How it happened how toIt’s possible to manage it

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Public concern remains about the North American Opioid Crisis (Anon, 2021). The subject has provoked numerous books, documentaries and, recently, a major Disney+ drama series “Dopesick”. In both 2016 and 2020 US presidential elections, proposals for addressing the Opioid Crisis were featured.
The core narrative runs throughout mainstream media commentary on opioid abuse in America. The core narrative suggests that until mid-1990s, opioid addiction was an established problem. This included heroin use by the most marginalised. Purdue Pharma, owned by the Sacklers, launched OxyContin in 1995. It combined slow-release technology and an existing, synthetic opioid, called Oxycodone. The powerful opioid medicine was misrepresented as an alternative to more expensive opioid painkillers. A deeply flawed regulations system for medications led to an explosive increase in the number of people who use opioid medication.
For chronic pain that is not cancer-related, other synthetic opioid drugs were also available on the market. Popular among them is fentanyl which can be 80 to 100x more powerful than morphine. Fentanyl was first used for anaesthesia in the 1960s. However, a transdermal patch formulation of fentanyl was developed in 1990 to treat chronic pain. These medications were used in good faith by many chronic pain sufferers who wouldn’t have received powerful opioids.
Mexican drug cartels recognized a lucrative market for street heroin and increased its availability across North America. Street heroin was the first choice for patients who are addicted to prescription opioids. This has resulted in a huge epidemic of opioid addiction. The number of opioid-related deaths has risen and small American towns that were not affected by the previous drug abuse waves are now facing serious social issues. These problems can be attributed to the greedy and dishonest behavior of the pharmaceutical industry.
The core narrative is based on hard evidence. However, some chains of causality may not seem so clear and unambiguous.
Trump declared the Opioid Crisis an emergency in October 2017. However, his administration’s policies were not entirely coherent. On the one hand, in 2018 Trump signed legislation to increase federal funding for drug treatment, but, on the other hand, his administration attempted to defund the Office of National Drug Control Policy and consistently undermined Obama’s Affordable Care Act. During the Covid-19 epidemic, opioid-related deaths have risen (CDC, 2021).
The number of deaths due to opioid misuse continues to rise in the US during the current pandemic. The North American Opioid Crisis began. What can be done to address it?

Stanford-Lancet Commission Report on North American Opioid Crisis

The Commission is a partnership between The Lancet and Stanford University’s addiction research group. Under the Trump presidency, The Commission began its work late in 2019. It comprised a group of North American experts on various aspects of the Opioid Crisis, who came together to make “a coherent, empirically grounded analysis of the causes of, and solutions to, the opioid crisis”.
The Commission’s 50-page report is the primary output of its work. The report consists of two major elements.

  • An historical overview of how the present situation came to be;
  • A series of recommendations for policy to deal with the Opioid Crisis.
  • The Report concentrates on Canada and the USA. The Commission explicitly avoided a comprehensive literature review on the grounds that the Opioid Crisis has been “well characterised”  in previous authoritative reviews. It instead presents an in-depth narrative overview of the evolution of current circumstances. The Commission formed a number of sub-groups to address particular themes, following a procedure resembling a Delphi technique (Niederberger & Spranger, 2020) to derive consensus expert recommendations on public policy. Major recommendations and conclusions were discussed in an iterative manner, which was modified and improved until the Commissioners gave their support. If the recommendation or conclusion could not achieve 90% support, it was dropped. In addition to epidemiological modeling, the work of Commission was also supported (Rao and al., 2021). A Lancet editorial was published with the Commission Report (Anon et all, 2022).

    What caused the North American Opioid Crisis?

    This Report follows the Opioid Crisis core narrative closely. It is clear that the Opioid Crisis began with the approval in 1995 of OxyContin to be used in the USA. The Report states that the Opioid Crisis emerged “when insufficient regulation of the pharmaceutical and health-care industries enabled a profit-driven quadrupling of opioid prescribing”. Report outlines a list of failures that contributed to the massive rise in opioid usage. These include pharmaceutic companies misconduct, regulatory failures, inappropriate relationships between opioid producers and a variety of groups including universities, professional societies and patients advocacy groups as well as politicians and regulators.
    The Report details three wave(s) of Opioid Crisis. It also describes the health effects on the public, with a particular focus on overdose death.

  • The Report states that the initial wave involved prescription opioids.
  • This second market was created in 2010 by illicit heroin traders who identified users of prescription opioids and made them a target.
  • According to some reports, the third wave began in 2014 as drug traffickers brought illicitly made synthetic opioids onto the American street drugs market. Fentanyl is often found in fake prescription drugs like OxyContin.
  • The report examines the situation and notes that the year 2020 saw the highest number of fatal overdoses from opioid overdoses in the USA and Canada in absolute numbers, and a percentage increase in overdoses compared to the year before. Some of the results of the Commission’s modelling exercise are reported here. According to the Lancet editorial, an additional 1.2 Million opioid overdose deaths will be recorded between 2020-2029 if no changes in public policy are made.
    It provides details about geographical, temporal and demographic variation in opioid death rates. The Report also touches upon a variety of other topics, such as poly-drug abuse. The report does not include a comprehensive discussion on the treatment of chronic pain. However, there is a brief discussion. The Report does not believe that the Opioid Crisis can be attributed solely to a highly-marketized, unique health care system. It asserts that Canada is experiencing an Opioid Crisis similar to those in the USA, even though it has universal healthcare. It also warns of the possibility that similar problems could be faced by other nations to North America’s in time.
    A Lancet editorial reported that another 1.2 million deaths from opioid overdoses are possible in Canada and the USA between 2020-2029, if public policies do not change.

    Recommendations for policy

    This is the bulk of the Report, which explains the reasons for the main recommendations. It falls under seven categories:

  • “The US and Canadian opioid crisis as a case study in multi-system regulatory failure
  • Opioids’ dual nature as both a benefit and a risk to health
  • Integrate, support and sustain a system for treating substance abuse disorders
  • Maximise the benefit and minimise the adverse effects of the criminal justice system’s involvement with people addicted to opioids
  • Healthy environments can lead to long-term decreases in addiction.
  • Encourage innovation to combat addiction
  • Prevent opioid crises beyond the USA and Canada”
  • The 32 major recommendations are a collection of many smaller, but more comprehensive, suggestions. These recommendations include regulatory reforms to the pharmaceutical industry as well as social policies that improve substance misuse environments. The majority of the recommendations can be easily understood by anyone who is familiar with substance misuse research. These include reframing addiction to a chronic disease rather than a crime and providing methadone or buprenorphine through publicly-funded treatment centers. Others recommendations reflect optimistic aspirations, for example, “Prioritise redesign of opioid molecules and development of non-opioid medications for pain and addiction”. Some recommendations are concerned with reversing past policy failures associated with ‘the War on Drugs’, such as US penal policy.
    They have made sure to not replace current problems by new ones in their recommendations. The authors emphasize, for example that they are not against the use of buprenorphine or methadone to flood the opioid market and they also don’t support the banning of prescriptions for opioids in chronic pain.
    Inaccessible and expensive health care systems in both the US and Canada are examples of weak policies and regulatory failures.

    Both strengths and weaknesses

    The Report provides a comprehensive and authoritative overview of North America’s Opioid Crisis as it has been understood. It also includes a number of policy recommendations based on evidence. Anyone interested in the issues associated with prescription opioids or illicitly purchased drugs will find this invaluable. It contains 387 references that provide much of the highest quality evidence to support the core narrative. Because of the way in which it was created, it seemed unlikely that it would challenge established orthodoxies.
    The Report is flawed in my opinion as a UK-based clinician who has experience with both substance abuse and chronic pain. Although there is not a clear indication of who the Report addresses, it seems to be aimed at policymakers from the USA and Canada. Joe Biden’s victory in the 2020 Presidential election has undoubtedly created a more receptive environment for the Commission’s conclusions. Tom Coderre, who was a policy-maker for the Biden Administration, withdrew his support from the Commission.
    It had an extensive mandate and produced a lengthy report. It skims over important topics, especially those related to chronic pain management. While tolerance and withdrawal symptoms can be expected from long-term opioid use, this doesn’t mean people suffering chronic pain will automatically develop addiction behaviors. The majority of people with chronic pain do not have these issues. But, long-term high-dose use can cause cognitive impairments as well as hyperalgesia.
    While hyperalgesia occurs in both opioid and nonopioid pain medications, the Report does not mention it. It is likely to play a significant role in maintaining high-dose opioid prescriptions. It has an effect on the recommendation for better, non-addictive pain medication development. This seems to be exactly the same mistake as with OxyContin. My belief is that pharmaceutical pain relief can solve the global opioid crisis. The public and health professionals need to adopt a rehabilitation approach for chronic pain, where opioids only play a limited role. This is a better way to go than continue discrediting the search for an effective treatment. This myth of pain elimination isn’t simply the invention of the pharmaceutical sector. It has deep roots in socio-cultural medical beliefs (Illich 1976).
    Before 1995, heroin addiction was a serious public health issue. It is well-known that heroin addiction can be influenced by social and economic factors. Although the vast majority of US heroin users have used prescribed opioids in the past, that does not necessarily mean there was a causal chain. However, epidemiological truths such as this one show that an association does NOT necessarily mean causation. The strong emphasis on prescribed opioid use as a prelude to heroin addiction reiterates the contested “gateway drug” argument that has been a justification for discredited cannabis criminalisation policies (Degenhardt et al., 2010; Nkansah-Amankra &, Minelli, 2016).
    It is especially weak in its assessment of the global implications of North American Opioid Crisis. While the UK is experiencing a serious problem with prescribed opioids it does not seem to have the same problems as the USA. There is always some drug abuse in the streets, but there are no signs that prescription opioids have led to an increase in heroin addiction. Drug-related deaths have increased in the UK (ONS-2021), but this may be because of a decreased availability for treatment and the large increase in drug-related deaths. It is not plausible to suggest that the US will have an Opioid Crisis. However, new opioid medication have been made available in this country for just as many years as they are here.
    The combination of heroin and gabapentinoids is often used in the UK. It can lead to respiratory depression, death, and even suicide. Gabapentinoids are prescribed widely, although they have limited use in pain management. These drugs can cause dependency in the same manner as benzodiazepines. (Goins and al., 2002). The Report does not mention gabapentinoids.
    This report did not address the treatment of chronic pain or withdrawal symptoms, which are all common in addicts.

    The Implications

    Although the Report adds to the literature about the North American Opioid Crisis it is not relevant to the UK. The UK needs to find a solution to the different problems associated with opioid prescribing. There are however two key messages that the UK should take away from this Report:

  • First, it is a warning about the potential consequences of deregulation in medicine at a moment when the UK Government contemplates adopting US-inspired models of regulation and health care.
  • Second, the Report emphasizes the need for harm reduction methods to combat drug addiction. These approaches were developed in Britain and have strong scientific evidence. The availability of such treatments has been reduced by the British government’s health policy since 2010. This policy, driven not by science but ideology, is responsible in large part for an increase in drug-related deaths in the UK.
  • Although the Stanford-Lancet Commission report addresses the important of harm reduction strategies and drug addiction policies, it is not relevant to the UK.

    Statement of interest

    Rob Poole heads a research team that studies the harms of prescribed opioids. There are no competing interests.

    Hyperlinks

    Primary papers

    Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, Chen JH, Cuéllar MF, Hurd YL, Juurlink DN, Koh HK, Krebs EE, Lembke A, Mackey SC, Larrimore Ouellette L, Suffoletto B, Timko C. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet. 2022 Feb 5;399(10324):555-604. doi: 10.1016/S0140-6736(21)02252-2.

    The Lancet Editorial. The opioid crisis and its management in North America. Lancet. 2022 Feb 5;399(10324):495. doi: 10.1016/S0140-6736(22)00200-8. Epub 2022 Feb 2. Lancet. 2022 February 16.

    Refer to other references

    The opioid crisis in America is at an acute stage. Lancet 398:10297, 277. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01653-6/fulltext
    Bailey J, Nafees S, Jones L, Poole R (2021) Rationalisation of long-term high-dose opioids for chronic pain: Development of an intervention and conceptual framework British Journal of Pain 15(3) 326–334 https://doi.org/10.1177/2049463720958731
    Degenhardt L, Dierker L, Tat Chiu W, Medina-Mora ME, Neumark Y, Sampson S, Alonso J, Angermeyer M, Anthony JC, Bruffaerts R,  de Girolamo G, de Graaf R, Gureje O, Karam AN, Kostyuchenko S, Lee S, Lépine J-P, Levinson D, Nakamura Y, Posada-Villa J, Stein D, Wells JE, Kessler RC (2010). Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys. Drug and Alcohol Dependence108: 1–2. 84-97 https://doi.org/10.1016/j.drugalcdep.2009.12.001
    Goins, A. and Patel K. Alles, S. (211) Gabapentinoid drugs: abuse potential. Pharmacology & Therapeutics 227: 107926 https://doi.org/10.1016/j.pharmthera.2021.107926 Pharmacology & Therapeutics 227: 107926 https://doi.org/10.1016/j.pharmthera.2021.107926
    Illich I (1976). Medical limitations. Medical nemesis is the taking away of your health. London: Maryon Boys.
    Niederberger, M. and Spranger, J. 2020 Delphi Technique for Health Sciences: A Chart. Front. Public Health 8:457. doi: 10.3389/fpubh.2020.00457 https://doi.org/10.3389/fpubh.2020.00457
    Rao IJ, Humphreys K, Brandeau ML (2021). The Effectiveness of US Opioid Epidemic Policies: A Model-Based Analysis by the Stanford-Lancet Commission. Lancet Reg Health Am. 3:100031. https://www.thelancet.com/journals/lanam/article/PIIS2667-193X(21)00023-5/fulltext
    Nkansah-Amankra S, Minelli M (2016) “Gateway hypothesis” and early drug use: Additional findings from tracking a population-based sample of adolescents to adulthood, Preventive Medicine Reports, 4, 134-141, https://doi.org/10.1016/j.pmedr.2016.05.003

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