Over the past few years, Canada and the United States have been experiencing an opioid crisis as a result of problematic opioid use fueled by the emergence of synthetic opioids such as fentanyl and carfentanil. Problematic opioid use is also spreading in other OECD countries, due to the upward trend of prescription opioid use and the complexities of the illegal drug supply. This report presents evidence on the magnitude of problematic opioid use across OECD countries, describes the main drivers, and identifies a set of policy actions to address them. The report highlights the opioid crisis as a complex public health issue that requires a comprehensive approach across all sectors, including health, social services, and law enforcement. Strong health information systems are also needed, particularly data and research. Preventing problematic opioid use requires a combination of policies that ensure more information is provided to patients and health care practitioners, while providing access to appropriate pain management treatment for patients. A public health approach to problematic opioid use must incorporate socio-economic considerations (e.g. employment and housing), which also need to be addressed to prevent problematic substance use in general.
Addressing Problematic Opioid Use in OECD Countries
Abstract
Executive Summary
Over-prescription of pain killers by doctors has contributed to a growing problematic opioid use in parts of the OECD with a surge in overdose deaths in the United States, Canada, Sweden, Norway, Ireland and parts of the United Kingdom pointing to a mounting health and social crisis fuelled by the illicit drugs trade.
The inappropriate use of opioids has hit diverse groups of the population, showing that a broad approach is needed to reach all the people at risk. Better treatment, care and support for people with use disorders to legal and illegal opioids (OUD) and better support for communities blighted by opioid dependence are vital at a time when opioid prescriptions and illicit sales by drug gangs are rising. Better and more closely monitored prescription by doctors and use of alternatives for dealing with chronic pain are also key to address the crisis. Awareness of the risks of the opioid crisis is growing but is relatively low outside countries where the crisis is most pronounced, such as the United States and Canada.
The average availability of prescription analgesic opioids has been steadily growing in the past 15 years across the OECD. There was a boom in the last decade. Between 2002-04 and 2005-07 analgesic opioids availability grew on average by more than 58%. More recently, between 2011-13 and 2014-16, the growth rate dropped to around 5% on average.
Not only has the average availability of both legal and illegal opioids risen across the OECD in the past 15 years but opioid-related deaths (ORD) have also climbed in many countries. Opioid abuse has also put a growing burden on health services through hospitalisation and emergency room visits. High opioid doses can lead to potentially fatal respiratory depression. Interventions such as needle and syringe programmes, supervised drug consumption rooms and opioid awareness in communities could all make a difference. More than half of all fatal overdoses occur in victim’s homes and more than half of deaths occur with another person present.
In 25 OECD countries for which data is available, the average of ORD has increased by more than 20% in 2011-2016, with the rise most pronounced in the United States, Canada, Sweden, Norway, Ireland, and England & Wales.
The majority of those who die are men, accounting for 3 out of 4 deaths. Other population groups, such as pregnant women have also been experiencing problematic opioid use. In the United States, having a mental health disorder was also associated with a two-fold greater use of prescription opioids. Prisoners too are vulnerable. The prevalence rate of opioid use disorders in Europe was less than 1% among the general public but 30% in the prison population. Social and economic conditions have also contributed to the crisis with opioid use and unemployment linked in some research.
In the United States, 399 230 people have died from an opioid overdose between 1999 and 2017, while in the years 2015 to 2017 life expectancy has decreased for the first time in more than 60 years, in part because of the opioid crisis. The United States is by no means alone in facing this crisis. In Canada, there were more than 10 000 opioid-related deaths between January 2016 and September 2018. In Australia, more than 1 000 people are dying a year due to opioid abuse with around three-quarters of those deaths linked to prescription opioids.
Opioid overprescribing is considered one of the most important root causes of the crisis. In the United States alone, there were 240 million opioid prescriptions dispensed in 2015, nearly one for every adult in the general population. In North America, hydrocodone, oxycodone, codeine and tramadol are the main prescription opioids used for non-medical purposes, while methadone, buprenorphine and fentanyl are the most misused opioids in Europe. The influence of pharmaceutical manufacturers on pain management has been considered significant, by conducting marketing campaigns targeted mainly at physicians and patients, downplaying the problematic effect of opioids.
However, higher rates of opioids availability are not necessarily correlated with higher overdose death rates, for instance, in Germany, Austria, Belgium, Denmark and the Netherlands. This suggests that appropriate regulation of prescription opioids can be compatible with higher availability of these drugs for medical use. Prescription monitoring and regulation to assure appropriate use of medical opioids is critical.
Opioids are used for the treatment of moderate to severe pain, including after surgery. Some opioids are also used in combination with counselling and behavioural therapies for the treatment of heroin and other drug addictions.
Opioid drugs work by binding to specialised receptors on the surfaces of opiate-sensitive cells, reducing pain messages and feelings of pain. These interactions trigger the same biochemical brain processes associated with feelings of pleasure in activities such as eating and sex. These reward processes can motivate repeated use and can lead to the development of opioid use disorders (OUD).
Illicit opioids constitute a significant product of international illicit trade. Heroin is a semi-synthetic opiate synthesised from morphine and is the most prevalent illicit opioid worldwide. Approximately twice as potent as morphine, heroin has a high potential for problematic use. In recent years, fentanyl and fentanyl analogues have become much more prominent in the illicit drugs scene in many countries.
Prescription opioids are analgesic medications that include natural opiates (e.g. morphine, codeine), semi-synthetic opioids (e.g. oxycodone, hydrocodone, hydromorphone, oxymorphone) and synthetic opioids (e.g. methadone, fentanyl, tramadol).
The opioid crisis is not only a health crisis. It also is a social and law enforcement dimensions.
Opioids have been over-prescribed by health care systems with limited alternatives for chronic pain management. There has also been inadequate access to the right treatments for opioid use disorder (OUD). Research and development on non-addictive treatments for chronic pain has not received the same priority as other areas.
Illicit opioids are increasingly available at low cost and with high purity, including highly toxic substances such as fentanyl and its analogues. A miniscule amount of pure fentanyl (about the size of a pinch of salt) can be fatal. In the United States, Canada and some European countries fentanyl analogues account for a large component of the opioid crisis.
Economic and social conditions, such as unemployment, housing and exclusion are also linked to the opioid crisis.
Countries can consider four key areas for a better approach to dealing with opioid use and harms.
Better Prescribing: Doctors can improve their prescribing practices, for instance, through evidence-based clinical guidelines (e.g. for opioid prescription, for adequate medication-assisted therapy for OUD patients), prescribers training, surveillance of opioid prescriptions, and regulation of marketing and financial relationships with opioid manufacturers. In addition, patients and the general public can also benefit from clear educational materials and awareness interventions to enhance their opioid-related literacy and reduce stigma.
Better care: Including the expansion of coverage for long-term medication-assisted therapy (e.g. methadone, buprenorphine, naltrexone) coupled with specialised services for infectious diseases management (e.g. HIV, hepatitis) and psychosocial interventions. Some countries have implemented interventions such as the availability of overdose reversal medications for all first responders, needle and syringe programmes, and medically supervised consumption centres. Quality of care must be improved and measured.
Better approach: There can be better coordination across the health, social and criminal justice systems. Governments can consider setting up of coordinated networks among the three sectors aiming to facilitate access to integrated services for people with OUD. In addition to health services, social interventions around housing and employment support, and law enforcement uptake of a public health approach are central.
Better knowledge and research: Including the use of big data and impact evaluations to generate new information from different sources along with the application of advanced analytics. In addition, quality of care measurement should be enhanced in areas such as opioid prescription, OUD health care services, and patient reported indicators (e.g. PROMs, PREMs). Research and development is needed in key areas such as new pain management modalities and OUD treatments.
