Current Opioid Access, Use and Problems in Asian Jurisdictions
Dinesh Sangarran Ramachandram, V. Chitra, Rini. R
Department of Pharmacology, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Chengalpet- 603203.
*Corresponding Author E-mail: rininannat95@gmail.com
ABSTRACT:
Background: Opioids are being used more frequently in the management of non-malignant chronic pain. This practice has now led to a new and growing problem with addiction and misuse of opioids. Because of various negative effects, the use of opioids for long term management of chronic pain is not indicated unless other pain relievers of low risk have been found ineffective. Opioids are commonly prescribed and widely used to treat pain outcomes in Asia. Method: A stretched analysis was used in this review, by a comprehensive study using MEDLINE/Pubmed, Google Scholar, Sciencedirect and library searches. Peer reviewed articles were also included in this review of opioid findings in Southeast Asia. Results: Results from the cross-sectional study with 465 adult cancer patients from 22 sites in Southeast Asia who received analgesic prescription shows 90.7% (419) of them were prescribed with opioids. Recent studies have shown that heroin misuse has advanced further in Asia, both geographically and economically, including countries as India and Sri Lanka, which had no history with this issue. Studies have also shown that the misuse of narcotic drugs has been growing and that heroin addicts devote to these when heroin is challenging to get. Administering drug among opiate misusers has been found as the major reason of the wide spread of HIV/AIDS in Southeast and Southwest Asia. Conclusion: Thus these data shows that both opioid use disorder and withdrawal symptoms are due to increased opioid abuse and accessibility in Asia. Better prevention strategies have to be implemented for effective decrease in the rate of opioid misuse and opioid overdose epidemic.
KEYWORDS: Opioid, Opioid use, Problems, Accessibility, Analgesia, Withdrawal, Asia.
Opioids are a class of drugs that includes the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone, hydrocodone, codeine, morphine, and many others.1 These class of drugs acts on opioid receptors found in both body and brain to produce morphine-like effects.2 Medically they are used for pain relief and anesthesia.3 Opioids are also frequently used non-medically for their euphoric effects or to prevent withdrawal.4,5
Side effects of opioids may include itchiness, sedation, nausea, respiratory depression, constipation, and euphoria.
Tolerance and dependence will develop with continuous use, requiring increasing doses leading to withdrawal syndrome upon sudden discontinuation. The euphoria attracts recreational use and this frequent, escalating recreational use of opioids typically results in addiction. An overdose or a concurrent use with other depressant drugs commonly results in death from respiratory depression.6
Opioids act by binding to opioid receptors, which are found primarily in the central and peripheral nervous system and the gastrointestinal tract. These receptors mediate both the psychoactive and the somatic effects of opioids. Because opioids are addictive and results are fatal on overdose, most are controlled substances.4
In this review, a scrutinized analysis was performed by a comprehensive study using MEDLINE/ Pubmed, Google Scholar, Science direct and library searches. Peer reviewed articles were also included in this review of opioid findings in Southeast Asia.
CURRENT MAGNITUDE OF OPIOIDS:
There has been a substantial rise in availability of illicit opioids and widespread abuse of prescription opioids. The non-medical use of prescription drugs is becoming a major threat to public health and law enforcement worldwide with opioids is causing more harm and accounting for 76 percent of deaths where drug use disorders were implicated, according to the latest World Drug Report.7
United States is the world's largest consumer of opioids. Drug overdose deaths and opioid-involved deaths continue to increase in the United States. The majority of drug overdose deaths (more than six out of ten) involve an opioid. Till the year 2016 more than half a million people died from drug overdoses. On an average 91 Americans die every day from an opioid overdose.8-10. When compared to Asian jurisdictions, the use of opioid is more prevalent in American region in the current scenario.
There is an increased rate of recreational use and addiction attributed to over-prescription of opioid medications and inexpensive illicit of heroin in the year 2016.11,12 Conversely, fears about over-prescribing, exaggerated side effects and addiction from opioids are similarly blamed for treatment of pain.13,14 In older adults, opioid use is associated with increased adverse effects such as sedation, nausea, vomiting, constipation, urinary retention.15,16 Opioids do not cause any specific organ toxicity, unlike many other drugs, such as aspirin and paracetamol. They are not associated with upper gastrointestinal bleeding and kidney toxicity.17
Earlier, prescribing of opioids increased significantly which was once used almost exclusively for the treatment of acute pain or pain due to cancer but opioids are now prescribed liberally for people experiencing chronic pain. This has been accompanied by rising rates of accidental addiction and accidental overdoses leading to death. According to the International Narcotics Control Board, the United States and Canada lead the per capita consumption of prescription opioids.18 The number of opioid prescriptions in the United States and Canada are double than the consumption in the European Union, Australia, and New Zealand. Certain populations who have been affected by the opioid addiction crisis more than others include first world communities and low-income populations. Public health specialists say that this may be result of unavailability or high cost of alternative methods for addressing chronic pain.19
Drugs like heroin and cocaine that have been handy in the market progressively coincides with New Psychoactive Substances (NPS) and prescription drugs. The number of people globally using drugs at least once a year continues to be stagnant in 2016 with around 275 million people. Concisely, mortality due to drugs increased by 60% by this millennium. Geriatric deaths count has increased to 39% in 2016. Women tend to increase their intake of drugs more than men as well as rapidly develop drug use disorders.19
Over the last two decades, as prescriptions for opioids began to soar, rates of addiction and overdose deaths increased in parallel. The increase in opioid prescription was fueled by a multifaceted campaign underwritten by pharmaceutical companies. In Asia, the use of opioids is sensitive because of the Opium Wars in the 19th century and for this reason, the focus of controlled substances policies has been on the prevention of diversion and dependence. Countries in Asia, which had previously accounted for more than half of global seizures, reported just 7 percent of the global total in 2016.
From 2016-2017, global opium manufacture increased by 65% which is about 10,500 tons according to world drug report. The capital assessment was documented by UNODC since it commenced to keep an eye on global opium manufacture by the start of the 21st century. A notable surge in opium poppy cultivation and slowly developing yields in Afghanistan grew in opium cultivation last year producing 9,000 tons.7
MEDICAL/PRESCRIPTION OPIOIDS:
Opioids are commonly prescribed and widely used to treat pain outcomes in Southeast Asia. Results from the cross-sectional study with 465 adult cancer patients from 22 sites in Southeast Asia who received analgesic prescription shows 90.7% (419) of them were prescribe opioids.20
Buprenorphine maintenance treatment was introduced at Malaysia in the year of 2002.21,22 According to Vicknasingam (2010), the treatment of buprenorphine is not restricted to only government authorities, licensed general practitioners were also allowed to prescribe subutex to opiate user for treatment. This rapid expansion of buprenorphine treatment in Malaysia has also lead to the misuse of this drug. From the survey conducted with 235 patients, 79% reported with a daily ingestion of buprenorphine with the dose of 2mg or less. 36% of them were tested positive for opioid drugs during the survey using urine toxicology test. 43% were reported of using illicitopioids, while 22% and 15% reported on the administration of buprenorphine and heroin respectively through injection.23
Global crisis have been observed when it comes to accessibility in pain management. WHO has considered the consumption of morphine to be 216.7mg equivalent per capita, while the consumption per capita of the country Taiwan was 0.05mg morphine in the year 2007 W. Scholten (2015) stated that stringent laws and regulations as well as lack of medical education on pain management have been the obstacle in accessibility of opioid pain relievers. Appropriate planning and analysis of the national situation by the policy makers and health professionals would enhance the access to opioid medicines.24 From the study conducted by Kang et al., (2017) suggested that there is an increase in trend of major opioid analgesic consumption during the thirteen years of study in Taiwan. These records showed that the consumption of morphine, fentanyl and buprenorphine has increased, but the use of pethidine and codeine has decreased in the recent years.25
A national registered study in Taiwan by S.Y Fang et al, (2018) on the excess mortality of children born to opioid addicted parents. Great disadvantages and troubles faced by budding children, parents with opioid use disorders. The objective of this study is to evaluate the excess fatality rate before the child attains the age of six and the seers of premature death in children of opioid addicted parents. A total of 3210 children were born from the year 2004 to 2009 to parents with opioid disorders (parental methadone treatment) and parents with HIV disease. The prominent predictors for the premature death in children are low- birth weight, and mainly paternal opioid problem severity which increases the risk of this death. Parents after being enrolled into methadone therapy, resulted in decreased risk of death.26
L Gilbert et al, (2018) has reported on the reduction in the overdose of opioid in Kazakhstan where a randomised controlled trial was conducted for a couple based integrated HIV/HCV and overdose prevention intervention “Renaissance”. In this study, 494 participants were enrolled from a sample of 600 participants with the criteria of lifetime heroine/opioid use.
Both these groups were randomised to (1) Promotion on the wellness and the comparative design on the overdose prevention with 5 participants per session. (2) Overdose prevention intervention condition for couple based HIV/HCV also with 5 participants per session. A remarkable reduction was observed in both intervention and comparison conditions after a 12-month follow up. These studies also proved to show favourable outcome in decreasing non fatal overdose and overdose risks.27
Opioid misuse and dependence areglobal issues and has huge impact in Malaysia. The most commonly used illegal opioid in Malaysia is heroin. Methadone Maintenance Therapy (MMT) has been there since 2005.28 The study was performed by N. Ali et al (2017) using cross-sectional method where 3254 respondents from 103 treatment centres were given a set of standard questionnaires. 93.6% response rate shows where 17.5% transferred to another treatment centres, 8.6% died, 29.2% defaulted, and 7.6% terminated for various reasons. Baseline and follow up data were analysed for about 37% respondents. As a result, there was a significant downfall in opioid use especially in the aspects HIV risk taking behaviours, social functioning crime and health. The change is resulted from the factors like being married, employed, consumption of alcohol and high crime rate at baseline. Therefore, this study concluded the Methadone Maintenance Treatment (MMT) was successful.29
Mukherjee et al, (2016) also conducted a study on the factors associated with interest on receiving prison based methadone maintenance therapy in Malaysia. Opioid use disorders and HIV are largely seen in large group of prisoners. The assessment is done according to the preferences and factors in receiving MMT among each individual prisoners. The inclusion criteria of pre-incarceration for opioid dependence were fulfilled by group of 96-HIV positive and 104-HIV negative male prisoners. An interview was held with a set of questionnaires for the interest in receiving prison based MMT. Among these group, 85 prisoners (42.5%) were interested in the MMT within prison. The other group which are previously married and incarcerated, as well as with depression and regular use of heroin showed interest in prison based MMT 30 days before incarceration.30
In Malaysia, compulsory drug detention centres (CDDCs) is a common centre to treat drug abusers. This centre have been under the operation of Malaysian National Drug Agency (NADA) while the voluntary drug treatments centres (VTCs) provides treatment for people who volunteer themselves to treat their drug dependence under Ministry of Health Malaysia.31,32 Wegman et al (2018) has conducted a study with 89 participants from CDDs and 95 people from VTCs that are undergoing the MMT treatments between July 2012 and August 2014. The study is about the comparison between the relapse opioid use in opioid dependence individuals released from CDDCs and VCTs. From the findings it was suggested that the opioid-dependent participants significantly from CDDC’s aremore likely to relapse to opioid use after release rather than the individuals from VCTs. From the result it was suggested that CDDCs has no role to treat opioid use disorder.33
Meanwhile George et al. (2018), discussed from the 7 case report that were view from the Malaysia methadone maintenance therapy (MMT) facilities in the public and private hospitals. The results showed that the patient with opioid dependence in Malaysia tend to have higher risk of co-morbidities. Considering this, they were treated with methadone since it is the main drug substitution in the country. The individuals with opioid dependent are reported to be more vulnerable to experience mental and physical difficulties such as mood disorder, HIV, hepatitis C and other illicit substance abuse.34
Zhang et al (2016) had developed a study to see the impact of the blended treatment literacy and psycho education on the MMT treatment outcome in Yunan, China. From this study, doctors and peer educators provided the treatment literacy and psycho education with history of relapse and the result found that this intervention reduce their tendency to relapse, increase their methadone dosage and improve their treatment compliance. This result indicated that the blended treatment literacy and psycho education intervention that involved both trained healthcare providers and peers could improve MMT outcome.35
There are many factors that influence the social and structural barrier that are associated with the adherence to MMT program among patients. Several studies has documented various reasons such as biological and individual factors which associated with non-adherence to MMT program, From the study that was conducted among the Vietnamese opioid dependence patients shows that higher age, having pain, patients disclosing status, found to be associated with better treatment adherence. Poverty, job commitment and patient having problem in self-care were described as the major structural barrier in adhering to the treatment.36
There have been major rise in the fatality rate and occurrence of cancer in Low and Middle Income countries (LMIC).37,38 Besides, accessibility of opioid pain relievers have also been poor in these countries. Medicines such as morphine are used to treat moderate to severe cancer pain. Nepal, being one of the poorest countries in the world took part in the International Pain policy Fellowship in the year of 2005. This program was designed to improve the accessibility to these classes of pain medicines. The colleagues and the mentors under this program, following World Health Organization (WHO) achieved initial success, where three forms of oral morphine (syrup, immediate release tablets, and sustained release tablets) are now manufactured in the country. Health care professionals have undergone training on the safe administration of opioids besides forming a palliative care curriculum by the palliative care association. Nevertheless, long term execution, funding and technical assistance are required from the government and external organizations in order to provide a better accessibility of opioid pain relievers and palliative care in LMIC.39
E.L Krakauer et al, (2015) have reported on the safe accessibility of opioid pain medicines in Vietnam. Pain is a perception which can be categorised as moderate and severe especially in life threatening illness and advanced cancer. The relief of pain is a human night. However, 80% of the poor population are lacking in the accessibility of strong opioid analgesics.
Vietnam being a country of opiophobia where it has restrictive opioid policies, a balance policy method was developed by working with committed local partners and high level officials from the ministry of health for the review of the policies on the opioid accessibility, barriers and regulations. This study demonstrated that Vietnam, a country with strong socio- historically based opiophobia showed improved accessibility to opioid pain medicines. This balanced policy method was also receivable by the government and the Vietnamese colleagues to break the major boundaries to the availability of opioids.40
According to World Drug Report (2015-2018), fentanyl and its derivatives endure a problem in North America, while tramadol - an opioid used to manage moderate to severe pain - has become a thriving worry in parts of Africa and Asia. Availability of tramadol and fentanyl for medical use are important for treating aches, but speculators mass-produce them under the counter and develop them in outlawed markets creating some disease.7
STREET OPIOIDS:
At India, R Rao et al. (2015) did a cross sectional study of opioid dependents people from India. A purposive sampling was done with 101 opioid dependent subjects where these subjects undertake in two community drug treatment clinics. Assessment was done specifically using a designed tool to record the criminal acts and substance use, before, during and after last imprisonment. 68% was observed in subjects before imprisonment, where opioids were the most common substance used daily. About 97% reported the availability of drugs in prisons, out of which 19% falls under the category of opioids. After the release from prison 13% of opioid users experienced opioid overdose.
The study by R. Rao et al, on the factors affecting drug use during incarceration found that people with opioid dependence have high influence on the law and the government authorities, before, during and after imprisonment. Therefore, this is the setback for the accessibility of opioid use in prisons due to their high dependence on this substances. Strong law enforcement should be tightened by the governing authorities and proper training on the substance related issues should be given. In addition, the treatment outcomes has to be available at any point of time in contact with the criminal justice system.41
According to World Drug Report (2015-2018), the global seizure of pharmaceutical opioids in 2016 was 87 tons, approximately the same as the loads of heroin snatched that year.42 Countries in Asia, which had already computed for more than half of global seizures, reported just 7% of the global total in 2016.43 Most recent studies have shown that heroin misuse has advanced further in Asia,44 both geographically and economically, including countries like India and Sri Lanka, which had no previous history with this issue.45 Studies have also shown that the misuse of produced narcotic drugs has been growing and that heroin addicts devote to these when heroin is challenging to get.46 Administering drug among opiate misusers has been found as the major reason of the wide spread of HIV/AIDS in Southeast and Southwest Asia.47
CONCLUSION:
Opioids are the first choice of drug opted for severe and chronic pain.48 However, along with its potent analgesic property, opioids have presently led to opioid overdose epidemic because of its improper habitude in recent days. Opioid epidemic is a nationwide public health catastrophe.49 Anxiety sensitivity can be one of the aspects pertinent to be the link between the severity of pain and opioid misuse among opioid-using individuals with deep-seated pain.50 This was originally impelled by marked up intake and on-hand pharmaceutical opioids.51 The surge in opioid overdose is now akin to heroin and under the counter produced fentanyl and its analogues.52 Laws produced to engage layperson in opioid-overdose reversal were linked with decreased rate of deaths by opioid-overdose. These standards must be treated as a necessary element of the system used to bring down the opioid overdose epidemic.
CONFLICTS OF INTEREST:
No competing financial interests exist.
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Received on 16.08.2019 Modified on 21.09.2019
Accepted on 01.11.2019 © RJPT All right reserved
Research J. Pharm. and Tech. 2020; 13(4):1989-1994.
DOI: 10.5958/0974-360X.2020.00358.3