The pattern of opioid use varies dramatically around the world.
There are significant variations not just in terms of how many prescription pills are used but also differences in the nature of the opioids used.
While today we’ll look at how these powerful prescription pills are abused outside the United States, it’s impossible not to touch upon the scope of the problem closer to home at the same time.
Figures from the CDC (Center for Disease Control and Prevention) show 130 Americans die each day from opioid overdoses. In the relatively short period from 1999 to 2017, the number of deaths from opioids had increased by a factor of 6. This sorry state of affairs led to the opioid epidemic ravaging the US being declared a public health emergency.
To place the issue of opioid use outside of the United States in full context, it’s worth underscoring one sobering statistic above all others:
While constituting less than 5% of the world’s population, US residents are responsible for consuming 80% of the global opioid supply with fully 99% of all hydrocodone supplied ending up in US hands.
All these figures point to a problem that’s demonstrably US-centric but how about use throughout the rest of the world?
Before we explore this in more depth, we’ll glimpse briefly at what opioids are and how users can descend into abuse before turning into full-blown opioid disorder.
Understanding Opioid Use and Abuse
The term “opioids” is used as an umbrella term for a class of medication employed as painkillers. Heroin is also an opioid but for the purposes of most studies of opioid use, the illegal drug heroin is set aside and treated separately.
Synthetic opioids, the focus of today’s examination, include:
- Hydrocodone (Vicodin)
- Oxycodone (OxyContin)
Opioids alter the way in which the mind perceives pain since they work efficiently on both opioid receptors in the brain and nerve cells throughout the body.
While undeniably effective pain relievers when used as prescribed, physical dependence sets in quickly and easily. If this dependence spirals into full-blown addiction, recovery can be problematic.
When used long-term to treat chronic pain, opioids are not as efficacious. Tolerance builds rapidly with an increased dosage required to achieve pain relief. Once tolerance takes hold, there’s a strong chance of withdrawal symptoms if use is discontinued. Unfortunately, this can occur even when opioids are being used exactly as prescribed.
From this point, it’s not unusual for opioid use disorder to set in.
Opioid Use Disorder
When opioids are used with the express intent of getting high or in order to sidestep withdrawal symptoms, this is characterized as opioid use disorder.
Whether a user is taking opioids in higher doses than prescribed or for reasons other than prescribed, whether lying to obtain prescriptions or trading prescriptions with others, opioid use disorder takes on many forms. The common thread is wholesale and disastrous effects rippling through the life of the user and their family.
Luckily, although a severe set of circumstances can unfold when opioid disorder develops, this addiction can be successfully treated. From medication-assisted treatment to a range of therapies like CBT (cognitive behavioral therapy), if someone with opioid use disorder takes action, full recovery is eminently achievable.
So, with those basics sketched in, how do we find ourselves in the situation where opioid abuse is devastating not just the US but the rest of the world, too?
How The Opioid Problem Began
Back in the 1990's, American pain specialists and advocacy groups claimed there was an epidemic of untreated pain that needed tackling. Spurred on by the American Pain Society, consumers and professional groups alike starting campaigning for the increased use of opioids for the purposes of pain management.
At one and the same time as this shifting attitude within the medical community, oxycodone (OxyContin) was introduced to the market and aggressively promoted. With the addictive potential downplayed and prescribing the medication heavily incentivized, so began the opioid epidemic.
This was not just a successful strategy for OxyContin sales in the US, though. Global sales grew from $48 million to over $2.4 billion from 1996 to 2012.
Simultaneously, global sales of other opioids like codeine and morphine took a sharp upswing.
While the US has undeniably been at the forefront of this catastrophe, the problem is equally certainly unfolding on a global scale
Before we dive down into how opioids are used across several continents, it’s worth highlighting the worldwide issue in broader strokes.
A Brief Overview of Global Opioid Use
In The 2018 World Drug Report released by the UNODC (United Nations Office on Drugs and Crime), opioids accounted for 76% of all deaths with drug disorders implicated.
Go back a couple of years and 87 tons of pharmaceutical opioids were seized, roughly comparable to the amount of heroin taken off the streets in 2016.
While fentanyl – up to 100 times more potent than morphine – remains a cause for concern in North America, tramadol has started to manifest as a serious problem in parts of Africa and throughout Asia.
What’s the deal with tramadol then and why is it causing mayhem outside of the United States?
Tramadol Use: Africa and Asia
According to the UNODC report, global abuse of synthetic opioids is booming. In this report, the non-medical use of the painkiller tramadol is flagged as receiving much less press but requiring immediate attention.
With opium production waning, there’s been a corresponding uptick in seizures of the narcotic-like pain reliever and opioid tramadol according to that same UN Drug Report. In 2010, less than 10kg of tramadol were seized globally. Seizures ballooned to 9 tons by 2013 then skyrocketed to 125 tons by 2017.
The tramadol problem is prevalent in Africa and India.
In a number of West African nations, tramadol comes a close second to marijuana as the most widely used drug not intended for medical purposes. Beyond its pain-relieving action, tramadol can be taken for the calming and analgesic effects it induces. It can also help combat fatigue, decrease the need for sleep and reduce appetite. Tramadol is also used recreationally in Africa due to its stimulant and euphoric properties. The drug is even fed to cattle in some farming communities to enable them to work under adverse conditions.
In Cameroon, 80% of all car accidents ending up with hospital visits are related to tramadol. In other African countries, tramadol deaths are outranking deaths caused by heroin use.
While Africans are consuming tramadol in escalating numbers, it’s India responsible for the bulk of production. According to the Center for Strategic and International Studies, over 1 billion tramadol tablets were seized last year leaving India. As always with figures on drug seizures, this obviously suggests actual exports are notably higher than this number.
Tramadol shipments from India are sent out on commercial shipping containers and supply networks have been tentatively linked with terrorist organizations from IS to Boko Haram. With Libya becoming a hub, the drug is also penetrating the Middle East. The drug works its way from India through Southeast Asia. Given that tramadol is not on the international drug schedule, if only one country regulates this drug, supply is not affected. Egypt made some attempts at stifling tramadol use through regulation but Indian exports to the country increased and it remains the single most abused drug in Egypt.
Why, then, does India do nothing to classify or regulate tramadol or other potentially destructive opioids?
The root of the problem lies in India’s ambivalent attitude toward addiction. Also, while the government openly acknowledges there’s a growing tramadol epidemic, ingrained government corruption also plays a part in the flow of opioids from India. To put this into clear perspective, Transparency International ranked India highest in the entire Asia Pacific region for rates of bribery.
Throw in the absence of international regulation and the problem is only likely to worsen until tighter controls and more meaningful international cooperation are in place.
Oxycodone Use: Europe
Scandinavian nations Norway, Sweden and Denmark are noticing statistically significant increases in prescriptions for oxycodone, the powerful pain medication. This was the medication that was prescribed to more than 1 in 7 Americans back in 2012.
While the pharmaceutical industry in these countries is stringently regulated and marketing to doctors restricted, the populations are aging and crying out for pain relief. While this is a benign start, it does beg the question of whether these Nordic nations might be heading toward a US-style epidemic. Outpatient prescriptions are already increasing, a red flag in itself. These have tripled over the past decade.
Ashley Elizabeth Muller from the Norwegian Institute of Public Health stated that the problem in Norway shouldn’t be underestimated and that the country shouldn’t become complacent or think that the US situation isn't applicable to Norway with oxycodone being increasingly prescribed.
In Germany, second to the US in terms of daily opioid use, fentanyl is more than twice as likely to be prescribed as any other opioid. Not only is fentanyl cheap in Germany, but it can also be administered with ease via patches.
We obviously can’t take you on a comprehensive tour of every country in the world so we’ll round out with a glance at opioid use in Latin America before looking at what can be done to arrest this global epidemic.
Opioid Use: Latin America
Following the 2017 declaration of the opioid crisis in the US, pharmaceutical companies applied the same strategies in Latin America in an attempt to regain lost sales.
While the nature of the problem remains the same, details differ. Mexico and Guatemala show no cases at all of opium misuse despite poppy crops in those countries. Opiates are not widely used either in Colombia or Argentina. Of those prescribed opioids, only 1.8% meet criteria for opioid use disorder. That said, reliability and availability of data are lacking and misdiagnosis is routine.
In Puerto Rico, opioid misuse is higher than in other parts of Latin America. Use is split between analgesics prescribed legally then abused and opioids sourced on the black market.
Tramadol and morphine are the most consumed opioids in Latin America rather than oxycodone in the US. That said, oxycodone has the largest increase in use while more users are seeking out synthetic opioids like fentanyl.
Due to the unreliability of data, we’ll limit ourselves to that snapshot of opioid use in Latin America but it’s certainly a problem that needs attacking. This is the case throughout the world so what can be done about it?
Solutions To The Global Opioid Epidemic
The UNODC rolled out an integrated strategy to help countries including and outside the US address the crisis of synthetic opioids.
This strategy is based on 5 pillars:
- Warning and trend analysis
- Addressing the non-medical use of opioids
- Prevention and treatment
- Disruption of trafficking
- Encouraging international cooperation
Time will tell how this strategy develops and what degree of success it brings about.
Prescription monitoring programs in Canada, Europe and Australia have been implemented but not yet evaluated although the same programs in the US are showing promising results.
The one thing that needs to be kept firmly in mind is that acute and chronic pain still needs treatment. Continued study of pain management and the elimination of misinformation and knowledge gaps can only be beneficial.
What should also remain uppermost in mind is that high quality of care for anyone in pain shouldn’t be impacted but that opioid use should only be encouraged when strictly necessary.
If you or a loved one with struggling with opioid abuse, Landmark Recovery is here to help. Our Indiana treatment center offers residential treatment, medical detoxification, intensive outpatient treatment and more. If you are ready to live the life you dreamed down the road to recovery, call our dedicated admissions team today.