Managing the opioid crisis in North America and beyond

2020 marked the deadliest year yet in the North American opioid epidemic: more than 100,000 drug overdoses were recorded in the USA, nearly 76,000 of them attributed to opioids, an increase of approximately 30% over 2019; in Canada, deaths rose by 67% in a single year, to more than 6200. The exceptional circumstances of the COVID-19 pandemic may have contributed to many overdose deaths by disrupting treatment programs and access to life-saving medications such as naloxone, and by limiting support networks. Yet the opioid epidemic has been a constant, complex, and decades-long crisis, since its inception in 1995 when OxyContin was approved and erroneously marketed as a safe and low-risk extended-release opioid analgesic.

Identifying the underpinnings of the opioid crisis has often focused on the unique confluence of factors within the USA. Much has been written about the series of dubious decisions made by the US Food and Drug Administration, which failed to enforce proper pain indication labeling on packaging, and the vast increases in the quotas of manufactured opioids approved by the Drug Enforcement Agency. Early warnings by public health workers and emergency services about the potential lethality of opioids went unheeded. So-called regulatory capture, or the prioritization of corporate over public interest, has been engrained in pharmaceutical manufacturing practices in the US. Drug makers such as Purdue Pharma (manufacturer of OxyContin) have wielded outsized power through providing heavy financial incentives to political campaigns, advocacy groups, and medical school programs. As investigative journalist Patrick Radden Keefe suggested in his book, Empire of Pain, “The opioid crisis is…a parable about the awesome capability of private industry to subvert public institutions”.

It is against that backdrop—the progression of the opioid epidemic and recognition of the breadth of institutions affected by the entrenched commercialization of pain—that a new report is published, Responding to the opioid crisis in North America and beyond: recommendations of the Stanford– Lancet Commission. The Commission analyzes the state of the opioid epidemic in North America and maps out an action plan for policy makers to de-escalate the crisis. Since 1999, there have been more than 600,000 deaths in North America from opioid overdose, over at least three distinct waves. Modeling performed by the group provides a bleak outlook: by the end of this decade, an additional 1 2 million people are predicted to die from opioid overdose without substantial policy reform.

Since 2011, ushered in by prescription opioids, expanding heroin markets, and illicit synthetic opioids such as fentanyl, there has been a cruel repositioning in the “deaths of despair” narrative—opioid overdose deaths have increased in Black (27/100 000 deaths) and Native American and American Indian populations (28/100,000 people) such that in 2020, they historically exceed greater white mortality (26/100,000 people). In addition to describing demographic changes, the Commission calls for a major shift in the treatment of opioid use disorder (OUD), by characterizing addiction as a chronic condition. Doing so has major implications for addiction treatment models in the USA, for example, by providing consistent funding for regional specialty addiction centers with additional, localized medication-assisted treatment services, such as offering methadone and buprenorphine. The Commission emphasizes the necessity of innovation in treatment of OUD and in the treatment of pain, serving as a call to the Biden Administration to reinvigorate the National Pain Strategy, generating improved population-level metrics and research, prevention programs, provider training, and service delivery.

Innovation and transformation in the approach to ending the opioid epidemic must be met with reinforced regulation. US institutions were subverted through failures in post-marketing surveillance and physician education, and by permitting financial conflicts of interest between regulatory agencies and industry. But the moral of the opioid crisis is not that it could happen only in North America. Without reigning in deceptive marketing and prescribing practices and international funding for subsidized generic morphine for low-income countries, the possibility of other opioid crises remains. The risk of global spread is greater where COVID-19 has ravaged health systems, where pain needs in resource-limited settings go unmet, and where corporations look for new markets, but are left to self-regulate. To manage pain, greed must be managed as well.

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Published: February 02, 2022

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DOI: https://doi.org/10.1016/S0140-6736(22)00200-8

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© 2022 Elsevier Ltd. All rights reserved.

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  • Responding to the opioid crisis in North America and beyond: recommendations of the Stanford–Lancet Commission
    • The Stanford-Lancet Commission on the North American Opioid Crisis was formed in response to soaring opioid-related morbidity and mortality in the USA and Canada over the past 25 years. The Commission is supported by Stanford University and brings together diverse Stanford scholars and other leading experts across the USA and Canada, with the goals of understanding the opioid crisis, proposing solutions to the crisis domestically, and attempting to stop its spread internationally. Unlike some other Lancet Commissions, this one focuses on a long-entrenched problem that has already been well characterized, including in several reviews by the National Academies of Sciences, Engineering, and Medicine.

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