Opioids: A Global Perspective. Treating Pain and Battling to Prevent Addiction.

By: Jody Lutz

Reading Time: 9 minutes

Date: 03/22/2019

The Opioid Epidemic in America is a topic covered extensively, each and every day in the news. AffirmHealth covers this topically frequently as well, most recently in our, "Where are We Now?" article.

During 2017, there were more than 72,000 overdose deaths in the United States, including 49,068 that involved an opioid, according to the CDC count. More than 130 people died every day from opioid-related drug overdoses in 2016 and 2017, according to the US Department of Health & Human Services (HHS).

Joshua M. Sharfstein, Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health, summed it up in an interview with The Washington Post: “I think this is a very dismal picture of health in the United States.”

As former U.S. Surgeon General Vivek Murthy once said, the U.S. “arrived here on a path that was paved with good intentions,” but “the results have been devastating.” “We have nearly 250 million prescriptions for opioids written every year. That’s enough for every person in America to have a bottle of pills and then some.”

Opioid Use in the US Compared to Other Developed Countries Around the World

The BBC reported on access to pain relief and the varying degrees of accessibility for patients in agony outside of the US. The article helps illustrates the two very distinct sides to this equation – access to medication for patients who are suffering and the fear of the cultural phenomenon that is opioid addiction. For many countries the question remains: Can you treat pain adequately, without sparking a crisis similar to what is being seen in the United States?

Access to Opioid Pain Relief for Patients in Different Countries:

  • US gets 30 times more opioid pain relief medication than it needs 
  • Mexico gets only 36% of what it needs 
  • China gets about 16% of what it needs
  • India gets 4% of what it needs
  • Nigeria gets just 0.2% of what it needs

Source: The Lancet Commission on Global Access to Palliative Care and Pain Relief 

In Europe:

The 2015 European School Survey Project on Alcohol and Other Drugs (ESPAD), indicated that American youths in 10th grade have a high illicit drug use compared to their European counterparts, but US students rank among the lowest in rates of drinking and smoking, according to the study.

US EU

Source: https://news.umich.edu/compared-with-europe-american-teens-have-high-rates-of-illicit-drug-use/

In July of 2018, US News and World Report, reported that, “In the U.S., 42,249 people died in 2016 from opioid overdoses from a population of 323 million, according to the U.S. Department of Health and Human Services. Nearly half of those deaths involved synthetic opioids, mostly fentanyl — a rate that increased nearly sevenfold, from 3,000 to more than 20,000, in just three years. By comparison, 349 people in France died of overdoses in 2016, according to a report by the European Monitoring Center for Drugs and Addiction (EDMCCA) among a population of 66 million people – a number that rose threefold in the previous decade, according to OFMA.”

The United Kingdom has also experienced a rise in opioid abuse. Reports that almost 1 in 3 of Europe’s overdose deaths occur in the UK have earned it the title of the “drug overdose capital of Europe” according to The Guardian. Additionally, data from the National Health Service shows an increase in opioids prescribed from 12 million in 2006 to 24 million in 2016.

The Office of National Statistics reports that:

  • There were 3,756 deaths relating to drug poisoning in England and Wales in 2017, a rate of 66.1 deaths per 1 million population, and similar to levels seen in 2016.
  • Two-thirds of drug-related deaths were related to drug misuse, accounting for 43.7 deaths per 1 million in 2017.
  • Deaths involving cocaine and fentanyl continued to rise while deaths related to new psychoactive substances halved in 2017.

The European Monitoring Center for Drugs and Drug Addiction provides a comprehensive overview country by country within the region:

· Austria

· Belgium

· Bulgaria

· Croatia

· Cyprus

· Czech Republic

· Denmark

· Estonia

· Finland

· France

· Germany

· Greece

· Hungary

· Ireland

· Italy

· Latvia

· Lithuania

· Luxembourg

· Malta

· Netherlands

· Norway

· Poland

· Portugal

· Romania

· Slovakia

· Slovenia

· Spain

· Sweden

· United Kingdom

· Turkey

Outside of Europe 

In Japan:

The Journal of the American Board of Family Medicine conducted an online research study evaluating attitudes and perceptions that might influence opioid prescribing. A Japanese version was distributed to members of the Japan Primary Care Association and an English version to members of the American Academy of Family Physicians who were practicing in Oregon.

The Results: Japanese respondents reported far less opioid prescribing than US respondents, especially for acute pain (acute pain: 49.4% vs 97.0%; chronic pain: 63.7% vs 90.9%; P < .001 for both). Almost half of respondents from both countries indicated that patient expectations and satisfaction were important factors that influence prescribing. US respondents were significantly more likely to identify medical indication and legal expectation as reasons to prescribe opioids for acute pain. Most US respondents (95.4%) thought opioids were used too often, versus 6.6% of Japanese respondents.

An interview with the lead author, Dr. Eriko Onishi who received her medical training in Japan, but currently practices in Oregon can be found here.

In Africa:

On August 27, 2018 the United Nations Office on Drugs and Crime, issued a press release that states in part, “Non-medical use and trafficking of tramadol is becoming the main drug threat in West Africa.” It goes on to state, “According to the World Drug Report 2017, in countries in West Africa, North Africa and the Near and Middle East, tramadol is the main substance used by people reporting non-medical use of pharmaceutical opioids.”

In Uganda:

Morphine is tightly regulated under governmental control for fear of an American style opioid epidemic. The New York Times reports, “The only opioid the government permits outside hospitals is pint bottles of morphine diluted in water. The drug is distributed free, at government expense, undercutting incentives for pharmaceutical companies to fight for market share. The bottled morphine comes in two strengths: 0.5 gram or 5 grams per 500 milliliters.” The article continues on to state, “Getting high would require drinking gallons of the bitter, slightly nauseating solution. Distilling enough morphine to inject would require boiling away gallons."

“You can drink a whole bottle and all you’d get is some nausea and constipation, and be sleepy,” said Rinty Kintu, the Uganda coordinator at Treat the Pain.

In Egypt: 

The Australian Broadcasting Commission reported in May of 2018, regarding tramadol abuse addiction sweeping Egypt as part of the world's growing opioid crisis. The report states in part: "It is difficult to accurately gauge how many Egyptians use the drug, but the Drug Control Fund treatment centre estimated in 2015 that tramadol is the most abused substance in Egypt. Around half of Egypt's 100,000 opioid users are dependent on tramadol, the other half heroin, according to the Ministry of Health and United Nations Office on Drugs and Crime's 2015 estimates." 

In Australia:

australia

Source:http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2016~Main%20Features~Drug%20Induced%20Deaths%20in%20Australia~6

Australian opioid induced death rates have not reached those seen in the United States. However, they are rising. The National Drug & Alcohol Research Centre as part of the National Illicit Drug Indicator Project published the following study:  Opioid-, amphetamine-, and cocaine-induced deaths in Australia: August 2018.

The Trend Update provides the following summary of Australian opioid-induced deaths: 

  • In 2016, two-thirds (65%, n=679) of deaths were attributed to pharmaceutical opioids only; one-quarter to heroin only (24%, n=247); and 11% (n=111) to both pharmaceutical opioids and heroin. There were 498 deaths attributed to natural and semi-synthetic opioids (e.g. morphine, codeine, and oxycodone), 357 deaths attributed to heroin, 214 deaths attributed to synthetic opioid analgesics (e.g. fentanyl and tramadol), and 205 deaths to methadone (these numbers are not additive) (Figure 2).

  • The percentage of opioid-induced deaths attributed to heroin only has increased from 19% in 2007 to 23% in 2016, however there has been a larger increase in the percentage of deaths attributed to both heroin and pharmaceutical opioids from 4% in 2007 to 11% in 2016.

  • The rate of deaths attributed to opioids overall has increased since 2007.

  • Rates of death attributed to heroin have increased (from 0.9 per 100,000 people in 2007 (n=126) to 2.2 per 100,000 people in 2016 (n=357)).

  •  

    The rate of deaths attributed to synthetic opioid analgesics (e.g. fentanyl and tramadol) has also increased from 0.11 per 100,000 people in 2007 (n=15) to 1.34 per 100,000 people in 2016 (n=214).

Global Legal Perspective

There are two perspectives: the countries with the strictest drug laws (and penalties ranging from death to work camps for infractions) to countries who have decriminalized drug use.

And while we do not have an answer – we will continue to cover this closely. New research, new programs and cross collaboration have made this an ever evolving global topic.

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