Preventing Harmful Drug Use in Australia

A Global Review of the Injection of Pharmaceutical Opioids: Essential treatmentPharmaceutical Opioids: Essential treatment

and diverted medication.

Benjamin Phillips

F t b L i D h dt B i L B dl

National Drug and Alcohol Research Centre (NDARC), Sydney, Australia

From a report by: Louisa Degenhardt, Briony Larance, Bradley Mathers, Tasnim Azim, Adeeba Kamarulzaman, Richard Mattick,

Samiran Panda, Abdalla Toufik, Mark Tyndall, Lucas Wiessing, Alex Wodak on behalf of the Reference Group to the United Nations onWodak, on behalf of the Reference Group to the United Nations on

HIV and injecting drug use.

Pharmaceutical Opioids

1 essential medical treatment1. essential medical treatment

2. global inequalities in access & availability

3. evidence of extra-medical use, diversion & injectioninjection

4. responses to inequalities

5. responses to illicit use

6 responses to associated harms6. responses to associated harms

Essential Medicine

Opioids are essential medicine: WHO Analgesic ladder

1. Acute pain management

2. Chronic pain managementcancer related-cancer related

-HIV palliative care-and non-cancer related: as a final line of treatment

3. Opioid Substitution Treatment

International Treaties

• Unlike other medications opioids are controlled by international treaties:international treaties:

-1961 Single Convention,

‘adequate amount for medical and scientific uses’

-regulated by INCBregulated by INCB

Global Inequalities: Pharmaceutical Opioid Consumption

Global Morphine Consumption 2005 (%)

5%

USA, Canada, UK, Sweden, Spain, S ede , Spa ,Denmark, France, Germany, Japan, Australia, New Zealand

95%

20% world's population 80% world's population

Source: INCB 2006

Global Inequalities: Pharmaceutical Opioid Consumption

Global Morphine Consumption 2005 (%)

4949

51

0 20 40 60 80 100

USA (49%)( )Rest of the world (51%)Source: INCB 2006

Essential Treatment and the Potential for Diversion

Potential for Diversion

LOW

Acute painChronic cancer pain LOW

RISKPalliative care: HIV/AIDS

MODERATE RISKOpioid substitution

treatment

HIGH RISK Chronic non-cancerHIGH RISK Chronic non cancer pain

Diversion of Pharmaceutical Opioids

Associated Harms

• Adverse effects compounded when used outside guidelinesguidelines

• Unsupervised use:-Overdose, dependence, medical conditions, sedatives

• Injection: j-HIV & HCV, non-sterile medication. dependence

Global Occurrence of Pharmaceutical Opioid Injection

Case Study: India

• Large scale diversion of pharmaceutical opioids: low potency

• Shift from heroin smoking pharma opioid injectiong p p j

• HIV prevalence IDUs: 10% limited OST & NSP

P ibi f ll t f i i d t i thi i• Prescribing for all types of pain inadequate in this region

• Misuse not been avoided thru limited medical supply

Case Study: United States of America

• 49% of world’s morphine consumption: 4.7% worlds populationpopulation.

• Largest per capita problem of extra-medical use, diversion, & injection in worldinjection in world

• Controlled-release Oxycodone widely misused: 99% of world’s consumptionworld s consumption

Case Study: United States of America

• INCB concern at extent of US problem

• Easily obtained from GPs for diffuse, non-specific pain conditions

• OxyContin aggressively marketed as ‘low dependence’: $600 million criminal charge of ‘misbranding’.

• Diversion: led to increased injection

• OST coverage poor despite extent of problem• OST coverage poor despite extent of problem

Summary

• Reduce inequalities

• Reduce diversion

• Reduce harm

Acknowledgements

• 2007 Reference Group:Tasnim Azim Mauro Guarinieri Matthew Hickman Fred OwitiTasnim Azim, Mauro Guarinieri, Matthew Hickman, Fred Owiti, Adeeba Kamarulzaman Kasia Malinowska-Sempruch, Fabio

Mesquita, Azarakhsh Mokri, Olanrewaju Onigbogi, Samiran Panda, Abdalla Toufik, Steffanie Strathdee, Fayzal Sulliman, yJallal Toufiq, Mark Tyndall, Lucas Wiessing

• Secretariat members (NDARC): Richard Mattick, Louisa Degenhardt, Bradley Mathers, BenjaminRichard Mattick, Louisa Degenhardt, Bradley Mathers, Benjamin

Phillips, Alex Wodak, Kate Dolan, Anna Roberts• 2007 Steering Committee Members:

UNODC: Paul Williams Monica Beg Fabienne HarigaUNODC: Paul Williams, Monica Beg, Fabienne HarigaUNAIDS: Anindya Chatterjee, Michael Bartos, Igor ToskinWHO: Annette Verster, Nico Clark, Vladimir Poznyak

• NDARC researchers• NDARC researcherswww.idurefgroup.unsw.edu.au