Synthesizing advice to the United States from other nations that have experienced drug epidemics

The attempts of the United States to end its epidemic of addiction and overdose will be easier if it learns from its fellow nations around the world. As Kolla and colleagues point out [5], the United States (US) overdose crisis has now spread well beyond prescription opioids. The recommendations of our colleagues for better regulation of the pharmaceutical and health care industries (e.g. Bergeron and Colson [3], van den Brink et al. [6], Frank [7]) remain important not only for preventing future US pharmaceutical drug addiction epidemics (e.g. to stimulants or benzodiazepines), but also for preventing the opioid crisis from spreading to other countries in which the same companies that initiated the North American crisis are increasingly active [8]. When legal drug manufacturers gain too much control over health care systems, their ability to spread addiction well exceeds that of any illicit drug trafficker. Increasing access to opioid agonist/partial agonist treatment services was the most common recommendation across the commentaries and the point is well made that the United States continues to have a relatively modest proportion of the population with opioid use disorder in this or any other form of treatment. As the Stanford-Lancet Commission noted, the United States must fundamentally accept the status of addiction as a legitimate chronic health disorder and make an enduring resource commitment to treating it within the mainstream of health care [8]. This also will involve a rollback of punitive approaches to addicted individuals, different forms of which are advocated by Kolla et al. [5] and the Stanford-Lancet Commission [8]. Although the United States is unlikely to start heroin maintenance clinics, it could provide more opioid agonist therapy easily with other drugs that are already scheduled and approved for medical use, such as slow-release oral morphine and injectable hydromorphone. It is also capable of building on prior expansions of health insurance covering addiction to benefit the millions of individuals who still lack it. Multiple commentators suggest broader changes in society as a solution. As the Stanford-Lancet Commission documented [8], Canada has many of the features commonly recommended for the United States: less inequality, universal health care coverage, a less punitive criminal justice system and better access to a range of health and social care services for people experiencing addiction. We support all of these recommendations on their own merits, but are humbled to acknowledge that Canada nonetheless also has an overdose crisis, with opioid overdose mortality increasing at double the US rate and currently exceeding the worst mortality rate of the HIV/AIDS crisis. Canada also had a dramatic, industry-fuelled escalation of opioid prescribing, suggesting that when there is no control over the supply of drugs, even robust health responses after the fact can at best reduce the damage [9]. The same point is echoed in several of the commentaries, which point out that supply control initiatives have been central to reducing overdoses. Jalal and Burke's observation is also relevant: we still lack full knowledge of how epidemics develop [10]. Finally, we very much agree with Clausen's call for non-opioid and alternative therapies for acute and chronic pain management to prevent iatrogenic opioid dependence [4]. However, we must go further and work out changes to make for the longer term such that the current generation of young people do not end up like the current one. Prevention is seen by many people as unglamorous, as embodied in the phrase ‘An ounce of prevention is a ton of work’. It is also very hard to persuade the public and policymakers to invest in programmes whose benefits take decades to be realized. Yet prevention science is clear that such investments are worth it, be it the horizontal approach [8] used by Teeson et al. in Australia [11] or the community collaborative approaches embodied in Communities that Care [12], originally in the United States, but elsewhere as well. The United States faces a long and difficult road as it attempts to end its epidemic of addiction and overdose. The journey will be easier, however, if it learns from its fellow nations around the world. None.

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