Thursday, August 23, 2007

End of heroin & advent of socially-approved big pharma narcotics provision

I posted a few days ago on the explosion in use of illegally-diverted prescription painkillers such as oxycodone now occurring in the US and throughout the western world. In my view this is a dramatic development that may signal the advent of a new global drug problem that is, in many ways, analogous to the nicotine century that we have just struggled through with its horrific record of millions of deaths from lung cancer and other tobacco-induced health disorders.

Rather than being driven by poppy farmers in Afghanistan and Myanmar, current global opiate use is increasingly under the control of big pharma who can make billions from this line of business.

The world now has about 10 million heroin addicts. Government controls and restrictions have squeezed the supply of illicit heroin but still a lot is supplied.

A recent Canadian study however suggests that heroin use in 7 major sites has dramatically fallen in recent years – in 5 of the 7 sites it is virtually absent. Most illicit opiates are now coming from the medical system not from illicit markets. Users are consuming painkillers that were originally legally supplied, or illegally imported from countries like Mexico. Alternatively users were consuming medically-prescribed substitutes for illicit opiates. All these sources of supply generate a buck for big pharma.

In recent years in Australia a heroin drought that started in 2002 has triggered major reductions in opiate use and overdose deaths. Is this outcome partly the result of medically-supplied pain-killers that in some cases have been illegally diverted and used to substitute for heroin? Certainly there has been growth in the substitute narcotics markets supplying methadone and buprenorphine. These are heroin ‘cures’ that substitute a medically-provided opiate for an illicit opiate. Moreover the demand for opiate-based painkillers has risen strongly in Australia as it has in the US.

Most of our attention has been driven towards thinking about ‘ice’ amphetamine substitutions for heroin but maybe there is a more straightforward route of substitutions towards medically-supplied opiates.

As I wrote in my earlier post, commercial interests are muscling in on a great market. Pharmos can sell these products to addicted users for a lifetime at government-subsidised costs.

I strongly urge those interested in this area to read the short editorial by Benedikt Fischer and Jurgen Rehm in Addiction. There are ideas here that might guide licit and illicit drug debates for the next 50 years.


conrad said...

I think your article is off the mark. There has been an addiction problem with legal prescription drugs for basically as long as they have been available -- the fact that there is a new one is no big deal. Its always been a big problem.

Also, the idea that the government is stopping the heroin trade is also rather grey -- the supply of heroin has always been cyclical, and no doubt when the US gets kicked out of Iraq/that area in general, the supply will go up again.

hc said...

Conrad, Why the sudden dramatic growth in demand for these painkillers? And why the disappearence of illicit heroin markets?

FXH said...

I tend to agree with this statement (summary?) from Benedikt Fischer and Jurgen Rehm in Addiction:

Furthermore, most national systems' drug use monitoring tools—e.g. the Canadian Addiction Survey (CAS)—have not been sensitive to the phenomenon of prescription opioid abuse or its harmful consequences (especially in marginalized user groups, e.g. street drug users): specifically, most even lack the most basic tools to differentiate ‘use’ from ‘abuse’ or ‘dependence’ [25]. It is quite possible that, for some user populations, a shift from heroin to prescription opioid abuse may mean a reduction in key consequential harms (e.g. overdose risk or injecting behaviours)—as suggested by the OPICAN data [10].

FXH said...

The statement means that "they" don't know what they are talking about with regard to "use", "abuse", "dependence", of prescribed opiods and that any such "abuse" may well end up delivering harm minimisation strategies.

Legitimate concern about Big Pharma profits, gouging and rent seeking should be examined for what they are and not mixed up with the emotional panic surrounding "addiction" "abuse" and heroin.


FXH said...

harry - I'm not clear about the "sudden explosive growth".

Is there a graph or table somewhere?

Most drug /treatment uptake doesn't follow a smooth line - due to many factors. There is often a slow uptake then a tipping point where usage explodes due to information, inherent (and desirable) conservatism on behalf of prescribers, Meta studies on drug or conditions, rules and regulations,etc etc.

I will still take a punt, without any info, that the biggest cohorts its precribed to is over 55 yo and cancer and /or terminal illness. And thatis also where the "dramatic growth" is.

conrad said...

Lots of drugs go through big growth phases before getting much tighter legislation due to addiction problems. Benzodiazepine's are an obvious example which probably fit a similar category to the newer pain killers. They're basically harmless, have some positive effects, but they're also addictive, so once you stop taking them, you'll have problems. They didn't displace other drugs as far as I'm aware.

As for heroin usage -- I think you are just looking at correlation, not causation, in terms of whether the newer painkillers are displacing it. The disappearance of Heroin is surely due to the current situation in Afganistan/Pakistanm where a lot of the supply is being cut-off. Once the US gets booted out of these places, no doubt the Heroin supply will increase again. The situation in Burma may also have calmed down a bit, which is another big supply centre.

Because of this, I don't think there's much the police can do about the Heroin problem in Australia without radical changes in legislation. Hence I think your attribution to policing is wrong -- its global policing which is important, not local policing. I doubt, the efficacy of local policing changes much over time, but the price of Heroin changes a lot.

You can look at this in recent history (you can find the number of deaths due to OD, which should provide a proxy for overall usage). Off the top of my head, it was big in the 80s, then use dimished a lot (speed replaced it a lot ), but then it was huge in the 90s again (remember the movie trainspotting?), and then it died out again. The next cycle will surely come again next time it becomes really cheap.

conrad said...

Sorry, I forgot to mention, the other reason I don't think pain-killers are displacing Heroin at all is that if it was, we should have seen a drop in the price of Heroin. Not that I''m wandering around Richmond much :) but I don't here any reports of that.

FXH said...

conrad if your chasin' then Ringwood Rail Station or Springy and Dandenong is a good bet, or Russell Street.

Or I hear the Economics Dept a LaTrobe is good for a gram or two but on principle they will only sell at an auction with full information on quality available. Cash on the knocker. Nothing on the slate. Dunno about mates rates or insider trading out there tho.

conrad said...

Thats ok FXH,

where I work has trials for the new and novel. I don't need passe stuff. Or am I just an old fogey thinking it is passe -- is it cool again?