Editorial

Opioid crisis: addiction, overprescription, and insufficient

There are many sources of opioids, including raw poppy lower (<2 per 100,000 people). As in North America, The Lancet Regional
seeds, products made from poppy seeds (eg, poppy seed fentanyl use is a growing problem in several Latin Health - Americas
tea or kits for smoking), semisynthetic drugs (eg, her- American countries. In Brazil, fentanyl is competing 2023;23: 100557
https://doi.org/10.
oin, morphine, and oxycodone), and synthetic drugs with codeine and oxycodone, which remain the main
1016/j.lana.2023.
(eg, methadone and fentanyl). Over the centuries, opi- drivers of opioid use and abuse. Unfortunately, little is 100557
oids have been used as surgical analgesics, to stop known about the status of fentanyl use in other coun-
diarrhoea and prevent tooth decay, as an adjuvant tries in the Americas and high-quality research is ur-
treatment of insomnia, to treat cancer and chronic pain, gently needed to better understand the real burden of
and as a recreational drug. opioid abuse in these populations.
The opioid-abuse epidemic is a major problem in Several measures have been proposed by the
public health worldwide. In this special issue, re- Stanford-Lancet Commission to tackle the opioid crisis,
searchers from the Americas present their views on the including better drug regulation, education (including
opioid crisis in Brazil, Mexico, and the USA. Although it the safe disposal of opioids and awareness of harmful
is difficult to establish the major drivers of this crisis, effects), restrictions on opioid prescription, and pro-
experts point toward the influence by pharmaceutical motion of prevention campaigns, for example the need
companies, inadequate regulation, overprescribing by for creating healthy environments as a strategy to reduce
the medical profession, and increased use of illegal opioid addiction. Alarming statistics suggest that opioid
heroin and synthetic opioids. An explanation for the overprescription has been a key factor in the US opioid
prevalent use or misuse of this class of drugs is their crisis. Opioid addiction is also a big problem among
highly addictive power. To put it in context, heroin is in physicians themselves. Nevertheless, despite a consis-
the most addictive drugs on the planet (category I, tent decline in opioid prescription in the USA since
together with lysergic acid diethylamide and cannabis; 2013, the number of deaths continues to increase,
among these drugs, only cannabis has a specific medical indicating that other causes have become equally or
indication for cancer pain). Category II of most addictive more important, such as the incursion and popularity of
drugs include commonly prescribed opioids for mod- synthetic opioids obtained from the illegal market and
erate and severe pain (hydrocodone, methadone, clandestine laboratories.
meperidine, oxycodone, and fentanyl). As a result, Naloxone, an opioid receptor antagonist, is the most
60,000,000 people struggle with the addictive effects of widely used drug to treat opioid overdose, with the
opioids globally and more than 100,000 people die every potential of preventing deaths. On March 29, 2023, the
year of opioid overdose, many of them with fentanyl, an US Food and Drug Administration approved naloxone
analgesic drug that is 50–100 times more potent than as a nasal spray to be classified as an over-the-counter
heroin or morphine. drug. Some scientists have expressed optimism that
In the Americas, the opioid crisis has particularly hit this policy could increase the availability of naloxone and
the USA and Canada, affecting mostly young and reduce stigma associated with the purchase of naloxone
middle-aged adults. In 2019, opioids were responsible in pharmacies. However, no study has assessed the
for 15.8 and 6.4 deaths per 100,000 people in the USA effectiveness of this policy, despite that over-the-counter
and Canada, respectively. This emergency prompted the naloxone has been available for many years in some
launch of the Stanford-Lancet Commission in 2022, countries, including Canada and Italy, the latter having
which points out that the North American opioid crisis implemented this policy more than 25 years ago. It is
originated from a multi-system regulatory failure. Con- still premature to call this measure a positive policy as
cerns have also been expressed in other territories in the there are also concerns about affordability.
region. For example, Guyana, Bolivia, and the Domin- Despite being an opioid itself, methadone is used to
ican Republic have the highest death rates due to opioid treat opioid addiction, including during pregnancy, and
use after the USA and Canada, although these are much to prevent severe withdrawal symptoms caused by
quitting heroin and other opioids. However, in Mexico,
DOIs of original articles: https://doi.org/10.1016/j.lana.2023.100520, the closure of the only methadone manufacturing plant
https://doi.org/10.1016/j.lana.2023.100507, https://doi.org/10.1016/j. in the country is threatening a shortage of this drug.
lana.2023.100518, https://doi.org/10.1016/j.lana.2023.100535 Justified or not, this decision could have immediate
© 2023 The Author(s). Published by Elsevier Ltd. This is an open access
consequences not only to opioid users but also to the
article under the CC BY license (http://creativecommons.org/licenses/by/
4.0/). whole society. In this issue, Bejarano and colleagues

www.thelancet.com Vol 23 July, 2023 1

presented an overview of the opioid crisis in Mexico, the public health authorities and policy makers are still
associated deaths linked to fentanyl, and the unresolved reluctant to prioritise primary prevention to tackle drug
issues that aggravate this crisis, including the insuffi- use and the opioid crisis. If we do not put enough focus
cient surveillance and emergency response, ineffective on primary prevention to discourage people from using
educational campaigns, unaccredited rehabilitation opioids as recreational drugs and from abusing medi-
centres, poor availability of methadone, scarcity of cated opioids, we will not be able to defeat the growing
naloxone, illegal market and production of fentanyl, and opioid crisis in our region and worldwide. More primary
overall failure of adequate health policies. prevention campaigns must be implemented alongside
Although commendable, most government efforts currently favoured health policies.
have focused mainly on secondary and tertiary prevention
to avert relapses, overdoses, and deaths. Unfortunately, ▪ The Lancet Regional Health – Americas

2 www.thelancet.com Vol 23 July, 2023