Without urgent interventions, including public health policy reform and stricter corporate regulations, 1.2 million additional opioid deaths are expected in North America by 2029, more than double the opioid overdose deaths that occurred in the past two decades, and more deaths are expected globally as the epidemic expands beyond North America.
- The COVID-19 pandemic has overshadowed and exacerbated the opioid crisis in North America. In 2020, the US saw a 37% increase in overdose deaths and Canada saw a 67% increase.
- The Commission calls for bold, evidence-based action to break the cycle of addiction, reduce the current epidemic, and lay the foundation for future health policies that can end the opioid epidemic and prevent future addiction epidemics.
Without evidence-based public health policies that treat drug addiction as a chronic condition and prioritize prevention, the number of opioid overdose deaths in North America is predicted to grow exponentially, adding 1.2 million more overdose deaths. by the end of this decade to nearly 600,000 deaths that have already occurred since 1999. Opioid overdose deaths are also expected to increase worldwide as the epidemic expands beyond North America.
The opioid crisis began in the 1990s when lawmakers and health care systems failed to stop the pharmaceutical industry’s aggressive push to increase opioid prescribing. The crisis worsened even more over the past decade as illegal drugs such as heroin and fentanyl became widely available.
The year 2020 was the deadliest year yet for opioid deaths in North America, with a total of more than 76,000 deaths.
The COVID-19 pandemic has simultaneously exacerbated and overshadowed the opioid epidemic by limiting access to opioid use disorder services, overwhelming healthcare systems, and creating stressors such as unemployment, disability, and loss of life. loved ones that can lead to increased drug use and addiction.
“Over the past quarter century, the opioid epidemic has claimed nearly 600,000 lives and unleashed a cascade of public health catastrophes such as disability, family breakdown, unemployment and child abandonment across North America. If no action is taken, by the end of this decade we predict that the number of deaths will be double what it has been in the last 20 years, with a total of more than 1.2 million overdose deaths by 2029,” it says. the president of the Commission, Prof. Keith Humphreys of Stanford University (USA).
To help combat the opioid epidemic, the authors of the new report, Responding to the Opioid Crisis in North America and Beyond: Recommendations from the Stanford-Lancet Commission, offer an analysis of the current state of the opioid addiction crisis. opioids and describe bold evidence-based strategies to respond through public policy, industry reform, and innovations in pain management and prescribing methods.
He adds: “The opioid epidemic is a public health crisis that has been decades in the making, and it could take at least that long to resolve. To save lives and reduce suffering immediately, a cohesive long-term public health strategy that can restrain and ultimately overcome the pharmaceutical industry’s powerful influence over healthcare systems is urgently needed. Health care systems must also dramatically step up their efforts to help people struggling with addiction. “Our Commission’s recommendations are an important guide to begin reversing the opioid crisis in North America, laying the foundation for a public health strategy based on prevention and evidence-based treatment that will stop its global spread.”
Opioids are an important class of pain relievers historically prescribed primarily in surgery, palliative care, and cancer care, but are now prescribed for many chronic and short-term conditions ranging from lower back pain to headaches and ankle sprains. Without proper supervision or alternative pain relief methods, millions of people have become addicted to prescription opioids and then to other synthetic and illicit opioids, such as heroin and fentanyl, leading to hundreds of thousands of fatal overdoses.
Dramatic, unregulated growth and global spread
Since 1999, nearly 600,000 people in the U.S. and Canada have died from an opioid overdose, and the current death rate exceeds the worst of the HIV/AIDS epidemic.
Without reform, 1.2 million more people in North America could die from opioid overdoses by 2029, according to modeling estimates recently released by the Commission.
The Commission’s analysis suggests that 2020 was the worst year on record for fatal opioid overdoses in the U.S. and Canada in terms of the total number of deaths and the percentage annual increase.
Opioid overdose deaths in Canada increased 72%, from 3,668 in 2019 to 6,306 in 2020, with another 3,515 deaths reported in the first six months of 2021. In the US, 70,168 in 2020, raising the total number of deaths since 1999 to 583,000. The authors note that although the 2020 spikes can be attributed in part to the effects of the COVID-19 pandemic, an upward trajectory of deaths was evident in both countries before the pandemic.
Opioid-related deaths initially disproportionately affected white and Indigenous populations, but mortality among Black people has grown rapidly since 2011 (27 deaths per 100,000 people in 2020), outpacing non-Hispanic white populations (26 deaths per 100,000 people in 2020) and almost on par with deaths among the American Indian and Alaska Native population (28 deaths per 100,000 people). Overdose mortality has also recently increased among Hispanics, from 5 deaths per 100,000 people in 2015 to 13 deaths per 100,000 people in 2020.
Fatal opioid overdoses are concentrated among men and middle-aged people. In 2020, men had an age-adjusted death rate 2.5 times that of women, accounting for 71% (49,682/79,168) of overdose deaths in the U.S. and the United States. 75% of deaths (3.2 times more than women) in Canada. In the US, 87% (61,279/79,168) of opioid overdose deaths occurred in people ages 20 to 59, and this same age group accounted for 89% of deaths in Canada in 2020 .
The Commission’s authors attribute the onslaught of the opioid epidemic to the profit motives of pharmaceutical and healthcare industry players combined with disastrous regulatory failures by the U.S. Food and Drug Administration ( FDA), the Department of Justice, the Joint Commission and many elected officials. This lack of oversight has led to a significant increase in opioid prescriptions since 1999 and represented a seismic shift in medical pain management practice.
Urgent action is needed to improve regulation related to opioid overprescribing practices and to make post-approval drug monitoring and risk mitigation a government function. To diminish the industry’s often overwhelming political influence, he also recommends exposing artificial industry-funded advocacy groups and restoring limits on corporate donations to political campaigns.
The authors warn that the opioid epidemic will expand globally without these provisions. Regulators should stop pharmaceutical producers from exporting aggressive opioid promotion practices abroad, just as the tobacco industry did when it was subject to stricter regulation in the U.S. Several countries outside North America targeted Industry leaders have already seen a sharp increase in opioid prescribing, including the Netherlands, Iceland, England, Brazil and Australia. For example, between 2009 and 2015, opioid prescriptions in Brazil increased by 465%.
The Commission calls on high-income nations where opioid manufacturers are located to extend legal restrictions and sanctions to global operations. To give countries with limited resources an alternative to partnering with for-profit multinational corporations, the Commission recommends that the World Health Organization and donor nations provide free generic morphine for analgesia to hospitals and hospices in low-income countries.
“Global regulations will be crucial in resource-limited countries, which already lack sufficient public health infrastructure and are often in need of effective analgesics that can help patients with pain management needs. However, at this time, many of these regions are ill-equipped to handle the public health consequences of a new opioid epidemic, especially after COVID-19,” Koh continues.
Treat addiction as a chronic condition with a focus on prevention and policy reform
In the US in particular, there is a lack of accessible, high-quality, non-stigmatizing , integrated health and social care services for people experiencing opioid use disorder. Therefore, the Commission strongly recommends that addiction-related services become a permanent feature of the health and social care systems in the US and Canada, following established models of chronic disease management that are funded and organize as a central public health commitment.
This step will also require reform of the public and private health insurance system to promote many pathways to addiction recovery, including methadone maintenance clinics, residential rehabilitation programs, and peer-led mutual aid groups and training. recovery.
Investment in workforce development, specifically increasing the number of addiction specialists and increasing the addiction-related knowledge and skills of general practitioners, will also be essential to creating a reformed public health approach to addiction that treat as a chronic condition.
“Addiction is an enduring part of population health and should not be treated as a moral failing that needs punishment, but as a chronic health condition that requires ongoing treatment and long-term support. "We may not know what future addictions could take hold in our society, but we do know that without a public health foundation based on prevention and recovery support, addiction will continue to plague our health systems and our communities," says the author. of the Commission, Professor Yasmin Hurd. from the Icahn School of Medicine at Mount Sinai (USA).
The Commission also suggests solutions for working with law enforcement and governments to maximize the good the criminal justice system could do and minimize the harm it can inflict. Recommendations include providing addiction treatment and other health services during incarceration, waiving incarceration for possession of illicit opioids for personal use, and ending punishment for opioid use during pregnancy.
Innovation and smart prescription for pain management
The Commission notes that opioid medicines are both medically essential and dangerous, and calls for a nuanced approach to the future of pain treatment, which must prioritize innovation in both society’s response to addiction to drugs through reformed policies such as supporting the development of new non-addictive pain management options.
“Opioids should not be seen as good or bad, but as a class of essential medications for pain management. However, opioids carry serious risks, some of which may be difficult to recognize. This is especially true when high doses are prescribed, which is more likely in the absence of oversight, clear medical practice guidelines, and government regulations.
"Physicians should begin learning about responsible prescribing of pain treatment in medical school and continue to learn about it as part of their commitment to continuing medical education throughout their careers," says Commission author Dr. Prof. David Juurlink, from the University of Toronto (Canada).
The Commission recommends opioid stewardship to help restore confidence in medicine among policymakers, physicians, and the public. Methods to encourage opioid stewardship include prescription drug monitoring programs, developing safer prescribing protocols, using opioid agonist therapies such as methadone maintenance, and improving strategies for dispensing opioid rescue medication. naloxone opioid overdose .
“This administration must be combined with treatment options for opioid use disorder that are supportive and effective, and that prioritize the development of innovative, non-addictive treatments for pain management. The COVID-19 pandemic has shown that rapid development of vaccines, treatments and public health policies is possible through collaboration and innovation. That same commitment and collaboration must now be applied to the opioid crisis,” Hurd says.
Investing in young people to reduce the risk of addiction
The cycle of substance use disorders can be broken by investing in education and community support for children from an early age. Research indicates that adverse experiences during childhood and adolescence, such as a lack of positive rewards in the environment, family breakdown, and physical and verbal abuse, can influence the likelihood of future addiction. This time of life is also when exposure and incidence of substance use disorders are most concentrated.
Commissioners suggest developing comprehensive youth programs that cover many different risks and risk factors and give youth the tools to navigate all of them. These programs should be combined with initiatives that aim to strengthen health, well-being, and school readiness from young children to reduce the risk of addiction later in life.
“Drug addiction prevention must be part of a comprehensive public health strategy that begins in childhood and lays the foundation for long-term addiction reduction. These programs will only be successful with other policies and regulations that reduce the likelihood that children and adolescents will encounter opioids in the first place. “Many parents falsely believe that their children will only encounter opioids outside the home, but most young people are more likely to access opioids for the first time from their home medicine cabinets,” says Commission author Assistant Professor Chelsea Shover of the University of California at Los Angeles. (USA).
Commissioners recognize that while some additional opioid overdose deaths are inevitable, the recommendations must be put into action immediately to reduce future deaths and establish a framework to prevent future addiction crises.
“Ending the opioid epidemic in North America and preventing its global spread is an audacious but achievable goal. It requires a dramatic shift in policy and culture where innovation, collaboration and regulation are encouraged. We can save and improve lives by marshalling the resources and political will necessary to eliminate the sources of addiction and boldly implement policies that maximize efforts to treat it,” says Humphreys.
A linked editorial published in The Lancet says: “Innovation and transformation in the approach to ending the opioid epidemic must be met by strengthened regulation. American institutions were subverted due to failures in post-marketing surveillance and physician education, and by allowing financial conflicts of interest between regulatory agencies and industry. But the moral of the opioid crisis is not that it can happen only in North America. Without reining in deceptive marketing and prescribing practices and international financing of subsidized generic morphine for low-income countries, the potential for further opioid crises remains. The risk of global spread is greatest where COVID-19 has devastated health systems, where pain needs in resource-limited settings are unmet, and where corporations seek new markets but are allowed to self-regulate. To manage pain, you must also manage greed.”
