The opioid mortality epidemic in North America: do we understand the supply side dynamics of this unprecedented crisis?

Abstract

While there has been extensive attention to the 'demand side'or use and adverse consequences, including mortalityof the 'opioid crisis' presently unfolding across North America, few considerations have focused on the supply side. This paper examines the supply side dynamics of this unprecedented public health phenomenon. We provide evidence for several interrelated supply-side elements that have contributed to the present public health crisis. We observe that initially, persistently high levels of prescription opioid availability and use exposed large proportions of the North American population to opioids, resulting in correspondingly high levels of medical and non-medical use (e.g., involving diversion). While various intervention measures to control prescription opioid availability and use have been implemented in recent years, leading to eventual reductions in opioid dispensing levels, these occurred late in the crisis's evolution. Moreover, these supply reductions have not been met by corresponding reductions in opioid use or demand levels. These growing discrepancies between opioid demand and prescription-based sources have left major gaps in opioid supplies. In response to such supply gaps, highly potent and toxic illicit opioid products have rapidly proliferated across North America, and become a core driver of the dramatic spikes in opioid overdose fatality levels in recent years. These supply-related interrelations are corroborated by a corresponding increase in illicit opioid-related fatalities, which arose just as medical opioid supplies began to decrease in many jurisdictions. Improved analyses and understanding of the supplyside dynamics of the opioid crisis are urgently needed in order to inform future intervention and policy development. Meanwhile, the high mortality toll related to illicit, highly toxic opioid exposure requires sustained solutions, including supply-oriented measures (e.g., safer opioid distribution for at-risk users) towards improved public health protection.

311 service requests as indicators of neighborhood distress and opioid use disorder

“…There has been extensive attention to the supply that contributes to the present opioid crisis 34 . Without denying that opioid availability might serve as a catalyst for the crisis, we argue that such public health crisis is jointly linked to the 'demand side' of substance misuse-the physical and psychological needs for opioids.…”

Supply-Side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids

“…The harmful effects of prescription opioids are particularly acute in the United States, the largest consumer of these drugs. 1 In 2014, nearly 2 million Americans abused or were dependent on prescription opioids, and 10.3 million had used prescription opioids for nonmedical purposes in the past year (RTI International 2015).…”

Opioid use, regulation, and harms in Brazil: a comprehensive narrative overview of available data and indicators

“…While North America and other wealthy nations have vastly increased utilization of (especially strong) opioids in a quest for ‘better’ pain care post-1990, many subsequently experience unprecedented adverse consequences from opioid-related fatalities, hospitalizations, and dependence, driven by persistent increases in opioid availability [ 11 , 71 , 72 ]. Increasing adverse consequences following recent restrictions on prescription opioids have been related to illicit/synthetic opioid products that appear to fill ‘supply gaps’ [ 9 , 73 – 75 ].…”

“…Yet, in 2016-18, North America alone still accounted for about 60 % of the world’s total opioid consumption [ 1 ]. Post-2000, and fueled by the persistently high opioid availability described, North America has experienced steep increases in population-level opioid-related harms, including opioid-related morbidity and mortality (e.g., acute poisoning deaths) [ 9 – 11 ]. For example, a total of 47,600 opioid-related deaths occurred in the United States in 2018, with proportionally similar rates, and a total of 4,398 opioid-related deaths in Canada [ 12 – 14 ].…”