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
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