Commentary on Degenhardt et al. (2014): Regional variation in the global burden of disease attributable to opioid dependence—where do the data come from and does population size matter?
Year: 2014
Type: editorial
Abstract: Our review paper, of course, relied solely upon those studies published by 2013 and we did not go to the length of calculating estimates by individual countries, as done by Degenhardt et al. Nevertheless, it raises questions about why there are these discrepancies. While measures and study inclusion criteria may differ, our first question pertains to where the data come from in those countries that do not have epidemiological data available. Both Degenhardt et al.'s and our review identified a limited number of studies from several regions such as Asia and Africa, where opioid use is historically widespread and is still increasing. These areas are characterized by punitive drug laws (e.g. incarceration) or limited resources, and opiate substitution therapies, such as methadone and other harm reduction strategies, were not introduced until the early to mid-2000s, mainly as part of efforts to contain growing rates of HIV infection and transmission 6, 7. Degenhardt et al. indicated that rather than excluding regions with no available data, they predicted prevalence estimates leading, as they note, to ‘considerable uncertainty around many of the estimates’. We caution that valid estimates can be useful to identify important issues requiring interventions and policy changes, but biased estimates can be harmful, as they lead to erroneous interpretation and misguided decisions. Secondly, it is intuitively contradictory that regions such as North America and Australasia are among those with the highest opioid dependence DALY rates. These regions, compared to many other resource-limited countries in the world, have the most developed and accessible treatment and health services. If the regional variation in burden of disease mainly reflects prevalence levels as indicated by Degenhardt et al., then it raises the question as to whether the prevalence rate is the appropriate way to measure levels of disease burden. Degenhardt et al. indicated that 41% of crude DALYs were concentrated in Asia, where population sizes are among the largest. Should population size be used to more accurately indicate regional variation in the size and location of the problem? Degenhardt et al. noted that in most regions burden was due mainly to years lived with disability, but in North America, eastern Europe and southern sub-Saharan Africa, greater levels of DALYs were due to years of life lost to premature death. Since 2003, more overdose deaths in the United States have involved prescription opioids than heroin 8-10 (a distinction not made by Degenhardt et al.), while in other parts of the world heroin is still the most commonly used opioid and therefore responsible for the majority of overdose mortality. These are important distinctions that have implications for development of region- or population-specific interventions that address local variations in patterns of opioid use, health-care system organization and capacity, and factors that facilitate or inhibit treatment seeking. Opioid addiction clearly is a global problem, and global challenges call for global strategies. The bottom line is: how can we eliminate or reduce the global burden of opioid dependence? Despite an intense and decades-long scientific effort that has provided treatment options and ways to effectively treat and manage opioid addiction and HIV, the global DALY has increased considerably over the past 10 years. Even in high-income countries where opioid addiction treatment and general health-care is more available and accessible, several of those countries were among the ones with highest DALYs. Obviously, the problem is complex. Is it that more people became dependent on opioids, more people died of opioid dependence, more people were living with disability, or a combination of these or other reasons? Answers to these questions will suggest courses of action to take. Given the regional variation suggested by Degenhardt et al.'s findings, global strategies to effectively reduce DALYs will need to be tailored to local context, taking into consideration the local patterns of opioid use and addiction, drug policies and interventions, and available treatment and public health resources. Nevertheless, if scientific-based interventions and practices are effective in addressing opioid addiction and problems, a starting-point will be to ask: are they widely adopted, well implemented and readily accessible? It is apparently not the case in resource-limited regions, and even questionable among low-income individuals in high-income countries. Given the current understanding of the long-term course of opioid addiction and its tremendous burden, it is crucially urgent to implement known effective strategies globally and continue to search for or develop better ways to reduce the global burden of opioid dependence. This work is supported by the National Institute on Drug Abuse (U10DA13045 and P30DA016383 to Hser). For the remaining authors, none declared. The authors alone are responsible for the content and writing of the article.
Source: Addiction
DOI: 10.1111/add.12597
Institution: University of California, Los Angeles
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2001156227