Opioid overdose crisis: time for a radical rethink

Abstract

The opioid epidemic is one of the worst public health disasters affecting the USA and Canada. Over the past two decades, nearly 600 000 people have died from an opioid overdose in these two countries, and an estimated 1·2 million people could die from opioid overdoses by 2029. The opioid crisis, which involves both prescribed opioids such as oxycodone and illicit drugs such as heroin, has reached new heights amid the pandemic. Against this backdrop, the Stanford–Lancet Commission on the opioid epidemic in North America, published on Feb 5, maps out an action plan to de-escalate the crisis. Although North America remains the centre of the opioid crisis, opioid use is an increasing public health concern in the UK, with almost half of all fatal drug poisonings involving opiates such as heroin and morphine. Furthermore, between 1998 and 2016, opioid prescriptions increased by 34% in England (and by 127% when accounting for the total oral morphine equivalency), while opioid-related hospitalisations rose by 48·9% between 2008 and 2018, with an estimated health-care cost of £137 million. In the immediate term, large reductions in opioid-related mortality could be achieved by expanding the distribution of naloxone. Naloxone is a life-saving intervention that can reverse the toxic effects of an opioid overdose, but to be effective it must be immediately available in such an event. Several countries, including Australia, Canada, Italy, Ukraine, and the UK, have introduced naloxone as over-the-counter medication. In 2020, take-home naloxone programmes were implemented in ten EU countries, Norway, and the UK. In this issue of The Lancet Public Health, a modelling study by Tracy Green and colleagues finds that nearly every state in the USA has under-developed naloxone distribution. Naloxone needs are highest in states were fentanyl—a potent synthetic opioid that is particularly dangerous when misused—dominates the local opioid epidemic. Green and colleagues estimate that naloxone distribution is most effective when done via pharmacies and community organisations. However, the success of community-based programmes depends on the support provided to people who use drugs and adopt the role of emergency first responder, as noted by Charles Marks and Karla Wagner in their accompanying Comment. The Stanford-Lancet Commission calls for accessible, high-quality, non-stigmatising, integrated health and social care services for people with substance use disorder. According to national reports, 30% of adults entering substance use treatment due to opiates in England had a housing problem, while 57% needed mental health treatment. The provision of drug treatment should be integrated with interventions addressing mental, physical, and social needs, including housing and employment support. Public health approaches responding to opioid addiction must ensure health equity. For example, drug consumption room sites are a harm-reduction intervention, offering a safe space particularly for hard-to-reach, marginalised populations. Currently, there are an estimated 200 consumption rooms in Australia, Canada, the USA, and Europe. In their Comment, also published in this issue of The Lancet Public Health, Adam Holland and colleagues strongly argue against the inertia of the UK Government; they note that concerns over the benefits of overdose prevention centres are based on moral perceptions of illicit drug use, whereas introducing consumption sites in areas with high rates of drug-related harm could be a suitable component of a multifaceted strategy to reduce drug-related deaths in the UK. While the current opioid crisis is mainly focused on the USA and Canada, other nations should be concerned. However, stigma around substance use continues to be widespread. Strategies targeting the social determinants of health associated with substance use disorder and investing in horizontal prevention programmes for young people may break the cycle of addiction. Society must respond to the opioid crisis through reforms of the regulatory systems and innovative strategies across multiple sectors, including improving epidemiological surveillance and effective pain management. Punitive and stigmatising approaches must end. Addiction is not a moral failing. It is a medical condition and poses a constant threat to health. The UN's Sustainable Development Goal 3 on illicit drug abuse will not be achieved without a shift in current practices and policies. Prevention, support, and recovery for opioid addiction is possible and should be a long-term investment. Overdose prevention centres in the UKIn response to the drug related death crisis in the UK, more than 80 prominent medical, academic, and third sector organisations have called for the introduction of pilot overdose prevention centres (also called drug consumption rooms).1 The government, however, has repeatedly indicated it has no plans to introduce them, and overdose prevention centres are not mentioned in it's 10-year drug strategy . Here, we question the arguments used to defend this position with relevance for other countries debating the introduction of overdose prevention centres. Full-Text PDF Open Access