Opioid Use Epidemic in Mexico: Global Solutions to a Global Problem

Association of globalization with the burden of opioid use disorders 2019. A country-level analysis using targeted maximum likelihood estimation

BACKGROUND

The "opioid crisis" has been responsible for hundreds of thousands deaths in the US, and is at risk of dissemination worldwide. Within-country studies have demonstrated that the rise of opioid use disorders (OUD) is linked to increased access to opioid prescriptions and to so-called "diseases of despair". Both have been related to the emergence of globalization policies since the 1980s. First, globalized countries have seen a reorganization of healthcare practices towards quick and easy answers to complex needs, including increased opioid prescriptions. Second, despair has gained those suffering from the mutations of socio-economic systems and working conditions that have accompanied globalization policies (e.g. delocalization, deindustrialization, and the decline of social services). Here, using data with high quality ratings from the Global Burden of Disease database, we evaluated the country-based association between four levels of globalization and the burden of OUD 2019.

RESULTS

The sample included 87 countries. Taking into account potential country-level confounders, we found that countries with the highest level of globalization were associated with a 31% increase in the burden of OUD 2019 compared to those with the lowest level of globalization (mean log difference: 0.31; 95%CI, 0.04-0.57; p = 0.02). Additional analyses showed a significant effect for low back pain (mean log difference: 0.07; 95%CI, 0.02-0.12; p = 0.007). In contrast, despite sharing some of the risk factors of OUD, other mental and substance use disorders did not show any significant relationship with globalization. Finally, socio-cultural de jure globalization, which compiles indicators related to gender equality, human capital and civil rights, was specifically associated with the burden of OUD (mean log difference: 0.49; 95%CI: 0.23,0.75; p < 0.001).

CONCLUSIONS

These findings suggest that OUD may have inherent underpinnings linked to globalization, and more particularly socio-cultural aspects of globalization. Key factors may be increased rights to access prescriptions, as well as increased feelings of despair related to the erosion of local cultures and widening educational gaps.

Optimising the secondary use of primary care prescribing data to improve quality of care: a qualitative analysis

OBJECTIVES

To explore available data sources, secondary uses and key considerations for optimising the actionability of primary care prescribing data to improve quality of care in the Dutch context.

DESIGN

An exploratory qualitative study was undertaken based on semi-structured interviews. We anchored our investigation around three tracer prescription types: antibiotics; benzodiazepines and opioids. Descriptive and explanatory themes were derived from interview data using thematic analysis.

SETTING

Stakeholders were sampled from across the micro (clinical), meso (organisational) and macro (policy) contexts of the Dutch primary care system.

PARTICIPANTS

The study involved 28 informants representing general practitioners (GPs), community pharmacists, regional chronic care networks (care groups), academia and research institutes, insurers, professional associations, electronic health record (EHR) vendors and national authorities.

RESULTS

In the Netherlands, three main sources of data for improving prescribing in primary care are in use: clinical data in the EHRs of GP practices; pharmacy data in community pharmacy databases and claims data of insurers. While the secondary use of pharmacy and claims data is well-established across levels, the use of these data together with EHR data is limited. Important differences in the types of prescribing information needed by micro-meso-macro context are found, though the extent to which current indicators address these varies by prescription type. Five main themes were identified as areas for optimising data use: (1) measuring what matters, (2) increasing data linkages, (3) improving data quality, (4) facilitating data sharing and (5) optimising fit for use analysis.

CONCLUSIONS

To make primary care prescribing data useful for improving quality, consolidated patient-specific data on the indication for a prescription and dispensed medicine, over time, is needed. In the Netherlands, the selection of indicators requires further prioritisation to better signal the appropriateness and long-term use of prescription drugs. Prioritising data linkages is critical towards more actionable use.

Global, regional, and national consumption of controlled opioids: a cross-sectional study of 214 countries and non-metropolitan territories

INTRODUCTION

The consumption of opioids has increased globally since the 1990s. Previous studies of global opioid consumption have concentrated on morphine alone or a subset of opioids, with a focus on cancer pain and palliative care. In this study, we have determined the global, regional, and national consumption of all controlled opioids, including anaesthetics, analgesics, antidiarrheals, opioid substitution therapies, and cough suppressants.

METHODS

We conducted a cross-sectional study using data from the International Narcotics Control Board (INCB). We calculated mean opioid consumption (mg/person) globally, regionally, and nationally for 2015-2017, where consumption refers to the total amount of controlled opioids distributed for medical purposes and excludes recreational use. We ranked countries by total consumption and quantified the types of opioids consumed globally.

RESULTS

Between 2015 and 2017, 90% of the world's population consumed only 11% of controlled opioids. An average of 32 mg/person was consumed annually, but this was not equally distributed across the world. Consumption was the highest in Germany (480 mg/person), followed by Iceland (428 mg/person), the United States (398 mg/person) and Canada (333 mg/person). Oxycodone (35%) was the most heavily consumed controlled opioid globally, followed by morphine (15.9%), methadone (15.8%) and tilidine (14%).

CONCLUSION

Large disparities persist in most of the world in accessing essential opioid medicines. Consumption patterns should continue to be monitored, and collaborative strategies should be developed to promote access and the appropriate prescribing of opioids in all countries and non-metropolitan territories.

The Opioid/Overdose Crisis as a Dialectics of Pain, Despair, and One-Sided Struggle

The opioid/overdose crisis in the United States and Canada has claimed hundreds of thousands of lives and has become a major field for research and interventions. It has embroiled pharmaceutical companies in lawsuits and possible bankruptcy filings. Effective interventions and policies toward this and future drug-related outbreaks may be improved by understanding the sociostructural roots of this outbreak. Much of the literature on roots of the opioid/overdose outbreak focuses on (1) the actions of pharmaceutical companies in inappropriately promoting the use of prescription opioids; (2) "deaths of despair" based on the deindustrialization of much of rural and urban Canada and the United States, and on the related marginalization and demoralization of those facing lifetimes of joblessness or precarious employment in poorly paid, often dangerous work; and (3) increase in occupationally-induced pain and injuries in the population. All three of these roots of the crisis-pharmaceutical misconduct and unethical marketing practices, despair based on deindustrialization and increased occupational pain-can be traced back, in part, to what has been called the "one-sided class war" that became prominent in the 1970s, became institutionalized as neo-liberalism in and since the 1980s, and may now be beginning to be challenged. We describe this one-sided class war, and how processes it sparked enabled pharmaceutical corporations in their misconduct, nurtured individualistic ideologies that fed into despair and drug use, weakened institutions that created social support in communities, and reduced barriers against injuries and other occupational pain at workplaces by reducing unionization, weakening surviving unions, and weakening the enforcement of rules about workplace safety and health. We then briefly discuss the implications of this analysis for programs and policies to mitigate or reverse the opioid/overdose outbreak.

'You're not just a medical professional': Exploring paramedic experiences of overdose response within Vancouver's downtown eastside

BACKGROUND

Overdose response has become an increasingly relevant component of paramedic practice, particularly in light of increased opioid overdose globally. Previous studies have noted gaps in our understanding regarding the unique challenges which paramedics face during this form of pre-hospital emergency care. The aim of this study is to explore and describe the ways in which paramedics experience overdose response, specifically within a community markedly affected by the overdose crisis.

METHODS

Ten participants were recruited from a single ambulance station located in an urban center in Western Canada. Two rounds of semi-structured individual interviews were conducted, and data saturation was found to have been reached. Verbatim transcripts were produced and subject to two rounds of descriptive and pattern coding. A second researcher reviewed all of the codes, with disagreements being handled by discussion until agreement was obtained. Themes were identified, along with a Core Category which seeks to describe the underlying dynamics of overdose response represented in our data. The concept of a Core Category was borrowed from Grounded Theory methodology.

FINDINGS

Five major themes were identified: Connecting with patients' lived experiences; Occupying roles as clinicians and patient advocates; Navigating on-scene hazards; Difficulties with transitions of care; and Emotional burden of the overdose crisis. A core category was identified as One's capacity to help.

CONCLUSIONS

This research contributes to existing literature on overdose response by specifically examining paramedic experiences during this form of emergency care. While paramedics felt highly confident in providing clinical care, their capacity to address underlying causes of drug use was understood as much more limited. Participants found ways to address this lack of control, along with feelings of frustration, by trying to understand patient perspectives and adopting empathetic attitudes.

Physician-Delivered Pain Neuroscience Education for Opioid Tapering: A Case Report

We describe the case of a 75-year-old female with chronic low back pain (CLBP), on opioids for more than 15 years. She presented with an acute episode of nausea, vomiting, abdominal pain, and shortness of breath. After a complete work-up, it was concluded that her presenting symptoms were likely due to her high levels of CLBP and high dose opioids. At the time of intervention, her opioid dosage was between 50-90 MME (Morphine milligram equivalent) (Norco 8 × 7.5 mg/day + Fentanyl 12 mcg patch). She was subsequently seen by the physician for seven outpatient internal medicine appointments over nine months and received Pain Neuroscience Education (PNE) in conjunction with monitored tapering of opioids and other medication associated with her CLBP. This case report demonstrates how a physician might deliver PNE as a viable nonpharmacological treatment option for the tapering of long-term opioids for chronic pain.