Addressing the opioid crisis globally
Authors: Nora D. Volkow, María Elena Medina‐Mora Icaza, Vladimir Poznyak, Shekhar Saxena, Gilberto Gerra
Journal: World Psychiatry (2019)

Since 2015, the United Nations Office on Drugs and Crime (UNODC) - World Health Organization (WHO) Informal Scientific Network (ISN) has strived to bring the voice of science, as it pertains to addiction medicine, to inform critical discussions at the Commission on Narcotic Drugs (CND), the policy-making body of the United Nations with prime responsibility for drug control matters1, 2. The opioid overdose crisis represents an increasingly global challenge3, one associated with high rates of morbidity and mortality4, 5. The contours of the epidemic have been most extensively documented in North America, but serious situations are developing around the world. Meanwhile, millions of people worldwide suffer moderate to severe pain without access to opioid analgesics, despite the provisions of the international drug conventions1. For these reasons, during the CND's 61st session, the ISN examined the opioid overdose crisis and presented a statement with recommendations for consideration of the CND. Effective public health measures are needed to maintain the delicate balance between reducing barriers to pain treatment and preventing the expansion of the opioid overdose epidemic. The opioid overdose epidemic is complex, heterogeneous, multifactorial and rapidly changing. Three conditions appear to have contributed to the epidemic of opioid related deaths in North America: the overreliance on, and prescription and use of excessive doses of opioid analgesics for pain management6, the availability of cheap pure heroin, and the large-scale supply of illicit fentanyl and analogues7. Among the key strategies to control the current opioid crisis in America or to prevent such crisis in other countries, it is recognized that access to comprehensive, evidence-based and quality treatment for opioid use disorders in a continuum of care model is essential. Appropriate services should be provided to the people with opioid use disorders in accordance with the stage and severity of the disorders, with responses ranging from low-threshold outreach interventions to multifaceted and multistage rehabilitation and social reintegration programs, including treatment for medical or psychiatric comorbidities. Funding to implement treatment services at the local level should be monitored and accredited by national authorities to ensure that services provided are the most cost-effective. Importantly, medications need to be provided free of charge and following clinical guidelines for medication management of opioid use disorders. In addition, the health workforce (doctors, nurses, nurse practitioners, physician assistants) needs to be fully engaged and appropriately trained on the screening, treatment and support of individuals suffering from an opioid use disorder. The expansion of access to naloxone has proven an effective means of preventing ovedose facilities from opioids. Naloxone should be made available to health care professionals and other first responders, along with the proper training in its administration as well as in other life-saving resuscitation techniques. Breaking social exclusion and addressing marginalization, stigmatization and discrimination of patients with opioid use disorders are all essential elements to ensure access to public health services, treatment retention and effectiveness of interventions, including overdose prevention. National policies and guidelines should be in place to promote the prevention of substance use, as well as quality treatment and care of substance use disorders. Given the high rate of relapse and overdose deaths following prison release, it is essential to establish tighter coordination between the health and criminal justice system, to ensure effective opioid overdose prevention measures as a part of the substance use disorder treatment and care programs, during and after release. In addition, countries need to implement systematic data collection, monitoring and evaluation of early warning systems to prevent and develop strategies to reduce abuse and misuse of existing and new emerging synthetic opioids.