Global patterns of opioid use and dependence: harms to populations, interventions, and future action

Abstract

We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.

Figure 1a:

Countries with the highest no. standardised defined daily doses (s-DDDs) of opioid analgesics consumed per million people per day, 2016

Figure 1b:

Opioid analgesic consumption in highest countries (as at 2016), no. standardised defined daily doses (s-DDDs) of opioid analgesics consumed per million people per day, 1990–2016 Source: Data provided by the International Narcotics Control Board. Used 3-year rolling averages. Opioid analgesics includes codeine, dextropropoxyphene, dihydrocodeine, fentanyl, hydrocodone, hydromorphone, morphine, ketobemidone, oxycodone, pethidine, tilidine and trimeperidine. It is important to note that there are gaps in reporting of data by member states and there may be differences in the quality of data reported across countries. See Appendix C for details on how INCB data are collected from member states and analysed. Please note that these figures report on a subset of opioids used for analgesia and do not include the full list of narcotic drugs the full list of narcotic drugs reported in the INCB’s annual reports.

Figure 2:

Estimated prevalence of opioid dependence and opioid overdose mortality, Global Burden of Disease study 2017 2a. Estimated age-standardised opioid dependence cases per 100,000 population

Figure 2b:

Estimated age-standardised opioid overdose deaths per 100,000 population Source: Global Burden of Disease 2017^,. For details on the methods used please see Appendix E.

Figure E1:

Summary of parameters across modelled settings

Figure E1:. Causes of death among PWID and ex-PWID; 2020–2040.

Figure shows the median percentage of deaths due to overdose, suicide, injury, HIV, HCV or other causes under the following strategies: if there were no OAT from 2020; if OAT was scaled-up to 40% coverage among PWID in the community; if OAT was scaled-up to 40% coverage among PWID in the community and the average duration of OAT is increased to 2-years; if OAT was scaled-up to 40% coverage among PWID in the community, incarcerated PWID enrol onto OAT at the same rate and the average duration of OAT is increased to 2-years. Deaths from other natural causes which account for 22%, 54% and 82% of deaths in Tehran, Kiev and Kentucky in Status Quo projections, respectively, are not shown.