The Netflix series Painkiller recently depicted how the over-prescribing of the medicine OxyContin wreaked havoc on American society.
Today the grim reality is that opioid-related deaths in North America reached a record level in 2022, with more than 109,000 fatalities in the United States. The same year in Canada, deaths exceeded 7,400, a number equivalent to 20 opioid-related deaths every day, and this is likely to continue to increase over the coming years.
The opioid overdose crisis has been ongoing for over two decades in Canada and the U.S. The current mortality rate is greater than the worst years of the HIV/AIDs epidemic in these countries.
Opioids are drugs primarily used to treat severe pain, such as after surgery. When prescribed responsibly they are an effective medication, but if over-prescribed or used recreationally they can lead to an addiction (known as opioid use disorder) that can result in overdose death and wider community problems.
The roots of the crisis
After introduction of the opioid painkiller OxyContin in 1996, Purdue Pharma marketed the drug aggressively, underplaying its potential for addiction. Prescriptions increased and many patients became addicted. Purdue Pharma eventually pleaded guilty to criminal charges in 2020.
To address addiction, prescription monitoring programs aimed to limit supply but many patients then sought illicit opioids, leading to large heroin markets in the 2010s.
From 2015 onwards, illegally made fentanyl — a very strong opioid that is easy to manufacture — became widely available, and rapidly replaced the heroin market. Fentanyl is extremely toxic — up to 100 times stronger than heroin — and is largely responsible for the increase in overdose deaths.
Now North Americans face an urgency on how to end the suffering. There is no single solution given the complexity of the problem, but we explain three potential strategies for treating patients and managing this epidemic.
1. Treat substance use disorders as a public health problem
The traditional “war on drugs” approach that focuses only on criminalization has been unsuccessful. In reality the data shows that illegal drug prices have fallen whilst purity and deaths have increased. Overdose deaths have also increased in prisons showing that places with even the highest level of security are vulnerable to drug smuggling.
Focusing on the opioid crisis through a public-health approach includes massively increasing access to care and treatment for patients experiencing substance use disorder. It requires more evidence-based services such as addiction clinics, psychotherapy harm reduction strategies and education for both patients and families about treatments that are available to them.
Beyond initial treatment there should be continued professional social support and a wider national effort to address the socioeconomic causes in disadvantaged communities.
Just as there is stigma associated with addiction that stops people from seeking help, there also appears to be stigma at the political and community level, as there is reluctance to fully acknowledge community drug problems. This stigma needs to be reduced so patients can get help.
2. Find better treatments through research
There are currently three main medicines approved for treating patients with opioid use disorder in Canada and the U.S.: methadone, buprenorphine/naloxone and extended-release naltrexone.
Although these are effective when used, there are barriers to access and long-term engagement with these treatments. Less than 10 per cent of overdose survivors have access to meaningful care. The limited number of medications available does not work for everyone. We need more innovation to rapidly increase access to care and to find better therapies that suit the needs of different patients.
For example, our research centre in Vancouver, is evaluating a slow-release formulation of morphine compared to methadone, which has been the dominant treatment for the past 40 years. This study will generate real-world evidence on the effectiveness of novel treatments in contexts of increasing fentanyl use.
Other research is exploring cannabis-based therapy and the best pathways patients can access for recovery. These research initiatives aim to increase the number of evidence-based treatments that can be used to enhance patient recovery and quality of life.
3. Stop the international spread of the epidemic
Currently the epidemic is contained within North America but there is the real concern of the crisis spreading to other countries. There is a steady increase in prescription and illicit opioid use in the United Kingdom and other European countries, which should be an early warning sign that they do not follow the same trajectory. Clinicians must remain actively vigilant on how they prescribe these drugs.
There should be greater international regulation in the marketing and operational strategies of pharmaceuticals, and oversight of the “revolving door” between industry and regulator employment. There is a potential conflict of interest when pharma companies hire the government employees who oversee their applications. As shown in Painkiller, the FDA regulator who initially had issues with the drug’s approval, and then later approved it, subsequently went on to work for Purdue.
Read more: ‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids
Another concern is that the current increase in overdose deaths is coinciding with increased deaths where other illicit recreational drugs, such as cocaine and benzodiazepines, are contaminated with fentanyl unknown to the users. More effort should be made towards the public awareness of the dangers of an increasingly toxic drug market.
Speaking at a health-care summit in June, Rahul Gupta, the director of the U.S. Office of National Drug Control Policy, said, “There is almost no other area today (that) affects our public health, national security and economic prosperity.”
Valuable knowledge has been gained in confronting this crisis. Governments and communities should support evidence-based recommendations to help patients. There are still many challenges, but they are not beyond solving.