may be attributed to its perceived safety profile compared with that of other opioids. Furthermore, in Austria, an opioid drug prescription label is required for “strong” opioids, necessitating additional organisational measures for the prescribing physician. Tramadol and dihydrocodeine do not require such a label, making them easier to prescribe. This fact may also contribute to the dominant prevalence of tramadol in Austria. In terms of prescribed morphine milligram equivalents, fentanyl is the leading prescription opioid, in accordance with the findings of Jayawardana et al., who reported that Austria ranked fourth worldwide in 2019 in terms of fentanyl consumption [10]. Between 2016 and 2021, the number of fentanyl prescriptions notably decreased in terms of MME/t/d, whereas the remaining opioids exhibited a consistent pattern. In contrast to other high-income countries like the US, where oxycodone is the most frequently prescribed opioid, Austria has a low oxycodone prescription rate [11]. Austria's cautious approach to oxycodone prescribing may have protected it from the opioid epidemic experienced in other countries, suggesting that strict regulatory frameworks can effectively address the risks of opioid misuse.

Dihydrocodeine is primarily prescribed as an antitussive agent; therefore, its prescription rates need careful interpretation. The dual use of dihydrocodeine for both pain management and cough treatment complicates the analysis because its prescription statistics may be inflated by its use for cough treatment rather than solely for pain relief. However, dihydrocodeine usage in Austria has remained consistently low and stable from 2016 to 2021, suggesting that it does not substantially contribute to overall opioid consumption in the country. Similarly, the prescription rate for tapentadol is notably low, which may be attributable to the complexities associated with the prescription process, including the necessity for separate authorisation from the health insurance company.

The question arises as to why Austria, a European high-income country, is not experiencing an opioid crisis and, in contrast, is even recording a decrease in opioid prescriptions. One explanation may be the traditionally strict prescription system for opioids. This system requires a special prescription for opioids, which is reported to a central register and results in an additional administrative burden for the prescriber. Moreover, the approach to pain management in Austria emphasises a more cautious use of opioids than practices observed in other countries, where opioids may be prescribed for less severe pain [12]. For example, whereas a patient in the US might be quickly prescribed opioids for a headache, this practice is uncommon in Austria [13]. This discrepancy may also be attributed to the fact that expensive diagnostics and treatments, including all medically necessary surgeries, are fully covered by compulsory insurance, with no age limit or similar restrictions. This coverage may not be the case in other countries. Because opioids are often prescribed in connection with musculoskeletal pain, orthopaedic surgery can result in significant pain relief, which consequently reduces the need for opioids or allows them to be discontinued. Furthermore, patients in Austria tend to stay in the hospital longer than those in the US do, allowing opioid therapy to be introduced and terminated under controlled conditions.

The logistic regression analysis demonstrated a significant correlation between all analysed factors and the likelihood of being prescribed an opioid. Notably, age, a history of persistent somatoform pain disorder, the use of benzodiazepines in the preceding year and a diagnosis of a pain disorder were positively correlated. Of particular concern is the strong positive correlation between opioid prescriptions and pain disorders, such as unspecific back pain and persistent somatoform pain disorders, because opioids are not indicated for this condition [14]. Nociplastic pain, which presents without a clear organic cause, should be managed through psychological and behavioural interventions rather than opioid analgesics [15]. This misalignment with established clinical guidelines, which advise against opioid use because of the risk of dependency and lack of efficacy, points to a significant area for improvement in clinical practice.

Furthermore, the coprescription of benzodiazepines and opioids is problematic because of the increased risk of complications, as both medications can cause sedation and respiratory depression. Jeffery et al. reported that 25% of long-term opioid users concomitantly consume benzodiazepines [16]. Several previous studies have shown that concomitant opioid and benzodiazepine use is associated with an increased risk of overdose compared with opioid use alone, a finding recently strengthened by Hamina et al. in a cohort of individuals receiving pharmacological treatment for chronic pain [17,18,19,20,21,22]. This finding emphasises the necessity for health care providers to be more aware and to adhere more strictly to appropriate treatment protocols. General practitioners are frequently the initial prescribers of opioids (82%) and are responsible for the majority (88%) of filled opioid prescriptions. They are the first point of contact for many patients and therefore play a pivotal role in pain management. However, general practitioners often lack specialised training in pain management. Enhancing their knowledge and optimising prescribing practices are therefore crucial to ensuring safer, more effective pain management while minimising the risks of misuse and dependence.

The decrease in the prescription of nonopioid analgesics is due mainly to a reduction in the prescription of NSAIDs. However, the total number of nonopioid prescriptions derived from insurance data may not accurately reflect their use because some drugs are available over the counter and therefore do not require a prescription.

Although the number of nonopioid prescriptions decreased, the number of metamizole prescriptions filled in Austria significantly increased between 2016 and 2021. Metamizole is only registered in a few countries, but its use is widespread in the DACH region (Germany, Switzerland and Austria). The main concerns are agranulocytosis and, more recently, drug-induced liver injury [23], which are rare but serious side effects associated with its use [24, 25]. Nevertheless, metamizole is a well-established analgesic, especially in elderly individuals, where renal insufficiency may be problematic, and it has fewer gastrointestinal and cardiovascular adverse effects. Metamizole may reduce the need for opioid administration [25, 26]. Prescribing nonopioid analgesics as a primary treatment and adding opioids only when necessary is consistent with international guidelines that aim to minimise the use of opioids [27,28,29]. The increasing use of metamizole prescriptions in Austria may indicate a shift in pain management strategies to reduce the use of opioids wherever possible and possibly reduce the use of NSAIDs to address concerns about gastrointestinal side effects.

A limitation of our study is the possible discrepancy between the quantity of dispensed medications and the actual consumption by patients. The discrepancy identified may lead to an overestimation of medication usage rates, which could affect the precision of our findings on opioid and nonopioid analgesic consumption patterns. Another factor that may result in over- or underrepresentation of opioid consumption is the variability in conversion factors employed to calculate morphine milligram equivalents. This variability complicates comparisons between studies because different conversion factors may yield different results. Furthermore, although Austria's comprehensive social insurance system covers most pharmaceuticals, our dataset may not include all instances of painkiller consumption, especially when medications are not covered by insurance, such as when they are priced below the prescription charge or are categorically nonreimbursable.

Additionally, this study may have limitations due to the overrepresentation of medications dispensed to patients who are exempt from the prescription charge and the multifaceted use of some medications beyond pain management. Among all filled analgesic prescriptions, 43.83% were exempt. Furthermore, in some cases, we cannot discern the indication for a prescription drug. For example, paracetamol and other nonopioid painkillers are used as both analgesics and antipyretics, whereas dihydrocodeine is also prescribed for its antitussive effect. Finally, our study covers a significant proportion of the Austrian population (98.5% coverage) and thus may have a minimal impact on the generalizability of our findings.