A forgotten opioid epidemic, but a mounting problem

Deaths from opioid-related overdoses continue to grow in the US, but public health events of recent times mean that attention has been focused elsewhere. Ben Hargreaves looks at how the situation deteriorated rapidly during the pandemic, and how the situation stands in Europe.

Prior to the COVID-19 pandemic, the opioid epidemic in the US was a public health crisis that was consistently raised as requiring immediate action. Both President Obama and President Trump unveiled significant campaigns to reduce the number of deaths from the use of opioids during their periods in office.

However, COVID-19 arrived, and suddenly the focus was, understandably, elsewhere. Funding is still being provided to counter the issue, but the discussion itself has moved on. This is a problem because the pandemic made the situation worse. Research published by the National Institutes of Health (NIH) found that the pandemic ‘significantly increased’ monthly overdose deaths from opioids. Understanding the situation as it evolves is crucial, with the NIH listing opioid addiction as the third most-pressing health challenge facing the US, only behind heart disease and stroke, and cancer.

How it came to be

The US Centers for Disease Control and Prevention references three waves in the development of the current opioid epidemic. The first wave began with the increase in the prescription of opioids in the 1990s. The lawsuits related to the behaviour of certain pharmaceutical companies continue to the present. Following this period of high levels of prescription opioids being abused, there was a rise in deaths related to heroin abuse starting in 2010.

However, the public health issue escalated rapidly with the third wave of the epidemic: the rise in the use of synthetic opioids. This period began in 2013 and continues to the present day. Synthetic opioids are now associated with the vast majority of deaths from opioids, most commonly through fentanyl that is often found in combination with heroin, counterfeit pills, and cocaine. Despite efforts to curb the problem, deaths have only escalated in recent years, with the CDC stating that 220 people per day died due to an opioid overdose in 2021. Between 2010 and 2019, the number of annual deaths almost doubled, rising from 38,000 to 70,000.

Pandemic escalation

According to research, the increase in overdose deaths occurred nationally, regionally, and locally, and therefore was not the result of isolated, disproportionate issues in specific regions. The reasons for this broad deterioration have been attributed to various factors, including reduced access to interventions, increased levels of stress due to isolation, and loss of mental health support. In addition, the restriction of movement and supply of drugs meant that there were changes in the types and combinations of drugs, as well as their purity.

One report that did focus on a specific regional area was research conducted in Chicago, which found that opioid overdose deaths increased by 45% from 2019 to 2020. The study explained why the opioid crisis has a grip on certain areas, which is then replicated throughout the US: “Opioid-related deaths are associated with socioeconomic marginalisation, a set of conditions that contribute to exclusion from social and economic opportunities and create vulnerability. Examples of socioeconomic marginalisation include labour market exclusions; informal or illicit income generation (e.g., theft, drug dealing, street-based work); material insecurity (e.g., housing or food insecurity); inadequate income; incarceration; homelessness and housing instability; social stigma or isolation; and low SES (socioeconomic status) or poverty, all of which contribute to OODs (opioid overdose deaths).”

The conclusion drawn was that it was the most vulnerable and disadvantaged communities that were hit the hardest by the rise in deaths from opioids. The authors called for policies to support the social and economic security of disadvantaged communities as a tool to fight the abuse of opioids.

Agency action

A study published by JAMA Network similarly found reasons for concern through the use of an analytical model that simulated the opioid epidemic in four US states hit particularly hard by opioids: Kentucky, Massachusetts, New York, and Ohio. The main findings were that reducing deaths would require ‘substantial scaling up’ of the delivery of medications for opioid use disorder, and increasing the supply of naloxone.

This conclusion effectively mirrors the action that the US FDA has taken, within its remit, to tackle the crisis. The FDA has worked to expedite the approval of treatments for opioid overdose, which has seen Emergent BioSolutions’ Narcan receive the nod for over-the-counter (OTC) dispensation. More recently, the first intranasal nalmefene therapy was approved, providing a new option for countering opioid overdose.

In addition, the agency is also encouraging the development of non-opioid painkillers, with Grünenthal recently receiving breakthrough designation for its potential painkiller, resiniferatoxin. The efforts are part of a push to look towards non-addictive alternatives to opioids to manage acute pain, and to decrease exposure to opioids, aiming to prevent new addiction before it begins. In a release at the beginning of 2022, the agency announced draft guidance aimed at fostering the creation of such treatments, offering potential use of the FDA’s expedited programmes to support development programmes.

Some success, but problems remain

There may be some signs that this approach is working, as the CDC released figures showing that, although deaths from drug overdoses continued to rise, the acceleration in cases was lower than had been previously seen. The preliminary figures showed that 109,680 overdose deaths were recorded in 2022, only slightly higher than the figure in 2021, which was estimated to be 109,179. The problem remains that this number of deaths is still extraordinarily high, necessitating additional efforts to get this under control.

However, a major question is why such high levels of opioid deaths have not been seen in Europe? By comparison to the figures in the US, there are estimates that there were at least 6,166 overdose deaths across the entire European Union in 2021. Though this is still a low figure, it marks an increase on figures for 2020, when deaths were estimated to be 5,796.

There are now concerns, expressed by Europol, that there may be efforts underway to expand the fentanyl market in Europe. The agency recently found fentanyl production facilities and fentanyl analogues in the EU. As of 2021, only 49 deaths were linked to the synthetic opioid. However, certain areas of Europe are being impacted more strongly, such as in Estonia, where the number of drug-induced deaths involving synthetic opioids doubled to 79, in preliminary 2022 data. The question may well be a matter of time before the situation in Europe begins to show closer similarities to the US. The advantage Europe will have is that the US has already created a blueprint to tackle the issue, and the region does not have the endemic issue with opioid abuse that was originally created in the US during the 1990s.