By Accountable Care Journal-
Opioid-related deaths have increased at an alarming rate over the last decade. The growing mortality rate is not only a public health issue, but constitutes a wider social crisis for many developed economies, perhaps most notably in the US, where recorded deaths surpassed 49,000 in 2017.
As a recent report from the OECD (Organisation for Economic Cooperation and Development) indicates, opioid-related deaths increased by an average of over 20 per cent between 2011 and 2016, a trend that looks likely to continue unless substantive steps are taken.
The complexities of the issue derives from the spectrum of both origin and type of opioids being abused – ranging from prescribed painkillers to illegal heroin and synthetic, high-strength, fentanyl. Opioids are prescribed to treat severe pain, in combination with counselling and behavioural therapies and in the treatments of drug addictions for heroin and others. However, while providing benefit in these instances, opioids become addictive as they release the feelings of pleasure. Most recently the primary concern for governments tackling opioid abuse has been fentanyl and high-potency synthetic opioids, where mortality rates have soared over the last five years.
A global predicament
The availability of prescriptions for analgesic opioids has been gradually increasing on average over the past fifteen years across countries in the OECD. However, despite this increase, only 32 per cent of deaths from opioids in the US were the result of prescriptions. The rest were the result of illegal consumption. In 2016, 11 million people in the US misused prescription opioids, with 2.1 million saying they were addicted. Currently, the most common prescription opioids that are misused include; hydrocodone, oxycodone, codeine and tramadol in North America. This differs somewhat to Europe where methadone, buprenorphine and fentanyl are the main culprits.
Case Study: Africa
The UN reports that almost 90 per cent of all pharmaceutical opioids seized globally in 2016 were in Africa. Most of these were tramadol, a strong pain medication which can suppress feelings of tiredness and hunger and can be consumed orally and intravenously. Latin American drug cartels are primarily responsible for the issue in the region, using West Africa as a shipment route for cocaine and other narcotics into Europe. From here, many opioids have ended up in conflict zones on the continent.
For recreational use, opioids such as cocaine and heroin are too expensive for consumption in Africa, creating a gap for strong painkillers such as tramadol and codeine to enter the market as a cheap alternative. Reliable figures are not available to quantify the extent of opioid abuse and addictions in the region. However, available evidence suggests widespread use across Senegal, Mali, Nigeria and Cameroon.
Tramadol is known to be available in high potency doses of up to 250 mg per tablet, with strips of ten being sold for as little as $0.30. With no coherent national or regional plan in place, the crisis is likely to worsen. In December 2018, Yury Fedotov, Executive Director of the United Nations Office on Drugs and Crime, referred to the “disruptive and destabilising effects” of trafficked drugs in the region which have damaging impacts on security, governance and public health.
While some action has been taken; Nigeria banning the production and import of codeine-based cough syrups and Ghana tightening the regulation of opioid imports, the crisis persists because of inaction in neighbouring nation states. In 2016, the UN Drug Agency estimated there were over 1.8 million cocaine users in west and central Africa. Concoctions of drugs are also popular in the region, especially among young people, many building on the basis of cannabis, which itself had 34 million plus users reported in 2016.
Driving intervention across scales
According to the OECD, there are four approaches that should be taken to combat the damaging effects of opioid use:
- Improving prescribing practices and information available to clinicians, using evidence-based clinical guidelines and better monitoring frameworks for patients who have been prescribed opioids,
- Expanding access to treatment for addicted users and prevention schemes,
- Better coordination approaches across health, social care and criminal justice systems,
- Implementing stronger frameworks for knowledge generation and research to support decision making at all levels to inform industry regulation.
Administering a solution
How should governments frame this crisis? While opioid abuse spans the criminal justice system as well as healthcare services, treating it as a public health issue as opposed to a legal matter may have a significant impact in improving health outcome.
Can opioid abuse only be dealt with using a combination of interventions? Offering naloxone, a drug to reverse the effects of opioid overdose, providing substance abuse and mental health services, encouraging needle exchanges and other community schemes can go some way in mitigating the damage of opioid abuse. However, due to the scope of the issue, there is no one size approach that can make significant impact in isolation.
Despite evidence suggesting interventions of this sort have worked on heroin and AIDS epidemics in the past, governments have been sluggish to implement policies targeted at treating the opioid crisis in the same way. Those holding the purse strings may be shifting uncomfortably in their seats at the thought of funding a multichannel approach to opioid abuse. However, the financial outlay required is nothing compared to the social costs of not addressing the issue.
The full OECD report can be read here.