The availability of analgesic opioids in OECD countries has been steadily growing in the past couple of decades, becoming an important public health concern in a few of them, with the United States and Canada experiencing a higher degree of opioid-related harms. Other countries, including Israel, Slovakia, Greece and Portugal, have experienced a growth in the availability of analgesic opioids in recent years but have so far not shown major signs of opioid-related harms.
In the 25 OECD countries where data is available, opioid-related deaths (ORD) have slightly increased in the present decade. The United States, Canada, Sweden, Norway, Ireland and England & Wales have rates above the OECD average, and have also seen increasing trends. Canada and the United States are confronted with a significant crisis, with substantial impact on population health (both overdose deaths and opioid-use disorder patients), health services (hospitalisations and emergency room visits), as well as on societal structures (e.g. families, communities) and the economy (e.g. social costs, unemployment). In both countries, the roots of the crisis are found in prescription and illicit opioids, though in recent years, illicit opioids have caused more deaths. Australia has also experienced increasing rates of overdose deaths, caused in this case by prescription opioids. In a different group, in Estonia, Sweden and Norway illicit opioids consumption are the main cause of overdose deaths, although with different patterns of what is the main illicit opioid substance.
Concerning prescription opioids, 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 an appropriate use and regulatory environment for prescription opioids can be compatible with having a higher availability of these drugs for medical use. However, countries should take active actions to reach and maintain an appropriate balance to cover the real needs for pain control without exposing patients to the threat of dependence development, especially in light of data showing increasing trends of medical opioid prescription and opioid-related deaths in some European countries. Prescription monitoring and regulation to assure an appropriate use of medical opioids should therefore always be considered.
Some illicit opioid users begin their consumption with prescription opioids. This is important particularly for countries that are experiencing growing trends in prescription opioids use. Furthermore, an increasingly dynamic market of illicit drugs -- that can travel more easily than ever around the world – also means that users of such drugs can more easily have access to them regardless of where they live.
The findings from a review of policies point to the need to consider OUDs as a chronic health condition, which should be addressed primarily as a public health issue. This should guide the design of health policy responses, but also social policy and law enforcement strategies. For example, medication-assisted therapy complemented with psychosocial support is an evidence-based treatment for OUD patients that could be supported not only by the health sector but also by law enforcement strategies, facilitating and promoting the connection of low-level offenders with health care. Likewise, health care networks can offer more recovery and reinsertion opportunities to OUD patients by having fluid channels of communication with employment or housing support services, which is particularly relevant for the most vulnerable population.
Taking a people-centred and public health perspective, countries can consider the following policy considerations to improve their preparation and approach to control opioid-related issues:
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.