Shifting North American drug markets and challenges for the system of care

Abstract

Drug markets are dynamic systems which change based on demand, competition, legislation and revenue. Shifts that are not met with immediate and appropriate responses from the healthcare system can lead to public health crises with tragic levels of morbidity and mortality, as experienced Europe in the early 1990s and as is the case in North America currently. The major feature of the current drug market shift in North America is towards highly potent synthetic opioids such as fentanyl and fentanyl analogues. An additional spike in stimulant use further complicates this issue. Without understanding the ever-changing dynamics of drug markets and consequent patterns of drug use, the healthcare system will continue to be ineffective in its response, and morbidity and mortality will continue to increase. Economic perspectives are largely neglected in research and clinical contexts, but better treatment alternatives need to consider the large-scale macroeconomic conditions of drug markets as well as the behavioural economics of individual substance use. It is important for policy makers, health authorities, first responders and medical providers to be aware of the clinical implications of drug market changes in order to best serve people who use drugs. Only with significant clinical research, a comprehensive reorganization of the system of care across all sectors, and an evidence-driven governance, will we be successful in addressing the challenges brought on by the recent shifts in drug markets.

Changes in supervised consumption site use and emergency interventions in Montréal, Canada in the first twelve months of the COVID-19 pandemic: An interrupted time series study

“…This shift was heightened during the pandemic, with the proportion of drug-related deaths in which fentanyl was detected rising from 8% during April 2019 to March 2020 to 17% during April 2020 to March 2021 (INSPQ, 2021; Santé Montréal, 2022 ). Border closures and other infection mitigation measures, as well as the increased use of certain drugs in medical settings, may have disrupted the drug market and affected modes of drug use, potentiating the transition to more potent synthetic opioids ( Krausz et al, 2021 ; Otiashvili et al, 2022 ; Schlosser & Harris, 2020 ). These findings dovetail with reports that increasingly scarce heroin is being replaced by novel synthetic opioids including higher concentrations of fentanyl, benzodiazepine-fentanyl mixtures, and benzimidazole in counterfeit opioid tablets ( RCCET, 2020 ).…”

Prevalence of Substance Abuse Among Trauma Patients in Rural West Virginia

“…It is logical to recommend the minimization of prescriptions for these substances in the hope of a positive effect on trauma management. The need to regulate the prescribing of these drugs is especially pressing given the recent spike in drug overdoses [33][34][35]. However, given that benzodiazepines, amphetamines, and opioids were used without a prescription in about 80% of cases in our study, overprescribing these medicines does not seem to be a key influence in their abuse.…”

Trends in mortality related to unintentional poisoning in the South Asian region from 1990 to 2019: analysis of data from the Global Burden of Disease Study

“…In contrast, the mortality rate due to unintentional poisoning, particularly opioid overdose causing three epidemics in the USA from 1990 to 2019, claimed 500 000 lives,41–48 while in these five South Asian countries we have seen decreasing death rates over the years. Deaths due to overdosing are increasing in the USA due to the increased availability of illegally manufactured synthetic drugs such as fentanyl and methamphetamine, toxic drug supply in which drugs are frequently contaminated or adulterated by multiple psychoactive substances, and polysubstance use 49. However, the declining trend in unintentional poisoning mortality in South Asian countries may be linked to a weak to non-existent surveillance system for poison exposures, and poisoning-related data may be under-reported due to the inadequate capacity of health professionals to characterise poisoning in hospitals and communities 50 51…”

“…Deaths due to overdosing are increasing in the USA due to the increased availability of illegally manufactured synthetic drugs such as fentanyl and methamphetamine, toxic drug supply in which drugs are frequently contaminated or adulterated by multiple psychoactive substances, and polysubstance use. 49 However, the declining trend in unintentional poisoning mortality in South Asian countries may be linked to a weak to non-existent surveillance system for poison exposures, and poisoning-related data may be under-reported due to the inadequate capacity of health professionals to characterise poisoning in hospitals and communities. 50 51 On a global level, there is high variability in the mortality rate attributed to unintentional poisoning ranging from 2.2% annual increase in mortality in Lesotho to −6.4% annual decrease in mortality in Mongolia.…”