Benefits and risks of pharmaceutical opioids: Essential treatment and diverted medication. A global review of availability, extra-medical use, injection and the association with HIV

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Author: 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 on HIV and injecting drug use

Resource Type: Working papers/discussion papers

This paper reviews the existing peer reviewed and “grey” literature on the injection of opioid pharmaceuticals and associated harm, including associations with HIV, and considers the context of the availability of pharmaceutical opioid medications for the medical indications for which they are recommended. The paper finishes with a brief review of interventions to address misuse, injection and harm.

Numerous pharmaceutical drugs have the potential for misuse. These include benzodiazepines (e.g. diazepam, temazepam); performance and image enhancing drugs (PIEDs, e.g. anabolic-androgenic steroids); antidepressants (e.g. tricyclics and selective serotonin reuptake inhibitors); and prescription stimulants (e.g. dexamphetamine).

The focus of this report is on pharmaceutical opioids for several reasons: 1) opioid dependence is a problem of considerable concern, and opioid dependence through use of prescription opioids has increased in low and middle income countries as well as high income countries; 2) injection of pharmaceutical drugs such as PIEDs is likely to be concentrated among specific subpopulations in high income countries and to our knowledge, has not been noted as an issue in low and middle income countries; and 3) although injection of benzodiazepines is associated with significant harm, it is thought to be typically concentrated among persons who are primarily opioid dependent. Injection of other pharmaceutical drugs is also worthy of investigation, however, and future work might examine in detail the epidemiology of injection and harm related to these drugs.

The risks of extra-medical opioid use and diversion are acknowledged by multiple international agencies, including those which monitor pharmaceutical opioid availability, and those which address injecting drug use, HIV and pain conditions. All of these agencies also emphasise the importance of providing medical treatment for those who need it, and are unanimous in assertions that pharmaceutical opioids must be made available.

The 1961 Single Convention stipulates that although the provision of designated drugs (including morphine-like opioids) is restricted for recreational purposes, their availability and supply should meet medical and scientific needs. The International Narcotics Control Board (INCB) is required to report on the adequacy of availability of drugs covered under the 1961 Convention. This report summarises – as part of the review of the “availability” of pharmaceutical opioids – the published data from the INCB Annual reports on the kinds of opioids available, and the extent of their availability adjusted for population size (Section 5). As will become clear, there are massive inequities in the availability of pharmaceutical opioids for medical and scientific purposes across countries and regions, inequities that nonetheless do not preclude misuse and injection occurring in many regions of the world.

There is a complex interplay of factors that appears to be linked to the extent of pharmaceutical opioid misuse and injection, and associations with HIV. This report attempts to highlight several factors that seem core: the extent of opioid availability – heroin and opium as well as pharmaceutical opioids; regulation of pharmaceutical opioids and the manner in which they are made available; the existence of established populations of injecting drug users (IDUs), and of dependent opioid users; the background prevalence of HIV, and the extent to which HIV harm-reduction interventions are in place – particularly needle syringe programmes (NSPs) and opioid substitution treatment (OST).

As might be imagined, this report provides an overview of these issues as covered in the literature. It is intended to act as a paper that might be used to stimulate further research into the many complexities surrounding this issue. As will become clear, not only are there huge gaps in our understanding of the extent of misuse, injection, and attributable HIV, but the literature on the mechanisms of diversion and comparative risks of diversion, misuse and injection is also very limited.