Addressing Problematic Opioid Use in OECD Countries

4. Policies to address the opioid crisis and prevent opioid-related harms

This section outlines the main policy areas that countries can consider for addressing the opioid crisis. As explained in previous sections, problematic use of opioids is a complex phenomenon, influenced by the combined effects of multiple interconnected factors. For this reason, the policy response is likely to require interventions cutting across sectors and policy fields. In order to assist countries in addressing opioid use, and identify a clear set of effective policy actions, a preliminary policy framework has been created (see Table 4.1).

The policy framework was developed following the range of actions and policies identified in reports by the Government of Canada (Government of Canada, 2018[92]), EMCDDA (EMCDDA, 2017[93]), the US Presidential Commission about the opioid crisis (Christie et al., 2017[41]), and both the literature review and interviews with experts. It will be further enriched with comments from OECD country delegates, so the current framework should be considered a preliminary version. The framework draws attention to sectors beyond health systems, such as social and law enforcement sectors. It thus emphasises the necessity of combined policy action. Finally, further good practices from OECD countries will be identified to complement the current version of the paper.

Table 4.1. Policy framework to address opioids use and harms

	PRESCRIPTION OPIOIDS	ILLICIT OPIOIDS
1. HEALTH SYSTEM
Prevention	Patient and family literacy, general population awareness and stigma reduction
	Prescription support and surveillance
	Regulation of opioids marketing and financial relationships
Opioid use disorder treatment and harm minimisation	Medication assisted therapy within long-term care programmes
	Coordination for early detection and linkage with specialised services
	Needle and syringe programmes
		Medically supervised consumption centres
2. SOCIAL POLICY
Housing	Housing services
Employment	Employment support services
Recovery services	Social services/Residential rehabilitation
3. REGULATION AND ENFORCEMENT
Law enforcement practice		Customs interventions
		Internet-darknet illicit trade of opioids
	Prevention of medication diversion
	Law enforcement officials interventions
Criminal justice system	Drug treatment interventions
	Laws around personal use and possession of drugs

This framework is organised into three dimensions, which apply to both prescription and illicit opioids. Within each dimension, there are policy areas that can relate to both subgroups of opioids or to just one. The dimensions are the following:

• Health system interventions: including prevention, treatment, harm minimisation and health financing issues that are designed and implemented mainly in the health sector.

• Social policy: covering housing, employment and recovery support services for people with OUDs and their families.

• Legal system and law enforcement: interventions around international cooperation, customs, and the criminal justice system, including police and investigation.

In addition, the area of information and knowledge generation was identified as a key policy lever. These are cross-cutting issues covering data, information and research that could contribute to better decision making at different levels of the health system, social affairs and law enforcement institutions.

In order to gain a more comprehensive understanding of countries’ response to problematic opioid use, a survey was administered to OECD countries. The 20 countries that responded show a mixed picture with respect to the development of policies and actions. Table 4.2 provides an overview of the main policy initiatives identified through the questionnaire in the dimensions of health system and social policies. The remainder of this section discusses these initiatives in more detail, complementing it with an extensive review of academic articles, grey literature and national reports.

Table 4.2. Health system and social policies for opioid control identified from the survey responses – 20 OECD countries

	AUS	CAN	CHE	COL	CZE	DEN	DEU	EST	FRA	IRL	ITA	JPN	KOR	LTU	LUX	LVA	NOR	SWE	SVN	USA
HEALTH SYSTEM DIMENSION
Clinical guidelines	●	●			●	●	●		●	●	●	●		●		●	●	●	●	○
Stewardship programmes	●	○		●		●	○			●		●				●	●	○	●	○
Medical treatment	●	○	●	●	●	●	●	●	●	●	●			●	●	●	●	●	●	○
Disciplinary actions for physicians overprescribing	○	○	○			●	●	●		●	●				●	●	●	●		○
Self-help and mutual aid groups	●	○	○	●		●	●	●	●	●	○		●		●	●	●	●	●	○
Needle/syringe programmes	●	○	○	○	●	○	○	●	●	●				●	●	●	●	○	●	○
Drug consumption rooms	○	○	○			○	○		●						○		○
SOCIAL POLICY DIMENSION
Residential rehabilitation	●	○	○	●	●	●	●	●	●	●	●		●	●	●	●	●	●	●	○
Social reintegration support	●	○	○	●	●	●	●	●	►	●	●	●	●	●	●		○	●	●	○

Level of implementation:

● = Nation wide

○ = Sub-national

► = Single / group of providers

* Stewardship programmes aims at promoting judicious use of opioids and at avoiding over-prescription. They generally include one or more of the following activities: i) creation of multidisciplinary teams composed by experts in pain management, clinical pharmacists, etc.; ii) training of prescribers; iii) review of prescribing practices and feedback; iv) use of prescribing tools as formulary with restricted prescribing of opioids or clinical computer systems.

** Support programmes, which may include behavioural and psychosocial interventions, education, and access to medicines (medication assisted therapy) such as naloxone (including take-home), naltrexone, methadone or buprenorphine, for instance, in emergency rooms (e.g. acute overdoses treatment), ambulatory care, etc.

*** Residential rehabilitation involves living in a treatment facility and following a structured care programme.

Source: OECD 2018 survey on opioids control.

4.1. Health system policies and interventions to address the needs of opioid use disorder patients and the population

Health system interventions include three main aspects: prevention initiatives -- targeted at the general population, high-risk people and families, prescribers, and industry; treatment, targeted at patients who suffer from an OUD; and interventions aimed at reducing the harm and negative consequences associated with opioid use or inappropriate use.

4.1.1. Prevention: changing behaviours of patients, providers, and industry practices

Patient and family opioid-related literacy, general population awareness and reduction of stigma

Primary prevention actions directed at patients and their families aim to improve opioid-related literacy, as patients commonly report not receiving sufficient information on the problematic potential of opioid analgesics and the consequences of abusing opioids (Hadden, Prince and Barnes, 2016[94]). At the same time, awareness initiatives serve to combat the stigma around opioid use, which represents a significant limitation to treatment access and social integration of people with OUDs (Olsen and Sharfstein, 2014[95]). A recent randomised controlled trial evaluated the effectiveness of an educational intervention (a one-page information sheet about hydrocodone-acetaminophen) and concluded that this strategy improved by 25% several, although not all, aspects of patient knowledge (McCarthy et al., 2015[96]).

Canada has emphasised on patient opioid literacy and awareness campaigns. Canada’s initiatives include making warning stickers and patient information handouts mandatory with all opioids dispensed to Canadians at pharmacies or in doctors’ offices (Health Canada, 2018[97]). Furthermore, the Canadian Government has supported summer festivals and post-secondary school orientation activities, as well as producing online interactive resources to help promote awareness on preventing opioid overdoses (Government of Canada, 2018[98]). In the UK, the initiative Opioids Aware (The Royal College of Anaesthetists and Public Health England, 2018[99]) is a web-based awareness resource, funded by Public Health England and hosted by the Royal College of Anaesthetists. The initiative includes a section targeted at patients, aimed to help them make an informed decision about starting opioid therapy, as well as to provide them with information on the opioid undesirable consequences.

In relation to stigma, one review (Livingston et al., 2012[90]) found evidence for interventions at three levels: self-, social and structural stigma. Self‐stigma can be reduced through therapeutic interventions such as group‐based acceptance and commitment therapy. Effective strategies for addressing social stigma include motivational interviewing and communicating positive stories of people with substance use disorders. For changing stigma at a structural level, contact‐based training and education programs targeting medical students and professionals (e.g. police, counsellors) have shown to be effective.

Drug take-back actions constitute a viable strategy to reduce the harm associated with problematic use of prescription opioids, since often pills dispensed exceed the quantity prescribed (Maughan et al., 2016[100]; Kennedy-Hendricks et al., 2016[101]). Drug take-back programmes provide a way of facilitating the proper disposal of controlled substance medications, including opioids (Gray and Hagemeier, 2012[102]). Studies have shown positive impacts on patient awareness (Yanovitzky, 2016[103]) and have proven that such programmes collect a significant quantity of medications (Stewart et al., 2015[104]), but there is no evidence about the effects on inappropriate use or harms associated with opioid use.

Opioid prescription support and surveillance to improve provider practices

The development and use of clinical practice guidelines (CPG) to steer the appropriate use of prescription opioids, for instance for chronic pain, has been expanding. CPG mostly agree on several opioid risk mitigation strategies, including upper dosing thresholds; cautions with certain medications; attention to drug–drug and drug–disease interactions; and use of risk assessment tools, treatment agreements, and urine drug testing (Nuckols et al., 2014[105]). Reviews have shown positive results of CPG implementation, with smaller percentages of patients managed with high dose opioids; higher percentages of providersavoiding long-acting opioids for acute pain or in combination with benzodiazepines; and physicians more likely to use tools like drug screens in patients with substance use disorder. Similar findings occurred in emergency department and hospital CPG, showing declines in number and rate of opioid prescribing, lower average daily doses, and decreases in emergency department visits and deaths. However, the design of the studies were weak and these findings must be interpreted carefully (Haegerich et al., 2014[106]). More recently, the release of the Guideline for Prescribing Opioids for Chronic Pain of the Centers for Disease Control and Prevention in the United States was associated with a greater decline on the overall opioid prescribing rate when compared with the pre-guideline period from 23.48 to 56.74 average prescriptions per month (Bohnert, Guy and Losby, 2018[107]).

Across OECD, 15 countries have clinical opioid guidelines in place. Except for the United States, where opioid prescribing guidelines are developed at the national level and are implemented at a sub-national level, opioid CPG are generally implemented at a national level. In most cases, clinical guidelines focus specifically on the use of opioid medications for chronic pain. For example, the Canadian guidelines address opioids for chronic non-cancer pain and do not look at opioid use for acute pain, nor for patients with pain due to cancer or in palliative care, or those under treatment for opioid use disorder (Busse et al., 2017[108]). Similarly, the guidelines released in Germany by the German Pain Society (Häuser et al., 2015[109])address long-term opioid therapy for chronic non-cancer pain. Germany’s guidelines represent a good example of evidence-based recommendations and included the participation of 26 scientific societies and two patient self-help organisations in their development.

Initiatives aimed at training opioid prescribers through specific evidence-based guidelines combined with educational initiatives, positively impact prescribing behaviours and lower inadequate treatment of pain (Stanek, Renslow and Kalliainen, 2015[110]). Accordingly, an opioid prescriber education programme among 2 850 clinicians licensed to prescribe opioid analgesics found an increase in correct responses to knowledge questions both immediately after the programme (60% to 84%) and two months later (60% to 69%). Among clinicians, 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes (Alford et al., 2015[111]). Academic detailing, a structured educational strategy of visits to health care providers by trained professionals who can provide tailored training and technical assistance, has shown promising results in reducing opioid dosage and in opioid treatment discontinuation (Zolekar et al., 2018[112]). Furthermore, some OECD countries have recognised addiction medicine as a full medical specialty. For example, over the last years, specialisation programmes in addiction medicine were created in Norway (Welle-Strand, 2015[113]), Australia (Haber and Murnion, 2011[114]) and the Netherlands (De Jong, Luycks and Delicat, 2011[115]).

Twelve OECD countries have implemented stewardship programmes, either at a national (8) or sub-national (4) level. Stewardship programmes aim at promoting judicious use of opioids and generally include training of prescribers and review of prescribing practices and feedback. In the province of Ontario, Canada an opioid stewardship programme for primary care providers has been available since 2014. The programme, funded by the Ministry of Health and Long Term Care, involves weekly training sessions, which include both a didactic lecture and a de-identified patient case presentation, with the aim of promoting safe and effective chronic pain management, as well as treatment follow-up (University Health Network, 2018[116]). In Australia, the Chief Medical Officer wrote to general practitioners who were identified in the top 20% of opioid prescribers for their region asking them to reflect on their prescribing practices. There is a website available to support GPs containing information and links to external resources regarding the use and safety of opioids in clinical practice (Department of Health, 2019[117]).

Box 4.1. Choosing Wisely® recommendations to promote rational use of opioid medications

Choosing Wisely® is an international health educational campaign aimed at improving doctor-patient relationships and reducing unnecessary health care by pulling evidence-based medicine into the public domain (ABIM Foundation, 2018[118]).

The campaign was launched in 2012 and it is currently implemented in eleven OECD countries (Levinson et al., 2015[119]). Some countries have put in place educational campaigns specifically targeted at reducing problematic opioid use and over-prescription.

• In the United States, the City of Philadelphia launched a campaign involving 1 300 physicians who were visited by Department representatives for brief discussions to gauge their awareness of opioid guidelines, understand their situations and re-enforce safe prescribing with a packet of resources (ABIM Foundation, 2018[120]).

In March 2018, Canada launched the Opioid Wisely campaign (Choosing Wisely Canada, 2018[121]). The campaign aims to reduce harms associated with opioid overprescribing through two main strategies: 1) providing information resources to help patients have informed conversations with their physicians about safe options for managing pain; 2) providing clinicians with recommendations for when the use of opioids should not be first line therapy. So far, a set of 15 specialty-specific recommendations are available.

Prescription monitoring programmes (PMP) consist of an electronic database that tracks controlled medicines prescriptions providing health authorities with timely information about prescribing and patient behaviours. Evaluations suggest that they have a positive impact in controlling problematic use by influencing both the health care and law enforcement systems. It has been shown that the use of data collected through PMP reduces the time spent by law enforcement authorities in investigating irregularities (GAO, 2002[122]). A review summarised that PMP effectively reduce “doctor shopping” strategies, and prescription substances problematic use while improving physicians’ prescribing behaviour (Worley, 2012[123]). More recent studies in the United States have shown that problematic opioid use increased more slowly in states with PMPs than in states without it (Reifler et al., 2012[124]; Rutkow et al., 2015[125]; Patrick et al., 2016[126]) and that states with more robust PMP have fewer prescription opioid overdose deaths (Pardo, 2017[127]). Moreover, the comprehensive legislative mandates to use PMP implemented during 2011‑15 were associated with a 6–9% reduction in opioid prescriptions with high risk for inappropriate use and overdose (Bao et al., 2018[128]). In Australia, the real time prescription monitoring assists doctors and pharmacists in identifying which patients are at risk of harm due to dependency or problematic use of controlled medicines. The national system is designed to provide information relating to prescription dispensing events from all states and territories to prevent cross‑border drug shopping abuses. Another recent initiative is the Turkish Coloured Prescription System (Renkli Reçete Sistemi), which started in 2017 and has helped to control counterfeit, lost and/stolen printed prescriptions and non-standard medicine use. At the same time, the system ensures proper doses and amounts of controlled medicines with the prescription, including opioids (TMMDA, 2019[129]).

In order to regulate opioid prescription, regulators or insurers have experimented with ‘utilization management’ schemes that place quantity limits, stepwise therapy rules, and/or prior authorisation requirements on opioid prescriptions (Lin et al., 2018[53]). Unfortunately, evidence evaluating the effectiveness of these schemes is relatively scarce. In this context, a programme in Oregon Medicaid in the United States developed a prior authorization policy for opioid prescriptions finding that it reduced the number of opioid-naive patients initiating extended-release/long-acting opioid use by more than half, but may also have increased short-acting opioid prescriptions by 7% (Keast et al., 2018[130]). Likewise, the programme reduced high dosage opioid prescriptions and multiple pharmacy use but saw no changes in opioid overdose (Hartung et al., 2017[131]).

In addition to the implementation of stewardship programmes, 13 OECD countries have put in place disciplinary actions for physicians overprescribing opioid medications. For instance, the German narcotic drug law explicitly states that narcotic drugs can only be prescribed if there is no other therapeutic option. Physicians who do not comply with this indication can face up to five years of imprisonment or a fine (Bundesamt für Justiz, 2018[132]). In some countries, opioid prescription monitoring schemes are part of wider monitoring actions. For example, in the United States prescription drug monitoring programs (PDMPs) are administered by single states, which collect and distribute data on the prescription of federally controlled substances, such as opioids and other potentially problematic prescription drugs (Finklea, Sacco and Bagalman, 2014[133]).

Regulatory actions can also support health systems’ work. In the case of prescription opioids, this entails regulating approved opioid medications, for instance, scheduling modifications, limiting access to high-dosage-unit versions and requiring abuse-deterrent formulations. For instance, on February 2018, the Australian Therapeutic Goods Administration rescheduled all over-the-counter medicines containing codeine as prescription only medicines. A Nationally Coordinated Codeine Implementation Working Group has been established to assist with implementing a communication and engagement strategy to help inform the community of the changes to the availability of low-dose codeine containing medicines (TGA, 2019[134]).

While strategies to reduce opioid over-prescribing are important, patients’ need for pain treatment should always be taken into consideration. Coverage of non-opioid evidence-based pain treatments can be fostered by incentives and actions from payers. Particularly for non-chronic pain, these strategies can be applied with success (Ballantyne, Kalso and Stannard, 2016[135]). Pharmacy policies are rarely aligned with corresponding medical policies for pain treatment, in part owing to separation in the design and administration of these two types of benefits. In a study among United States insurers exploring the coverage policies for pharmacologic treatments for low back pain, only one plan out of 50 had fully integrated non-pharmacological therapies into its step therapy requirements for opioid initiation (Lin et al., 2018[53]).

Regulation of industry: marketing of prescription opioids and financial payments to providers

In some OECD countries, there has been widespread marketing and financial incentives directed towards opioid prescribers and patients. These practices have raised concerns about potential conflict of interest, which can drive opioid overuse going over the strictly medically appropriate use that benefits patients. OECD countries have relied significantly on self-regulation of prescribing practices by prescribers and industry. Lately, governments have expanded regulations, particularly through enhancing transparency of marketing and financial relationships, but there is a remarkable lack of impact evaluations.

Although no evidence specifically on opioids is available, the general trend is to increase transparency. In 2013, the United States instituted a disclosure law wherein firms were required to publicly declare the payments that they made to physicians. A recent study found that through a 29-month period between 2013 and 2015, the monthly pharmaceutical companies’ payments to physicians declined by 2% on average. However, there was considerable heterogeneity in the effects with 14% of the drug-physician pairs showing a significant increase in their monthly payment. Moreover, the decline in payment was smaller among drugs with larger marketing expenditure, and among physicians who were paid more heavily pre-disclosure and who prescribed more heavily (Guo, Sriram and Manchanda, 2017[136]). In Europe, a Disclosure Code by the European Federation of Pharmaceutical Industries and Associations (EFPIA), the trade association of the research-based pharmaceutical industry, was mandated to implement disclosure programmes in 33 countries. A study found that in many cases, individuals can still opt out and reporting is incomplete, with common influential gifts such as food and drink excluded. In addition, in several countries data are only available as separate PDFs from companies, thus making the payment reports difficult to access and analyse (Fabbri et al., 2018[137]). Canada is in the process of restricting most forms of marketing and advertising of prescription opioids. Until new regulations are in place, Health Canada is calling on opioid manufacturers and distributors to immediately cease marketing activities associated with opioids in Canada, on a voluntary basis (Health Canada, 2018[138]).

4.1.2. Effective treatment and actions to minimise opioid use negative consequences are key for patient management

Medication assisted therapy can be part of long-term programmes benefits patients

Policies focusing on increasing the availability of medication assisted therapy (MAT) increase the quantity of opioid agonists/antagonists provided and widen the range of medications used, in order to maximise the chances of effectively treating patients who do not respond to methadone, buprenorphine and other common first-line opioid substitutes (Sordo et al., 2017[71]). Ideally, MAT should be part of a long-term comprehensive treatment and rehabilitation programme. MAT for OUD is provided by all OECD countries, except for Japan and Korea. In France, for example, MAT was implemented in 1996 and it is currently administered to around 180 000 patients who suffer from a substance use disorder (Fédération Française d’Addictologie, 2004[139]). The Canadian province of British Columbia offers MAT as a long-term treatment and explicitly recommends prescribing it without a pre-determined end-date (British Columbia Ministry of Health, 2017[140]). Once stabilization is achieved, and if patient and prescriber agree that de-intensification of treatment is appropriate, the province supports voluntary, long, gradual stepped-tapering schedules where dose reductions are scheduled to occur monthly or bimonthly, over a period of many months, as suggested by the available evidence (Bruneau et al., 2018[141]). Similarly, Australia recognises psychosocial support as an inherent component of MAT and recommends tailoring the duration of MAT to the unique needs and processes of every patient (Gowing, Ali and Dunlop, 2014[142]).

An extensive body of evidence supports the effectiveness of MAT for the treatment of OUDs. A systematic review found that methadone maintenance treatment was more effective than non-pharmacological approaches in retaining patients in treatment (3 RCTs, RR=3.05) and in the suppression of heroin use (3 RCTs, RR=0.32) (Mattick et al., 2009[143]). A second systematic review conducted by the same authors on buprenorphine found similar results (Mattick et al., 2014[144]). Addressing OUD as a chronic illness, and thus not restricting MAT to a short period of time is particularly important, since premature termination of treatment increases the likelihood of overdose-related deaths (Degenhardt et al., 2009[145]; Strang et al., 2016[69]). In the case of prescription opioid dependence, a systematic review found that methadone and buprenorphine work well to keep people in treatment, and to reduce opioid use with similar side effects. The review also showed that buprenorphine is associated with a 19.5% increase in treatment retention compared with methadone treatment and that buprenorphine may reduce use of opioids (Nielsen et al., 2016[146]). Extended-release injectable naltrexone is another alternative of MAT, for which a recent review found that it might decrease opioid use but there are few experimental demonstrations of this effect (Jarvis et al., 2018[147]).

Integration and coordination with specialised services contributes to early detection and managing co-occurring diseases

The needs of people with OUD seem to be better addressed when integration with other parts of the health system occurs. The aim is early detection and treatment of any substance use disorder and other health conditions, such as infectious diseases (hepatitis B and C, HIV, tuberculosis) and mental health illness. In addition, psychosocial interventions can complement the treatment to obtain better results for patients.

In relation to co-occurring infectious diseases, a review studied the impact of behavioural interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions, finding that multiple combined strategies reduced risk of HIV seroconversion by 75%, significantly better than single-method interventions (Hagan, Pouget and Des Jarlais, 2011[148]). More specifically, the main evidence-based programmes for HIV and HCV prevention interventions which should be covered in order to halt the HIV and HCV epidemics for persons who inject drugs were identified, including: MAT, HIV counselling and testing, HIV antiretroviral therapy, and condom distribution (Larney et al., 2017[149]). Models to organise the integration or co-location of OUD, HIV and hepatitis services have been implemented in different settings such as primary care, HIV specialty care, opioid treatment programs, transitional clinics, and community-based harm minimisation programs (Rich et al., 2018[150]).

Psychosocial interventions can represent an important resource to promote a people-centred medicine, address co-occurring mental health illnesses, and provide a complement to MAT. Psychosocial interventions can be delivered in different treatment modalities (e.g. inpatient, outpatient) and in a variety of formats (e.g. social skills training, individual, group and couples counselling, cognitive-behavioural therapy, contingency management, 12-step facilitation therapy, motivational interviewing, family therapy and others (Dugosh et al., 2016[151]). A systematic review found that the addition of a psychosocial intervention to medication detoxification treatment improved the number of people who completed treatment, reduced the use of opiates, increased abstinence from opiates at follow up and halved the number of absences (Amato et al., 2011[152]). However, a systematic review found that combining psychosocial interventions and MAT may not change the effectiveness of retention and opiate use during treatment (Amato et al., 2011[153]). Among adolescents, a qualitative review found that most of them have positive experiences with self-help groups and stress the importance of the group component of the therapy and the learning experiences they have when participating, which highlights that network support appears to be an important facilitator for recovery (Hannes et al., 2017[154]). Psychosocial interventions play a central role in the administration of MAT in Ireland, where MAT is conceived within an integrated perspective that emphasises the importance of psychosocial needs (HSE Primary Care Division, 2014[155]). Accordingly, MAT is administered in Ireland along with a wide spectrum of other interventions, including complementary and alternative therapies, individual and couple cognitive behaviour therapy, coping skills, motivational interviewing, relapse prevention, dialectical behaviour therapy, contingency management, counselling and psychotherapy, community reinforcement approach, as well as family interventions and family therapy.

Both in the case of prescribed and illicit opioids, strategies can be developed to identify people who are at risk of developing an OUD and effectively engage people who need specialised treatment. For illicit opioids, a review found that screening, brief intervention and referral to treatment (SBIRT) schemes were an effective method to address adolescent substance use (Beaton, Shubkin and Chapman, 2016[156]), which can be provided in primary care by paediatricians or embedded behavioural health care practitioners obtaining good results (Sterling et al., 2015[157]). A 2015 study on the Florida BRITE (BRief Intervention and Treatment of Elders) Project showed that thirty days after the initial screening, the average use of illegal drugs among older adults decreased from 36.2% to 11.8% (Schonfeld et al., 2015[158]). Likewise, emergency departments have implemented SBIRT-like schemes for illicit substances showing good results in improving abstinence, reducing consumption, controlling overdose risk behaviours and non-medical opioid use (Hawk and D’Onofrio, 2018[159]). For prescription opioids, a review found insufficient evidence to assert the effectiveness of SBIRT schemes for reducing inappropriate use of psychoactive substances (Young et al., 2014[160]).

Australia’s National Drug Strategy 2017‑26 includes primary assessments and brief interventions to be performed by general practitioners, nurses, allied health professionals, in both health care facilities and other relevant settings, including criminal justice (Australian Department of Health, 2018[161]). Similarly, SBIRT schemes have been implemented in the United States, where since 2003 the Centre for Substance Abuse Treatment (CSAT) has awarded 32 SBIRT grants to enhance services for persons with, or at risk for, substance use disorders (Bray et al., 2017[162]).

Naloxone is an effective harm minimisation intervention

The efficacy of opioid antagonists such as naloxone to treat the acute phase of an opioid overdose and save lives has been documented by a robust international literature (Chimbar and Moleta, 2018[79]). Additionally, providing overdose medications to first-aid responders and other people who may witness unintended overdoses (such as opioid users’ relatives, friends or partners) has proven effective in different contexts. For instance, widening the availability of overdose programmes in New York City in the United States was associated with a 27% decrease in the unintentional heroin poisoning mortality rate (WHO and UNDOC, 2014[163]). Similar results were obtained in Massachusetts, where non-governmental organizations are allowed to distribute naloxone without the presence of a physician (Walley et al., 2013[164]). In fact, evidence shows that overdose reversal medications can be successfully administered by non-medical professionals (Green, Heimer and Grau, 2008[165]).

Take-home Naloxone (THN) programmes have been implemented in Australia, Canada, Estonia, France, Germany, Ireland, Italy, Lithuania and the United States. In Australia, the Government has made rapid progress in removing regulatory barriers to naloxone in recent years, and THN programmes currently operate in five Australian jurisdictions. Moreover, a multi-faceted approach to drug dependence has been adopted in Australia, where alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients (Dwyer et al., 2018[166]). Additionally, a number of OECD countries are considering (or in the process of) implementing THN programmes (Strang, 2016[167]). For instance, France has made naloxone "ready-to-use" ("take-home naloxone") available at an early stage via a temporary authorization of use in 2016, then by granting a marketing authorization in 2017. This is a nasal form that can be used outside a health care facility and in the absence of a health professional, and can be dispensed without a prescription (optional medical prescription) by providers related to substance use disorders, in emergency services, and in a penitentiary environment (ANSM, 2018[168]).

Increasing naloxone distribution is likely to be a cost-effective intervention. A cost‑effectiveness analysis modelling the societal impact of the distribution of naloxone to users of illicit opioids (Coffin and Sullivan, 2013[169])found the intervention cost-effective, with 6% of overdose deaths prevented with naloxone distribution and one death prevented for every 227 naloxone kits. Similarly, a more recent cost-effectiveness analysis of take-home naloxone for heroin users in the United Kingdom (Langham et al., 2018[170]) found that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was deemed cost-effective with an incremental cost per QALY gained well below a GBP 20 000 willingness-to-pay threshold set by UK decision-makers. 

Needle and syringe programmes help to reduce blood borne diseases

Needle and syringe programmes (NSP) aim to prevent acquisition of blood borne diseases such as hepatitis C virus (HCV) and HIV in people who inject drugs, as well as invasive bacterial and fungal infections caused by pathogens present on skin at the site of injection. A systematic review of the evidence on NSP (Abdul-Quader et al., 2013[78]) found that such programmes are associated with a significant reduction in the prevalence of HIV and HCV and decreases in the incidence of HIV, among people who inject drugs. More recently, another review found that high NSP coverage in Europe was associated with a 76% reduction in HCV infection. Moreover, the impact of combined high coverage of NSP and MAT may result in a 74% reduction in the risk of HCV acquisition (Platt et al., 2017[171]). Needle and syringe programmes are available in 32 OECD countries that have at least one operational programme (Stone and Shirley-Beavan, 2018[172]). Among the 20 countries that responded to the OECD questionnaire, eight have programmes implemented at a national and six at sub-national level. These programmes are not currently available in Japan and Korea, while in Italy are implemented by social and health care workers in mobile units, not yet uniformly distributed throughout the country.

Furthermore, NSP are a cost-effective policy action. For instance, the needle and syringe programme implemented in New York City has been shown to reduce HIV treatment costs by USD 325 000 per case of HIV averted, and to have averted 4–7 HIV infections per 1 000 clients, producing a net cost savings (Belani and Muennig, 2008[173]). It has been predicted that increasing investment in needle and syringe exchange programs would entail a high rate of financial return on investment (USD 7.58–6.38 for each USD invested), and both main and sensitivity analyses strongly suggested that it would be cost-saving for the United States to invest in syringe exchange expansion (Nguyen et al., 2014[174]).

Medically supervised consumption centres and alternative medical approach to opioids are used in some OECD countries

Medically supervised consumption centres (MSCCs) are legally sanctioned facilities where users can consume pre-obtained drugs under medical supervision (May, Bennett and Holloway, 2018[175]). A wide body of internationally-sourced evidence has documented the effectiveness of MSCCs in reducing the harm associated with drug injection. A systematic review of the evidence on MSCCs found that all studies converged to find that MSICs were efficacious in attracting and staying in contact with highly marginalised target populations, meaning safer injection conditions, enhanced access to primary health care and reductions in overdose frequency. MSCCs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments, and were found to be associated with reduced levels of public drug injections and dropped syringes. For instance, the opening of Sydney’s first MSIC saw a 12% reduction in public injection and a 21% reduction in dropped syringes (Potier et al., 2014[176]). A recent EMCDDA report concluded that “these services facilitate rather than delay treatment entry and do not result in higher rates of local drug-related crime” (EMCDDA, 2018[80]). MSCCs are currently available with at least one facility in Australia, Belgium, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Spain and Switzerland (Stone and Shirley-Beavan, 2018[172]).

Concerning illicit opioids, drug checking has been developed as a relatively new harm minimisation strategy. Drug checking (also referred to as pill testing or adulterant screening) is a service that chemically tests drug samples, which are voluntarily submitted by drug users, in order to help them identify the content and purity of substances they intend on consuming. Thus, this strategy aims to prevent the main harms associated with the consumption of unknown substances (Brunt, 2017[177]). Drug checking services are being implemented in an increasing number of OECD countries, and the evidence on their effectiveness appears promising, although not yet sufficiently robust. In fact, the impact of drug checking on drug consumption and substance use behaviour has not yet been analysed through a clinical trial (Kerr and Tupper, 2017[178]) and the available evidence on drug checking’s effectiveness is based on drug users’ self-reported intentions to avoid dangerous drugs and adopt a safer behaviour (see, for example, (Sherman and Green, 2018[179]; Tupper et al., 2018[180]). A recent study (Karamouzian et al., 2018[181])evaluating a fentanyl drug checking service in Vancouver (Canada) shed light on the relevance of drug checking services for fentanyl contamination. The study found that 80% of the drugs checked were contaminated with fentanyl. Following such results, more than one third (36.3%) of participants reported planning to reduce their drug dose, while only 11.4% planned to fully dispose of their drug. In light of these findings, further research is needed to corroborate the effectiveness of drug checking services on substance use behaviour.

Prescription-grade heroin (diacetylmorphine) is an alternative that has been used for selected patients refractory to standard treatment. Reviews (Ferri, Davoli and Perucci, 2011[182]; Strang et al., 2015[183]) have found that heroin prescribed alongside flexible doses of methadone in a maintenance programme might help these patients remain in treatment, limit the use of street drugs, reduce involvement in criminal activity and incarceration, and possibly reduce mortality. Moreover, heroin assisted therapy shows a cost-saving benefit, attributable mainly to the reduction in the cost of criminal procedures and imprisonment. Furthermore, heroin maintenance appeared to be more cost-effective than methadone maintenance when costs of crime are included (EMCDDA, 2012[184]). Among OECD countries, heroin assisted treatment is currently implemented in Canada, Denmark, Germany, Luxembourg, Netherlands, Switzerland and the UK.

4.2. Social policies to address the economic and societal factors of the opioid crisis

Social policies play a crucial role in addressing the multi-faceted phenomenon of opioids problematic use, since individuals with problematic opioids use may be vulnerable people at risk of social exclusion, and because recovery and re-integration of those people into society may require policies beyond the health sector. Social policies can support people’s (re)integration into society, particularly in areas such as employment, housing and recovery support (Hollingsworth, Ruhm and Simon, 2017[81]; Krueger, 2017[82]).

Social reintegration support initiatives, such as employment services, housing and education, are in place in 19 out of the 20 countries analysed. Ireland’s National Drug Strategy strongly emphasises that the provision of accommodation and vocational rehabilitation are integral elements of drug treatment, fostering close collaboration between the Homeless Preventative Strategy and all agencies working on behalf of drug users (Keane, 2007[185]).

Although often neglected, housing policies constitute a crucial component of the strategy to address problematic opioid use. In fact, research shows that problematic drug and alcohol use is associated with a higher likelihood of experiencing homelessness (Fitzpatrick, Johnsen and White, 2011[186]). More specifically, substance use is one of the determinants of chronic homelessness, rather than transitional homelessness, which is shorter in length and associated with factors such as loss of employment and relationship breakdown (OECD, 2015[187]). Stable housing is cited by people with drug use disorders as one of the main elements leading to successful abstinence from drug use (Davis and O’Neill, 2005[188]). Such perceptions have been confirmed by studies showing that drug treatment has better results when associated with housing interventions. A subgroup analysis within a systematic review found that full abstinence was achieved by 50% of individuals in the recovery housing and treatment group, compared with 37% for recovery housing alone and 13% for usual care. At three months, participants in both of the recovery house conditions were significantly more likely to be earning money from employment than those in usual care (Chambers et al., 2018[189]). Stable housing is also an important tool in the prevention and reduction of harms associated with HIV and Hepatitis C (CORNEIL et al., 2006[190]). Nonetheless, the integration between housing policy and the other social and health services involved in the response to the opioid crisis is often insufficient. For example, a recent report (Bowen Matthew, 2018[191]) showed that in the United States, as a consequence of the insufficient integration between social services, the consumption of illicit opioids is often sanctioned with eviction from public housing.

Box 4.2. Housing First: a viable strategy to address OUD-related homelessness

Initially developed in New York in the early 1990s by the nongovernmental organisation Pathways to Housing, the Housing First model has been adopted by seven OECD countries (Canada, Denmark, Finland, France, Ireland, Norway and the United States), and is currently being explored by an increasing number of OECD countries, including Australia, Germany, Italy, the Netherlands, New Zealand, Portugal, Sweden and the United Kingdom (OECD, 2015[187]). The key principles of the Housing First approach are:

• Stable housing as the first priority. As opposed to many housing services, that aim to make homeless people with high support needs ‘housing ready’ before they are rehoused, the Housing First approach emphasises the need to provide stable housing before providing any other support service (Housing First Europe Hub, 2018[192]).

• Choice for service users: Housing First is a recovery-oriented model, which actively encourages service users to minimise drug and alcohol related harms, as well as to seek medical treatment. Unlike other housing models, however, such behaviours are not required (ibid.).

• Housing as a human right: The Housing First model explicitly emphasises the need to treat homeless people with compassion and respect, and it recognises access to suitable and stable housing as a human right (Tsemberis, 2010[193]).

A large body of evidence has shown that, as concerns ending chronic homelessness for people with high support needs, the Housing First model appears very effective (Tsemberis, 2010[193]; Latimer et al., 2014[194]).

The effectiveness of Housing First appears to hold true also with specific respect to substance dependence. With respect to opioid use, a randomised trial performed in Toronto, Canada (Kirst et al., 2015[195]), found that opioid use among participants in the Housing First intervention group was 50% less (6% vs. 12%) than the control group, which had received no specialised services. Further research is needed to corroborate these results, as the majority of studies on Housing First focus on housing stability and use of publicly funded services, rather than on its effects on substance use (Collins et al., 2012[196]).

Providing people recovering from OUD with employment opportunities is an action to favour their social reinsertion. Not many studies have been performed about employment support and OUD, but there are more studies about drug use. Vocational training, simulated employment and contingency management interventions show good results, albeit more evidence is needed (Sumnall and Brotherhood, 2012[197]). A more recent review found that employment support initiatives might be effective as relapse prevention measure, and to reduce substance use and homelessness rates (Walton and Hall, 2016[198]).

Residential rehabilitation programmes, compared to outpatient treatment, provide patients with safe housing conditions, peer support for recovery and self-control skills to resist the pressure to relapse. A review of the evidence on residential programs for people with severe mental illness and co‐occurring substance use disorders found that nine out of the ten studies examined suggested advantages for integrated residential programmes (Brunette, Mueser and Drake, 2004[199]). A more recent review evaluating recovery housing programmes found that they might have positive substance use outcomes and improvements in functioning, including employment and criminal activity (Reif et al., 2014[200]). Furthermore, in implementing social policies and recovery support initiatives, particular attention should be paid to the cultural specificities of ethnic minorities and indigenous communities affected by OUD (Catto and Thomson, 2008[201]).

With the exception of Japan, all of the 2018 survey respondents offer residential rehabilitation programmes. The majority have implemented residential rehabilitation programmes at a national-level, while a small percentage of countries (20%) have implemented residential rehabilitation programmes at a sub-national level. In the US, the Centers for Medicare & Medicaid Services (CMS) has announced a new policy that enhances access to residential rehabilitation programmes by increasing the flexibility for States to apply for new expenditure authority (CMS, 2017[202]). States will be able to pay for a fuller continuum of care to treat OUD, including critical treatment in residential treatment facilities that Medicaid is unable to pay for without a waiver.

4.3. Regulation and enforcement to address illegal opioids use

Regulation and law enforcement related actions aim to reduce the supply of illegal opioids by preventing illegal manufacturing, trafficking, and the diversion of substances from medical use and scientific research into the illegal market. In addition, law enforcement actors can be a first point of contact between opioid users and the institutions that could provide support and help. This dimension of the policy framework mainly focus on the links of the law enforcements sector with public health issues and the coordination between the health, social and judicial systems.

4.3.1. Law enforcement practice

Customs services, as part of their duty of enforcing regulation and documenting the flow of goods in and out of countries, are a key actor that can contribute to reduce the supply of illegal opioids, particularly since narcotics are one of the central illicit shipment concerns for OECD countries (OECD, 2018[203]). Recent actions have been proposed aiming to more accurately identify high-risk shipments, including the registration of import of pill presses, encapsulators and certain chemical precursors (Suzuki and El-Haddad, 2017[204]; INCB, 2018[205]); pre-load or pre-arrival air security, focusing on requirements for the provision of advance data, in electronic form, before the loading of goods onto airplanes; and allowing customs to open low-weight mail if suspected of containing unauthorised controlled substances (McCaskill, 2018[46]). For instance, Canada now allows border officials to open mail weighing 30g or less if there is reasonable grounds to suspect it is not in conformity to laws/regulations (Health Canada, 2017[206]).

Prevention of medication diversion can be augmented by increasing inspection and education activities to regulated parties, for instance, about the proper storage of controlled substances. Law enforcement authorities can also leverage on prescription monitoring programmes to identify and investigate individuals who may be engaging in diversion, leading to raids of clinics that prescribe significantly more than is medically justifiable (“pill mills”) (Compton, Boyle and Wargo, 2015[207]). For example, France monitors unusual sales of medicines; in December 2018, the National Medicines Agency (ANSM) and the National Council of the Association of Pharmacists signed an agreement to strengthen the control of unusual drug sales, thanks to a specific monitoring and reporting system. A pilot phase started including wholesaler-distributors, farmers and regional health agencies to monitor three opioid medicines.

Law enforcement officials (LEO) are commonly the first point of contact with opioid users, which makes them a central actor in the public health perspective needed to address the crisis. LEO can be trained as first responders to assist OUD patients going through an overdose episode, ensuring that LEO will have support to avoid disrupting their usual activities. Training LEOs in naloxone administration can increase knowledge and confidence in managing opioid overdose emergencies and may have positive effects for overdose victims (Wagner et al., 2016[208]). Likewise, LEO can create synergic partnership to work cooperatively with some of the newest harm minimisation strategies, such as supervised consumption centres, in order to hold greater and more sustainable public health and law enforcement value. In a qualitative study covering Australia, Canada, Denmark, France, Germany, Netherlands and Spain, the main contributors for cooperative actions between LEO and supervised consumption centres were early engagement and dialogues; supportive police chiefs; dedicated police liaisons; negotiated boundary agreements; and regular face-to-face contact (Watson et al., 2018[209]). Box 4.3 presents the example of a programme in the United States that goes in line with these collaborative approaches.

Box 4.3. ‘Law Enforcement Assisted Diversion’ programme as an experience of coordination between law enforcement and public health sectors

Law Enforcement Assisted Diversion (LEAD) is a pre-booking diversion pilot programme developed with the community to address low-level drug and prostitution crimes in Seattle, Washington in the United States (LEAD, 2018[210]). The program allows law enforcement officers to redirect low-level offenders engaged in drug or prostitution activity to community-based services, instead of jail and prosecution. The LEAD pilot program was established in 2011 and comprises three primary components: 1) an initial program entry process, which includes diversion from the criminal justice and legal systems; 2) harm‑reduction case management (i.e., low-barrier counselling and connection to social and clinical services that is offered with neither requirement of nor pressure towards substance-use treatment or abstinence); and 3) higher-level coordination of legal system involvement.

Compared to the usual arrest, incarceration and prosecution scheme, LEAD participants had 60% lower odds of arrest during the six months subsequent to evaluation entry; and both a 58% lower odds of arrest and 39% lower odds of being charged with a felony over the longer term (Collins, Lonczak and Clifasefi, 2017[211]). In terms of costs, a study found that the LEAD program averaged USD 899 per person per month, including programme start-up, but then decreased to USD 532 per month towards the end of the evaluation. Across nearly all outcomes, there was a significant reductions for the LEAD group compared to the control group on average yearly criminal justice and legal system utilization and associated costs. Notably, from pre- to post-evaluation, entry LEAD participants showed substantial cost reductions (USD -2 100), whereas control participants showed cost increases (USD +5 961) (Collins, Lonczak and Clifasefi, 2015[212]).

Finally, investigation entities in countries could strengthen capacity to control the illicit trade of opioids through the internet, particularly the darknet, given its growing use in drug trafficking (Quintana et al., 2017[213]). For instance, advanced machine learning techniques have been used to monitor and detect marketing and sale of opioids by illicit online sellers via Twitter, which can proactively alert regulators and law enforcement agencies of illegal opioid sales. (Mackey et al., 2018[214])

4.3.2. Criminal justice system approaches to people who use drugs

Different legal protection arrangements for people using drugs, including opioids, have been established in some countries in recognition of the fact that this is a chronic health issue requiring multiple strategies. Among the relevant possible interventions, we focused on discussing drug treatment courts, ‘good Samaritan laws’, and the legal status of personal use of drugs, since these have been more widely implemented and explored.

Drug treatment courts are specialised court process to allow defendants charged with drug possession or other eligible offences to enroll in court-directed treatment and rehabilitation, rather than having their case handled through the traditional process and sanctions such as imprisonment. Drug treatment courts have been established in Australia, Austria, Belgium, Canada, Chile, Ireland, Mexico, New Zealand, Norway, United Kingdom and the United States. The evidence about the effects of drug treatment courts is mixed, with some studies showing lower re-arrest rates for any offence and drug-related offences (GAO, 2011[215]; Mitchell et al., 2012[216]), while other studies find that these courts “cherry-pick” by targeting drug users who do not need treatment in order to obtain better results (Csete and Tomasini-Joshi, 2016[217]), and “punish” individuals for failing treatment giving them longer prison sentences (Sevigny, Fuleihan and Ferdik, 2013[218]). Evidence from Canada shows that drug treatment courts can be a catalyst for increased participant engagement with community health and social supports, which can help in the recovery process (Rezansoff et al., 2015[219]). 

“Good Samaritan” laws usually provide a level of immunity from prosecution for drug possession to anyone who seeks emergency assistance in the event of a drug overdose; these have been implemented in both the United States and Canada. For the latter, the federal “Good Samaritan Drug Overdose Act” provides some legal protection for those who seek emergency medical or law enforcement assistance for themselves or another person following an overdose on a controlled substance. The implementation of these laws has shown mixed results. A study covering 35 states in the United States did not find an association of these laws with significant changes in opioid-related deaths or nonmedical use of prescription painkillers (Rees et al., 2017[220]). A similar study covering 30 states found that Good Samaritan laws were associated with 15% lower incidence of opioid-overdose mortality and no increases in non-medical opioid use (McClellan et al., 2018[221]). Since lack of awareness about the law has been identified as a barrier, a study found that the odds of a trained bystander calling emergency number were over three times greater than when the witness had incorrect knowledge (Jakubowski et al., 2018[222]).

Box 4.4. Drug decriminalisation and public health approach in Portugal

In 2001, Portugal decriminalised the possession and consumption of all narcotics and psychotropic substances for personal use, intended as the quantity required for an average individual consumption during a period of ten days. Exceeding this quantity, criminal procedures apply. Portugal’s decriminalisation reform has been particularly influential, since by introducing a de jure decriminalisation (changes in the law instead of changes in the daily practice), it has been a pioneer of the explicit decriminalisation of all drugs. Some of the main benefits of decriminalisation mentioned by Portuguese authorities can be summarised as follows:

• Changes in the mind-set of the general population, contributing to consider drug use disorders as a medical condition rather than a criminal offence.

• Creation of supplementary entrance doors to the public health system, particularly, through the Commissions for the Dissuasion of Drug Dependence.

• Coherence enhancement between the health and judicial systems, markedly, to provide and expand access to public health interventions.

Portugal has a National Plan for the Reduction of Dependence Behaviours and Dependency 2013‑20 and takes a strong intersectoral approach integrating actions from 13 government sectors, with the leadership of the General Directorate for Intervention on Dependence Behaviours and Dependencies (SICAD). The Commissions for the Dissuasion of Drug Dependence provides an opportunity for an early, specific and integrated interface with drug users. Through these commissions, the decriminalisation policy was connected with universal access to public health services through the National Health Service, including MAT (e.g. methadone), psychosocial services, medical specialty services (e.g. psychiatry, infectious diseases), social services (e.g. aid on job seeking, vocational training), school programmes for alcohol and drug use prevention, needles exchange, and outreach activities on recreational settings. Notably, many of the prevention and harm minimisation activities taking place in the community are implemented by non-profit NGOs, which are mainly funded and supervised by the Ministry of Health through the five Regional Health Authorities.

The decriminalisation of drugs is controversial in nature. However, empirical evidence shows that following decriminalization, Portugal has not witnessed major increases in drug use, but has experienced reductions in problematic use, drug-related harms (e.g. HIV-AIDS, hepatitis, overdose deaths) and criminal justice overcrowding (EMCDDA, 2018[223]; Hughes and Stevens, 2010[224]; Greenwald, 2009[225]). In addition, decriminalisation seems to have caused no harm through lower illicit drugs prices, which would lead to higher drug usage and dependence (Félix and Portugal, 2017[226]).

In the past decade, there has been heated discussions around the legal status of drug use and possession for personal consumption and several countries have moved forward with modifying a restrictive approach that previously prevailed, mainly around cannabis legislation. As matter of reference, Table 4.3 presents the legal status about decriminalisation and depenalisation of opioids in OECD countries

Table 4.3. Illicit opioids for personal use: decriminalisation and depenalisation in selected OECD countries

	Decriminalisation	Depenalisation
Australia	○
Austria	●
Belgium	-	-
Canada	-	-
Chile	-	-
Colombia	●
Czech Republic	●
Denmark	-	-
Estonia	●
Finland	-	-
France	●	-
Germany	●	-
Greece	-	-
Hungary	-	●
Iceland	-	-
Ireland	-	-
Israel	-	-
Italy	●
Japan	-	-
Korea	-	-
Latvia		●
Lithuania	-	-
Luxembourg	-	-
Mexico	●
Netherlands	●
New Zealand	-	-
Norway	-	-
Poland	-	-
Portugal	●
Slovak Republic	-	-
Slovenia	●
Spain	●
Sweden	-	-
Switzerland	●
Turkey	-	-
United Kingdom	-	-
United States	-	-

Notes: The ‘personal use’ threshold is considered as defined by each country. Such quantity may thus vary significantly across OECD countries.

Level of implementation: ●= Nation-wide; ○= Sub-national; - = Illegal where criminal penalties apply. Definitions (EMCDDA, 2016[227]) (p.2): - Decriminalisation refers to the removal of criminal status from a certain behaviour or action. This does not mean that the behaviour is legal, as non-criminal penalties may still be applied. - Depenalisation refers to introducing the possibility or policy of closing a criminal case without proceeding towards punishment, for example as the case is considered ‘minor’ or prosecution is ‘not in the public interest’.

Source: (Hughes et al., 2016[228]; EMCDDA, 2018[229]) and responses from countries.

4.4. Information and knowledge generation as relevant levers for policy development and implementation

All policies should be closely monitored and evaluated. Three main components are considered here: data availability and information generation; research and development in key areas to provide new tools to address and prevent the crisis; and the need for rigorous evaluation of policies.

4.4.1. Better data and analytics for improved decision making

Data collection and information analysis should be improved. First, there is a need for improving collection and harmonisation of data from vital statistics and the services used by opioid users, which is particularly challenging in countries with numerous jurisdictional levels. The need for involving actors that are commonly within non-health sectors such as coroners, forensic institutions, police, criminal justice and social policy sectors also complicates collection. At the same time, data collection relating to population-level opioid use patterns and consequences, especially nonmedical use of prescription opioids and use of illicit opioids, should be upgraded (Bonnie, Ford and Phillips, 2017[230]).

Advanced analytics have the potential to help identify at-risk individuals and provide insights into risk factors, helping to prioritise scarce resources, optimise interventions, compare the efficacy of different approaches and improve the efficacy of each intervention (Charumilind et al., 2018[58]). Linking data from the different sources would provide new and relevant inputs to improve decision making for all sectors involved. An interesting example of formal institutional development is the French Observatory of Analgesic Medicines (OFMA, Observatoire Français des médicaments antalgiques) created in 2017. OFMA aims to synthesize the various available pharmacovigilance and substance use data on these drugs from the literature and national health authorities, promoting observational, pharmaco-epidemiological and clinical studies intended to characterise the use, misuse and complications related to analgesics. The observatory plays a role in informing health professionals and users about the proper use of analgesics and their associated risks. It also plays a role of proactive vigilance that informs the health authorities in case of identification of emerging signals. The observatory, and the members of its team, endeavor not to enter into conflicts of interest related to their expertise on analgesics (OFMA, 2019[231]).

A specific focus should be placed on measuring quality of health care services, at least at three levels.

• In the area of prescription opioids, where measurement and monitoring of appropriate prescribing practices is highly needed for high dosages, multiple providers and pharmacies, duration of use, and concurrent use of opioids and benzodiazepines (Cochran et al., 2018[232]).

• Through the opioid use disorder (OUD) health care process where a ‘cascade of care model’ has been proposed comprising the following steps to measure: 1) identification of those with OUD (diagnosis); 2) their engagement in care (access); 3) initiation of medication-assisted treatment (MAT); 4) retention in MAT for at least six months; and 5) remission from dependence (lasting recovery) (Williams, Nunes and Olfson, 2017[233]).

• Innovations on outcome measures relevant for and reported by patients should be developed and implemented within health care services. Measures could draw from developments around Patient Reported Outcome Measures (PROMs) tools such as the brief treatment outcome measure (BTOM) (Lawrinson, Copeland and Indig, 2005[234]) and the substance use recovery evaluator (SURE) (Neale et al., 2016[235]).

The role of national and international medicines regulatory agencies is also relevant to improve monitoring and risk management for opioid medicines. For instance, risk minimisation plans, drug utilisation studies as well as periodic safety update reports for both pain and medication-assisted therapy products can be further strengthened. International collaboration, for instance, to collect data about pharmacovigilance, can be of great use to guide decision making at national levels.

4.4.2. Encouraging research and development for new pain and OUD-related treatments

Research and development (R&D) in the fields of pain management and OUD-related treatment seem to receive relatively little attention. In the United States, only USD 1 billion was invested for opioid-related R&D compared to USD 6 and 7.7 billion for HIV/AIDS and cancer in 2017, and only 27 industry-sponsored clinical trials for OUD-related treatment were registered as of July 2018, compared to 1 400 for HIV/ADIS and 12 720 for cancer (Charumilind et al., 2018[58]). Such underdevelopment of R&D in the field of pain management is reflected in the relatively small number of analgesic drugs approved in the last three decades, where only seven new analgesic drugs have been approved since 1986, two of which are non-opioid analgesics (see Figure 4.1).

Figure 4.1. Pain relief medications – Research & Development timeline

Note: The timeline includes the main Mu opioid agonists, Acetaminophen, Nonsteroidal anti-inflammatory drugs (NSAIDs) approved by the F.D.A. (first approval date) and still marketed.

For analgesics that are not marketed in the US, but are in use in other OECD countries, the date of first patent approval was considered. The timeline does NOT include adjuvant analgesics or co-analgesics (e.g. anticonvulsants and tricyclic antidepressants) and local or topical anaesthetics.

Source: Authors’ elaboration on FDA data (Food and Drug Administration, 2018[236]) and NCBI data (PubChem, 2018[237]).

Given the significant and increasing public health burden of pain and OUD worldwide, some of the areas that have been identified as priorities (Bonnie, Ford and Phillips, 2017[230]; Volkow and Collins, 2017[238]) are the following:

• Refining understanding of the neurobiology of pain by which new pain treatment modalities, especially for chronic pain, can be developed including non-addictive analgesics and non-pharmacologic approaches.

• Improving understanding of the intersection between pain and OUD, including the relationships between use and inappropriate use of opioids, pain, emotional distress, and the brain reward pathway; vulnerability to and assessment of risk for OUD; and how to properly manage pain in individuals with and at risk for OUD.

• Developing new and better OUD-related treatments, including overdose-reversal and prevention interventions to reduce mortality, saving lives for future treatment and recovery; and finding new, innovative medications and technologies to treat OUD.

The National Health Institutes of the United States launched the Helping to End Addiction Long-term (HEAL) Initiative in April 2018 with the aim of speeding scientific solutions to stem the opioid public health crisis. The initiative builds on the established NIH research, including basic science of the complex neurological pathways involved in pain and addiction, implementation science to develop and test treatment models, and research to integrate behavioural interventions with MAT for opioid use disorder OUD (NIH, 2019[239]). 

4.4.3. Better evaluation of opioid-related policies and interventions

The evaluation stage of the public policy cycle is often left behind. From the literature review, there are many areas or interventions where scientific evidence is either lacking or of quality insufficient to assert strong conclusions. This is the case for studies using observational data alone, common in the opioid epidemic field, where certainty on the findings is difficult to establish (Binswanger and Gordon, 2016[240]). Therefore, well-designed and rigorous evaluation should accompany the most relevant and innovative actions and policies implemented in relation with the crisis. Responses to the 2018 OECD survey on opioid control suggest that 15 out of the 16 OECD countries analysed have performed evaluations on at least one relevant outcome of their opioid policy.