Addressing Problematic Opioid Use in OECD Countries

Annex A.  Description of the opioid crisis in Australia, Canada and the United States

Description of the opioid crisis in Australia, Canada and the United States

Australia’s epidemic is situated mainly around prescription opioids

Australia has been experiencing growing rates of opioids consumption that are affecting population health. In 2016, there were 1 119 opioid related deaths (ORD), which represents an increase of 62% compared with 2007, or an increase from 2.9 to 4.7 deaths per 100 000 population. This growth has been driven by an increase in both accidental and pharmaceutical opioid deaths. Males have experienced higher ORD rates than females while lower socioeconomic groups have the highest ORD rates among socioeconomic groups (AIHW, 2018[26]).

The highest rates of opioid-induced death in 2016 were for natural and semisynthetic opioids (e.g., morphine, oxycodone, codeine), with 3.1 deaths per 100 000 people (498 deaths). The rate of deaths attributed to heroin has been increasing with 2.2 deaths per 100 000 people in 2016 (357 deaths) compared to 0.9 in 2007. The rate of deaths attributed to synthetic opioids (e.g. tramadol and fentanyl) has also increased, passing from 0.11 per 100 000 in 2007 to 1.3 deaths per 100 000 people (214 deaths) in 2016 (see Figure A.1). The rate of opioid-induced deaths was higher among males, and among those aged 35‑44 years, with low rates recorded among the 15‑24 age group, which has been a consistent trend. Most of the opioid-induced deaths were considered accidental (85%), with 12% recorded as intentional (Roxburgh et al., 2018[241]).

Figure A.1. Rate of opioid-induced deaths per 100 000 inhabitants, by type of opioid, Australia 1997‑2016

Source: (Roxburgh et al., 2018[241]). Adapted and reproduced with permission from the authors.

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In relation to prescriptions, between 2012-13 and 2016-17, rates of prescriptions in Australia increased, in particular for strong opioids such as oxycodone. However, after adjusting to rate of Oral Morphine Equivalent doses to account for the different dosage strengths and potency of each opioid, there was no change over the period indicating prescriptions were on average for lower doses and/or quantities per prescription (AIHW, 2018[26]). Studies have found a considerable geographic variation in opioid utilisation, with higher rates of use in less populated rural areas that had more men and older people, proportionally more low-income earning households and greater proportions in jobs requiring physical labour (Degenhardt et al., 2016[242]).

In the area of inappropriate use and illicit use of opioids, among the population aged 14 and over in 2016, 3.6% had recently used prescription opioids for non-medical purposes, and of those reporting use, over-the-counter codeine products were the most common (2.5%), followed by prescription codeine products (1.4%). Less common was oxycodone (0.6%), tramadol (0.3%), morphine (0.1%) and fentanyl (<0.1%). Only a small proportion (1.3%) reported ever using heroin in their life, and 0.2% reported using it in the last 12 months, situating heroin behind cannabis, methamphetamine, pharmaceutical drugs and psychoactive substances. However, frequency of use is much higher than other drugs with 49% of recent users reported using heroin once a week or more. In addition, heroin is the preferred drug among people who inject drugs in Australia (Australian Institute of Health and Welfare, 2018[243]).

The Australian Burden of Disease Study (AIHW, 2016[244]) estimated that in 2011 opioid use was responsible for 0.9% of the total burden of disease and injuries. Most of the burden due to opioid use was due to accidental poisoning (63%), followed by opioid dependence (30%) and suicide and self-inflicted injuries (7.8%). Opioid use was responsible for just over half (51%) of all accidental poisoning burden, all opioid dependence burden and 3% of suicide and self-inflicted injuries burden.

In terms of health services demand, from 2007–08 to 2016–17, the rate of hospitalisations per 100 000 population with a principal diagnosis of opioid poisoning increased by 25%, from 14.1 to 17.6 hospitalisations, while the rate of hospitalisations with any diagnosis (all reasons for hospitalisation) of opioid poisoning increased by 38%, from 29.0 to 40.1 per 100 000 population. The increase in hospitalisations was mostly driven by increases in the numbers of hospitalisations for poisoning by pharmaceutical opioids. Likewise, there were 4 232 emergency department presentations (17.5 presentations per 100 000 population) with a principal diagnosis of opioid poisoning—12 per day. The rate of ED presentations was 1.3 times as high for males as for females (19.7 and 15.3 per 100 000 population, respectively) (AIHW, 2018[26]).

In terms of treatment, in 2016–17, 8.2% of all alcohol and other drug treatment services had opioids listed as the principal drug of concern—a total of 16 428 closed treatment episodes. In 2016–17, heroin was the fourth most common principal drug of concern and accounted for 5% of all closed treatment episodes (AIHW, 2018[245]).

Canada’s recent unfold of an opioid crisis

Canada is currently facing an opioid crisis that has affected every part of the country. According to data reported as of March 2019, there were more than 10 300 opioid-related deaths between January 2016 and September 2018. Most deaths were accidental apparent opioid-related deaths (92‑94%), happened mainly among males (76‑78%) and in individuals between the ages of 30 and 39 (27‑28%). In this scenario, the death rate increased from 8.4 per 100 000 population in 2016 to 11.1 in 2017 and 11.8 in 2018 (Jan‑Sept). In the latter period, the Provinces of British Columbia and Alberta had the highest death rates with 30.9 and 19 per 100 000 population, respectively (Special Advisory Committee on the Epidemic of Opioid Overdoses, 2019[31]).

From 1990 to 2014, the age-standardized years-of-life-lost rate due to opioid-related mortality in Canada increased by 142.2%. Likewise, the age-standardised opioid-related disability-adjusted life years rate in the country was 355.5 per 100 000 population in 2014, which was higher than the global rate of 193.2, but lower than the rate of 767.9 in the United States (see Figure 3.5) (Orpana et al., 2018[246]). Life expectancy at birth was analysed in British Columbia, showing that it decreased by 0.38 years from 2014 to 2016 with fatal drug overdoses (the majority involving opioids) accounting for 32% of the decrease (Ye et al., 2018[32]).

Figure A.2. Age-standardized opioid-related mortality rates per 100 000 population, males and females, 1990‑2014, global and Canada

Source: (Orpana et al., 2018[246]); Statistics Canada: Vital Statistics.

The Canadian health system has also experienced increased demand related to opioid harm. In 2016/17, opioid poisonings resulted in an average of 16 hospitalisations a day in Canada, with an increase of 53% in the rate of hospitalizations over the past ten years (see Figure 3.6). In 2016/17, there were an average of 11 emergency department visits in Alberta and 13 in Ontario each day. Over the past five years, the age-adjusted rate of emergency department visits due to opioid poisoning has more than doubled in Alberta and has increased by 47% in Ontario. Both for hospitalisations and emergency department visits, most of the increases have occurred over the last three years (O’Connor, Grywacheski and Louie, 2018[247]).

Figure A.3. Opioid poisoning hospitalisations, Canada, 2007/08 to 2016/17

Source: (O’Connor, Grywacheski and Louie, 2018[247]); Canadian Institute for Health Information: Hospital Morbidity Database.

Between 2012 and 2017, both the number of prescriptions and the amount of opioids prescribed decreased. Compared to 2016, there was a 10.1% of reduction in the quantity of opioids prescribed in 2017 passing from 6 269 to 5 633 DDDs per 1 000 population. In 2017, 21.3 million prescriptions for opioids were dispensed, compared with 21.7 million in 2016. This is still higher than the number of prescriptions in 2012 but the first decline in overall prescription between 2012 and 2017 (CIHI, 2018[248]).

Awareness about the opioid crisis vary across provinces, with 38% of the population in British Columbia declaring being very aware but only 18% in Québec. Remarkably, 71% of the population declares being very aware that drugs illegally obtained have the potential to contain fentanyl. In addition, three-in-ten Canadians aged 18 and over reported using some form of opioids in the past five years. Of those, more than one-in-four have leftover opioids being stored in the home (Statistics Canada, 2018[249]).

Opioid crisis in the United States: a tale of three cumulative waves over more than 20 years

The United States is facing one the worst drug crisis in its history, mainly driven by problematic use of opioids. From 1999 to 2017, 399 230 people died from an overdose involving an opioid, representing 56.8% of all drug overdoses deaths. Opioids were involved in 42 249 deaths in 2016 and in 47 600 overdose deaths in 2017 (67.8% of all drug overdose deaths). From 2013 to 2017, drug overdose death rates increased in 35 of 50 states and DC, and significant increases in death rates involving synthetic opioids occurred in 15 of 20 states, likely driven by illicitly manufactured fentanyl (Scholl et al., 2018[250]).

In 2016, nearly 92 million people reported use of a prescription opioid, while 11.5 million reported inappropriate use, and 2.1 million met the criteria for an OUD (Substance Abuse and Mental Health Services Administration, n.d.[251]). The latter occurred along with an upsurge in injection-related infections, including increments in hepatitis C, endocarditis and osteomyelitis, and HIV diagnoses among persons who inject drugs (Johnson et al., 2018[252]).

This rise in opioid overdose deaths can be outlined in three distinct waves (see Figure 3.7) (CDC Injury Center, 2018[253]; Jones, Einstein and Compton, 2018[254]).

• The first wave began with increased prescribing of opioids in mid-1990s, with overdose deaths involving prescription opioids increasing since at least 1999. In 2016, they were involved in 40% of opioids overdose deaths.

• The second wave began in 2010, with rapid increases in overdose deaths involving heroin. In 2016, they were involved in 36.6% of opioid overdose deaths.

• The third wave began in 2013, with significant increases in overdose deaths involving synthetic opioids – particularly those involving illicitly manufactured fentanyl. In 2016, they were involved in 46% of opioid overdose deaths, which increased to 60% in 2017.

Figure A.4. Overdose deaths involving opioids, by type of opioids, United States, 1999‑2016

Source: (CDC-NCHS, 2018[35]).

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Life expectancy in the United States has fallen in 2015 and 2016, a two-year run that happened for the first time since 1962 and 1963 (see Figure 3.8). These declines in life expectancy are due largely to increases in mortality in younger age groups, especially ages 15‑34 and increases in mortality due to unintentional injuries, especially drug overdoses; along with a slowdown in the improvements in mortality. Heart disease mortality in particular is declining at a much slower rate, reportedly driven by the worsening opioid crisis. Recent data for 2017 showed a new slight decline in life expectancy, passing from 78.7 in 2016 to 78.6 years (Murphy et al., 2017[255]).

Figure A.5. Two-year declines in life expectancy at birth: United States, 1950‑2016

Source: (CDC-NCHS, 2018[35]).

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Regarding the economic consequences of the opioid crisis, a recent study found that between 1999 and 2015 the decline in labour force participation caused by opioid use in the United States cumulatively cost the economy 12.1 billion work hours, and the reduction in work hours slowed the real annual economic growth rate by 0.2 percentage points, cumulatively costing USD 702.1 billion in real output (Gitis and Soto, 2018[83]). Likewise, the Council of Economic Advisers in the United States White House estimated the cost of the opioid drug epidemic in 2015 at USD 504 billion or 2.8% of GDP that year, stating that previous data was underestimating the real economic impact of the crisis (Council of Economic Advisers, 2017[34]).