From the Journals

Clinical interventions for global drug use need updating

Public health approach requires greater emphasis on harms, benefits of substance use.



Strategies aimed at reducing drug-related harm should be informed by evidence, and recognize the contribution of social and economic factors to drug use, report the authors of a series of four papers published in The Lancet.

Louisa Degenhardt, PhD, and coauthors wrote in the first paper that, although the availability and use of drugs have been transformed over recent decades – including the emergence of hundreds of new psychoactive substances – professional and public policy has not yet adapted to those new realities (Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)32229-9).

“In many instances we have, in many countries, and in many debates, the things that are implemented are not evidence-based, and the discussion around illicit drugs is often in an incredibly emotive and morally laden one, in a way that you don’t see in other areas of public health,” Dr. Degenhardt, of the National Drug and Alcohol Research Centre at the University of New South Wales in Sydney, said in an interview. “There has been an increasing level of awareness of issues but also level of recognition that we need to have hard evidence to work out the best ways to respond.”

The paper by Dr. Degenhardt and coauthors addressed the issue of opioid use and dependence around the world, citing evidence that in 2017, 40.5 million people were dependent on opioids and 109,500 deaths were attributable to opioid overdose. An effective treatment exists in the form of opioid agonists methadone and buprenorphine, both of which are recognized as World Health Organization essential medicines.

While the best evidence for positive outcomes from opioid agonist treatment is in people using illicit opioids such as heroin, there is also evidence for their effectiveness in people with pharmaceutical opioid dependence. A study in Kentucky suggested that scaling up the use and retention of opioid agonist treatment, including in prison, could prevent 57% of overdose deaths among injecting drug users.

“Despite strong evidence for the effectiveness of a range of interventions to improve the health and well-being of people who are dependent on opioids, coverage is low, even in high-income countries,” the authors wrote. They also called for international efforts to eliminate marketing strategies that have contributed to the increase in opioid prescription and harms in North America.

The second paper examined the public health implications of legalizing cannabis for medicinal and recreational use (Hall W et al. Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)31789-1). Cannabis has been considered an illicit drug for more than 50 years but recently has been decriminalized or legalized in many parts of the world in recognition of the lower levels of harm, compared with other illicit substances.

Cannabis is used to treat a range of medical conditions, including muscle spasticity in multiple sclerosis. It also is used to treat pain, nausea, and vomiting in palliative care, and to reduce seizures in epilepsy. However, the authors noted that the evidence for many medical applications was absent, and that weakly regulated medical cannabis programs in some U.S. states were blurring the boundaries between medicinal and nonmedicinal use.

They also wrote that the public health effects of legalization could not be assessed, because legalization had happened only in the last 5 years.

“A major determinant of the public health effect of cannabis legalization will be the effect that it has on alcohol use,” they wrote. “The substitution of cannabis for alcohol would produce substantial public health gains, but any increase in the combined use of alcohol and cannabis could increase harm.”

The authors also looked at the effect of use of stimulants such as cocaine and amphetamines. While their use is associated with higher mortality, increased incidence of HIV and hepatitis C infection, poor mental health, and increased risk of cardiovascular events, no effective pharmacotherapies are available, and psychosocial interventions such as cognitive-behavioral therapy have only a weak effect.

“Many governments rely on punitive responses, such as involuntary detention in drug centers, despite the absence of evidence for their effectiveness and their potential to increase harm,” the authors wrote. “Substantial research investment is needed to develop more effective, innovative, and impactful prevention and treatment” (Farrell M et al. Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)32230-5).

They focused on interventions to prevent the transmission of blood-borne and sexually transmitted infections – such as the provision of safe injecting equipment, condoms or pre-exposure prophylaxis against HIV – and improve treatment of these, and interventions to prevent and treat overdose, injury, and other harms.

The final paper in the series explored new psychoactive substances, such as synthetic cannabinoids, stimulants, hallucinogens, and dissociative and depressant substances (Peacock A et al. Lancet 2019 Oct 23. doi: 10.1016/S0140-6736(19)32231-7).

There really needs to be massive change in systems in terms of the way monitoring occurs and the speed with which new drugs are identified, Dr. Degenhardt said in the interview. She also said the risks that are identified need to be communicated more effectively.

“At the moment, the way that drug surveillance works in most countries, things come and then particular drugs may spread in use, cause massive harm, and all of our systems of detecting and responding are not fit to detect those things in a timely way and disseminate information to reduce those risks.”

The papers were supported by European Monitoring Centre on Drugs and Drug Addiction, and the Australian National Drug and Alcohol Research Centre. The authors declared support from a range of institutions and funding bodies, and several also declared unrelated grants, funding, and other support from the pharmaceutical sector.

SOURCES: Degenhardt L et al. Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)32229-9; Hall W et al. Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)31789-1; Farrell M et al. Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)32230-5; and Peacock A et al. Lancet. 2019 Oct 23. doi: 10.1016/S0140-6736(19)32231-7.

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