Illicit opioid use in the 21st century: witnessing a paradigm shift?
Article first published online: 12 MAR 2007
Volume 102, Issue 4, pages 499–501, April 2007
How to Cite
FISCHER, B. and REHM, J. (2007), Illicit opioid use in the 21st century: witnessing a paradigm shift?. Addiction, 102: 499–501. doi: 10.1111/j.1360-0443.2006.01738.x
- Issue published online: 12 MAR 2007
- Article first published online: 12 MAR 2007
According to recent epidemiological counts, the world is home to 10 million heroin users with an estimated 2–4 million or more in western Europe and North America alone [1,2]. For almost a century, the image of the ‘heroin junkie’ has epitomized the illicit drug problem in western countries, and the phenomenon of ‘heroin addiction’ has been the central target of both ideology and interventions. Key researchers (e.g. Courtwright  and Lindesmith ) have described the pre-World War II ascent of the heroin addict as the ultimate expression of deviance and pathology expressed by narcotic drug use, while the latter part of the 20th century was dominated by resource-intensive efforts at the poles both of enforcement and therapy to control the problem. For decades, international drug policing has expended much of its resources to intervene against the seemingly indestructible heroin supply influxes to the Anglo-Saxon and western European parts of the world . It is a widely accepted fact that only a small proportion of the production is seized, and it has become police routine to celebrate larger seizures as if they were the pivotal breakthrough in effective heroin supply control . At the same time, beginning in the 1960s, the establishment of opioid (initially methadone) maintenance therapy—based on key North American studies—led to a treatment intervention which, for years, became both controversial and unique in the addiction treatment field [6,7]. While the basic controversy on the practice of ‘substituting a drug with a drug’ persists, millions of dollars in research trials have been invested in determining the relative merit of different opioid substitution therapies—nowadays including medical heroin prescription—in dealing with the problem of heroin dependence [8,9].
Amid this noisy ‘business-as-usual’ scenario, the critical question needs to be asked: are the above efforts still aiming at the right target? We should note here that we ask this question from a scientific, and not an ideologically motivated angle. To illustrate: in a recent longitudinal and multi-site survey of illicit opioid and other drug users, the Canadian OPICAN study (a multi-site cohort study to characterize social, health and drug use of illicit opioid use in Canada) has just documented that the prevalence of heroin use has declined significantly in its seven study sites in 2005 (compared to 2001 ). More specifically, in five of these sites, heroin use is completely or virtually absent. The predominant drugs of choice, instead, have become a variety of prescription opioid drugs: hydromorphone, oxycodone, morphine, codeine. Evidence exists for similar developments in other countries . Thus, several studies from the United States have reported dramatic increases in the prevalence of prescription opioid abuse, e.g. fentanyl, morphine and oxycodone [12,13]. Overall, the yearly incidence of opioid analgesic abuse in the United States increased from slightly over 600 000 in 1990 to more than 2.4 million in 2001. The latter number was at least double the size of the estimated existing heroin-user population . In addition, the number of opioid analgesic poisoning deaths in the US almost doubled between 1999 and 2002, and by 2002 was listed in more deaths than either heroin or cocaine . In Australia, recent epidemiological monitoring data suggest the use of opioids other than heroin—codeine, morphine, oxycodone—to be very ‘common’ or ‘substantially increased’.
In a series of recent studies and commentaries, Canadian and Australian colleagues have linked recent locally observed declines in heroin use patterns to temporary ‘heroin droughts’, i.e. shortfalls in (corresponding local) heroin supply or availability [17,18]. We think that these interpretations may only scratch the phenomenon's surface, and not reveal the true nature of the mountain which we may be facing. In fact, we see reason to believe that the role of heroin use as the perceived dominant core of the street drug use problem in Australia, Europe and North America may have come to an end or at least become substantially diminished, and that instead the opioid abuse phenomenon may be in the process of shifting into a landscape dominated by the illicit use of a great variety of prescription opioids. At this point we cannot explain this development causally, but only describe it. However, there appears to be reason to assume that shortages in heroin supply have probably not played a major role in this development, because the drug's overall supply has never really been ‘short’ in recent years; in fact, overall global heroin production 2003 has been up rather than down .
Hence it appears that other dynamics may be at work. Whatever the causes may be, the observed epidemiological developments described for ‘western’ regions undoubtedly have major implications for interventions, policy and research across a wide spectrum. First, given the decreasing prevalence and relevance of its use, the hundreds of millions of supply control dollars expended on supply control of the ‘heroin problem’, which were ineffective even in their best days, may be valuable water better pumped towards fires burning elsewhere. The keyfeatures of the emerging problem of prescription opioid use are, of course, fundamentally different: the relevant ‘sources’ of these drugs are not countries such as Afghanistan, Pakistan or Myanmar, linked by international drug import organizations to the streets of New York, Sydney or Toronto. Instead, prescription opioids are (legitimately) produced by pharmaceutical companies and provided by physicians and pharmacies, but result in being prescribed to the wrong people, for the wrong reasons, or in the wrong quantities (eventually allowing for direct or indirect diversion), or they are accessed (e.g. through the phenomenon of internet shopping) in ways that effectively detour existing mechanisms of regulatory control [10,14,19]. The availability and prescription of medical opioids in established market economies has increased substantially in recent years—and this has been considered as an overall medically beneficial development, primarily with regard to pain therapy. The complex challenge now is to find ways for improved opioid prescription control which will reduce supply for opioid abuse, while retaining adequate access for legitimate use purposes [19,20]. Recent mechanisms of prescription monitoring programs (PMPs) in the United States have resulted in considerable declines in narcotics prescriptions—yet in ways that may have penalized the wrong targets (i.e. legitimate users) by causing a ‘chilling effect’ among prescribers .
A second key implication concerns both treatment and research. While enormous efforts have been made with regard to the development of treatment interventions for opioid dependence, most of the existing interventions (e.g. opioid maintenance programs) are limited in terms of their evidence base to application to the specific phenomenon of heroin abuse [22–24]. Hence, we know little or nothing about to what extent existing opioid maintenance therapies—ranging from methadone maintenance treatment (MMT) to injection opioid prescription—can be applied to the phenomenon of prescription opioid abuse or dependence. Thus, little is known empirically on what should be conducted therapeutically with the hydromorphone or oxycodone addict. It seems reasonable to assume that opioid maintenance interventions may be similarly beneficial here, yet we lack a solid empirical base for interventions, especially with regard to optimized treatment matching. Given the epidemiological trends we have described, filling these gaps is a fundamental challenge for clinically relevant research in the opioid abuse area for the immediate future.
A final implication relates to epidemiology and research. The recent observations regarding the shifts away from heroin towards an increasing prevalence of prescription opioid use were, in a sense, made accidentally. Furthermore, most national systems' drug use monitoring tools—e.g. the Canadian Addiction Survey (CAS)—have not been sensitive to the phenomenon of prescription opioid abuse or its harmful consequences (especially in marginalized user groups, e.g. street drug users): specifically, most even lack the most basic tools to differentiate ‘use’ from ‘abuse’ or ‘dependence’. It is quite possible that, for some user populations, a shift from heroin to prescription opioid abuse may mean a reduction in key consequential harms (e.g. overdose risk or injecting behaviours)—as suggested by the OPICAN data . On this basis, it is essential that the necessary research methodological and operational steps—as recognized formally in an invited expert consensus conference convened by Health Canada —should be taken which will allow us to examine and monitor this phenomenon in a systematic manner. Given current indicators, the phenomenon of prescription opioid abuse requires informed and effective interventions so that the benefits of prescription opioid use continue to outweigh its harms in the long term.
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- 26Health Canada. Draft consensus statement. Workshop to build consensus on concepts and indicators for research on psychotropic pharmaceutical abuse. Ottawa: Health Canada; September 2006.