The Global Opioid Overdose Crisis

This AJPH supplement provides a global perspective on an ongoing public health problem, the opioid crisis. In doing so, the articles in this supplement seek to meet two objectives. First, recognizing the unreal expectations and repressive measures stemming from an abstinence-only approach, these articles call for greater investment in community-based programs developed by and for people who use substances. Second, several articles provide information on the social and political contexts that motivate and enable implementation of substance use treatment and harm reduction programs in various countries, which can provide the AJPH readership with valuable information on best practices from all over the world.

In addition to these two overarching aims of this supplement, we call attention to a few key points in this body of work. First, there is the double-edged sword of attaching a medical label to certain behaviors and thereby broadly identifying them as “mental disorders.” On the one hand, a biomedical label designation legitimizes the addictive forms of these behaviors as health problems rather than as personal or moral failings. On the other hand, such designations can lead to a negation of the sense of agency among people who use drugs (PWUDs) and consequently to further restrictions on their ability to lead their lives as they see fit.

Second, PWUDs affected by substance use disorder face stigmatization and discrimination that is usually compounded by bigotry based on gender, race, or class and varies from place to place. This further complicates creating public health policies to address the needs of PWUDs, creating barriers to accessing appropriate social and medical services, programs, and facilities.

Third, much of the research presented in the articles is based on qualitative methodologies that rely on social theory for their design and analysis. Under the social theory umbrella lies a wide gamut of theoretical and empirical approaches, unlike quantitative methods predominantly used in most public health research. This distinction presents a different set of demands for authors and this journal. Qualitative methods are by their own nature far less standardized than their quantitative counterparts, thus requiring more detailed description of the procedures and additional efforts in contextualizing findings and results. Furthermore, the need to make theoretical choices explicit to readers further compounds the problem of fitting relevant information into a word limit intended for presenting quantitative findings.

Finally, an adequate response to the challenges of the global opioid overdose crisis can clearly benefit from the past experiences of self-organized groups that faced similar public health issues, such as activists during the early period of the HIV/AIDS epidemic. Those activists developed forms of advocacy that spearheaded governmental programs. They also led the charge for creating community-based responses that helped affected persons when no other resources were available. These responses included the buddy system, access to protected houses, and safe sex approaches, which were necessary in the early period before the availability of antiretroviral therapies and preexposure prophylaxis. The approaches finally contributed to the advancement of the research enterprise in many ways, including providing funding and helping to design and implement trials and surveys. Whatever response can be created to meet the challenges presented by the global opioid crisis, the involvement of PWUDs certainly must be prioritized.

3 Years Ago

The Gobal Crisis in Access to Pain Relief

The poor, worldwide, have little or no access to palliative care or pain relief. Approximately 298 metric tons of morphine-equivalent opioids are distributed in the world each year. However, only 0.1 metric tons . . . are distributed to low-income countries. More than 61 million people worldwide experience serious health-related suffering annually throughout the life course that could be alleviated if they had access to palliative care. More than 80% of these individuals reside in low- and middle-income countries where palliative care is limited or nonexistent. . . . A balanced approach is necessary in designing and implementing health systems strategies to promote an understanding of medical need for and appropriate use of opioids as well as risks of nonmedical use. Two crises are under way – an opioid crisis in a few countries, including the United States, Canada, and Australia, and a global pain crisis with millions of people who have untreated pain. . . . In Western Europe . . . rational and balanced regulations on prescribing opioids have averted either crisis within this context.

From AJPH, January 2019, pp. 58–59, passim

3 Years Ago

Access to Pain Management as a Human Right

In light of the current opioid crisis in the United States, it is important to point out that the right to pain management does not imply an automatic right to opioid medications. A criticism leveled at the concept of human rights and pain management is that the right appears to give free rein for patients to say, “You must give me opioids—that is my right.” In fact, the right to health requires “quality” of services in terms of skills and expertise in addition to availability, accessibility, and acceptability. Those skills and expertise require a conscientious assessment of pain and development of a treatment plan, guided by the best evidence available, but that plan does not include providing opioids on demand. . . . In CNCP [chronic non cancer pain] . . . opioids may play a more circumscribed role. The right to access pain treatment means that physicians should be able to make the clinical determination of the best treatment options—without inappropriate government interference—and patients should have access to them, including opioids.

From AJPH, January 2019, p. 63

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