1. Canada

2. Outside North America

3. Accessibility of prescribed opioids

4. References

Canada

In 1993 an investigation by the chief coroner in British Columbia identified an “inordinately high number” of drug-related deaths when there were 330. In 2017, there were 1473 in British Columbia and in Canada as a whole, 3996.^[2]

Canada followed the United States as the second highest per capita user of prescription opioids in 2015.^[3] In Alberta emergency department visits as a result of opiate overdose rose 1,000% in the previous five years. The Canadian Institute for Health Information found that while overall a third of overdoses were intentional, among those ages 15–24 nearly half were intentional.^[4] In 2017 there were 3,987 opioid-related deaths in Canada, 92% of these deaths being unintentional. The number of deaths involving fentanyl or fentanyl analogues increased by 17% compared to 2016.^[5]

North America's first safe injection site, Insite, opened in the Downtown Eastside (DTES) neighborhood of Vancouver in 2003. Safe injection sites are legally sanctioned, medically supervised facilities in which individuals are able to consume illicit recreational drugs, as part of a harm reduction approach towards drug problems which also includes information about drugs and basic health care, counseling, sterile injection equipment, treatment referrals, and access to medical staff, for instance in the event of an overdose. Health Canada has licensed 16 safe injection sites in the country.^[6] In Canada, about half of overdoses resulting in hospitalization were accidental, while a third were deliberate overdoses.^[4]

OxyContin was removed from the Canadian drug formulary in 2012^[7] and medical opioid prescription was reduced, but this led to an increase in the illicit supply of stronger and more dangerous opioids such as fentanyl and carfentanil. In 2018 there were around 1 million users at risk from these toxic opioid products. A local project in Vancouver was established by the British Columbia Centre for Disease Control in 2017 to distribute medical-grade hydromorphone through secure dispensing machines ^[8]

Outside North America

Approximately 80 percent of the global pharmaceutical opioid supply is consumed in the United States.^[9] It has also become a serious problem outside the U.S., mostly among young adults.^[10] The concern not only relates to the drugs themselves, but to the fact that in many countries doctors are less trained about drug addiction, both about its causes or treatment.^[12] According to an epidemiologist at Columbia University: "Once pharmaceuticals start targeting other countries and make people feel like opioids are safe, we might see a spike [in opioid abuse]. It worked here. Why wouldn't it work elsewhere?" ^[12]

Most deaths worldwide from opioids and prescription drugs are from sexually transmitted infections passed through shared needles. This has led to a global initiative of needle exchange programs and research into the varying needle types carrying STIs. In Europe, prescription opioids accounted for three-quarters of overdose deaths among those between ages 15 and 39.^[10] Some worry that the epidemic could become a worldwide pandemic if not curtailed.^[12] Prescription drug abuse among teenagers in Canada, Australia, and Europe were comparable to U.S. teenagers.^[11] In Lebanon and Saudi Arabia, and in parts of China, surveys found that one in ten students had used prescription painkillers for non-medical purposes. Similar high rates of non-medical use were found among the young throughout Europe, including Spain and the United Kingdom.^[11]

From January to August 2017, there were 60 fatal overdoses of fentanyl in the UK.^[12] Opioid prescribing in English general practice mirrors general geographical health inequalities.^[13] Scotland has a drug mortality rate of 175 per million population aged 15 to 64 by far the worst in Europe.^[14]

Accessibility of prescribed opioids

The worry surrounding the potential of a worldwide pandemic has affected opioid accessibility in countries around the world. Approximately 25.5 million people per year, including 2.5 million children, die without pain relief worldwide, with many of these cases occurring in low and middle-income countries. The current disparity in accessibility to pain relief in various countries is significant; the U.S. produces or imports 30 times as much pain relief medication as it needs while low-income countries such as Nigeria receive less than 0.2% of what they need, and 90% of all the morphine in the world is used by the world's richest 10%.^[15] America's opioid epidemic has resulted in an “opiophobia” that is stirring conversations among some Western legislators and philanthropists about adopting a “war on drugs rhetoric” to oppose the idea of increasing opioid accessibility in other countries, in fear of starting similar opioid epidemics abroad.^[16] The International Narcotics Control Board (INCB), a monitoring agency established by the U.N. to prevent addiction and ensure appropriate opioid availability for medical use, has written model laws limiting opioid accessibility that it encourages countries to enact. Many of these laws more significantly impact low-income countries; for instance, one model law ruled that only doctors could supply opioids, which limited opioid accessibility in poorer countries that had a scarce number of doctors.^[17]

In 2018, deputy head of China's National Narcotics Commission Liu Yuejin criticized the U.S. market's role in driving opioid demand.^[18]

In 2016, the medical news site STAT reported that while Mexican cartels are the main source of heroin smuggled into the U.S., Chinese suppliers provide both raw fentanyl and the machinery necessary for its production.^[19] In British Columbia, police discovered a lab making 100,000 fentanyl pills each month, which they were shipping to Calgary, Alberta. 90 people in Calgary overdosed on the drug in 2015.^[19] In Southern California, a home-operated drug lab with six pill presses was uncovered by federal agents; each machine was capable of producing thousands of pills an hour.^[19]

References

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• Nersès Bédros XIX Tarmouni