The opioid crisis: the time to wake up is now

The USA opioid crisis has long spilled over into other countries. Poorer countries are particularly affected, but opioid use is also on the rise in Europe.

HIV and AIDS in times of opioid crisis

People who inject drugs are more at risk of contracting HIV than any other population group. They have a 35% higher risk of HIV infection compared to non-users. A sign that drug use needs to be decriminalised and harm reduction and other programmes for drug users need to be expanded, according to Julie Bruneau at this year's AIDS conference in Montreal.

Oxycontin, heroin, fentanyl: opioid epidemic in the USA

The opioid crisis in North America began in the 1990s and was actually a well-intentioned attempt at pain management and palliative care, but then also proved to be a stepping stone to the rapid increase in opioid prescriptions. The drugs were sometimes aggressively and misleadingly labelled as non-addictive by pharmaceutical companies or even advertised and downplayed with discount coupons.

More and more people were exposed to opioid analgesics. During a second wave of the opioid crisis around 2010, there was increased scrutiny of opioid prescriptions and a reformulation of Oxycontin that no longer allowed the tablets to be crushed and injected. As a result, there was an increase in deaths among people switching from Oxycontin to heroin. Mainly in cities and within non-white populations. But the epidemic also continued to spread among white young men in the suburbs against a backdrop of economic hardship and lack of harm reduction opportunities. A dramatic third wave is currently on the rise, characterised by deaths from fentanyl, a derivative that is 50 to 400 times more potent than heroin.

In Scott County, Indiana, there was an HIV outbreak within a large network of people injecting prescription opioids between 2014 and 2015. 95% were also already infected with HCV, and Indiana had a far higher than average national opioid-related death rate. The epidemic was ultimately brought under control through a highly supervised programme that combined the exchange of used needles for sterile cutlery, HIV screening and HIV treatment. The Scott County case clearly demonstrates the vulnerability of people who use drugs when resources and health care are not available to meet their needs. The programme in Scott County expired in spring 2022 and was not further funded despite its great success.

Opioid use during the COVID 19 pandemic

The influence of social and structural factors on the opioid crisis was also evident during the Corona pandemic. Especially in larger areas of higher income inequality and within non-white populations.

In Canada, opioid prescriptions increased in much the same way as in the United States. In the last six years, more than 30,000 people died from opioid overdoses here. In 2019, opioid-related deaths had begun to decline, only to rise abruptly in 2020 during the COVID 19 pandemic to the highest number of documented cases to date. It is worth noting that multiple substance use also plays a crucial role. More than 50% of the people who died in connection with opioids had also used stimulants. People who use drugs are often excluded from mainstream care and unable to access culturally appropriate or non-stigmatised care services.

This is also true within the general Canadian care system, which is virtually non-existent outside of large cities. Prisoners are denied evidence-based care in most prisons when drug addiction is involved. The Corona virus has exacerbated these structural barriers. Mental illness, homelessness and isolation have added to the damage. And what happens in terms of HIV and HCV within these populations is hardly known because monitoring is not possible.

HIV, HCV and overdose in an international context

In the international context, various interventions have been shown to be effective in reducing deaths and drug-related diseases. One effective method against HIV, HCV and overdose is replacement therapy. However, the knowledge gained so far falls short of the problems to be solved and funding for treatment of drug-related diseases and drug treatment is far too low. Canada is doing relatively well according to the WHO targets on replacement therapy and syringe exchange. By and large, the Canadian government has responded to the opioid crisis at the national level in most areas of responsibility, both with legislative adjustments to reduce barriers and with a number of implementations and scaling up of measures to decriminalise drug possession, harm reduction and destigmatisation. However, support services need to be further expanded and optimised, and access to primary care needs to be facilitated.

The two drugs for substitution therapy that are recognised internationally and according to WHO guidelines are methadone and buprenorphine. Methadone was developed in the 1940s, buprenorphine in the 1960s. However, dispensing is highly regulated, not needs-based and subject to strict controls. Dosages are often too low, and treatment is often ineffective. It is significant that pharmacotherapy stagnates over such a long period of time for such a serious disease as drug addiction.

What can be learned from what is happening in North America?

There are already good strategies to prevent HIV infections and HCV infections, such as pressure rooms or sterile syringes available free of charge. Replacement therapies can prevent overdose deaths.

This article is based on the presentation "The opioid epidemic" by Julie Bruneau at this year's AIDS conference. esanum covered the 24th International AIDS Conference in Montreal, Canada, from 29 July - 02 August 2022. We invite you to visit esanum's conference coverage.