Seven Countries That Beat an Overdose Crisis

Cheap, non-stigmatized, widespread access to Opiate Substitution Therapy is the key difference in successful countries.

It’s no secret that there's a drug overdose crisis in the United States. Opioid overdose deaths have risen 255% from 1999 to 2015. The US has failed to beat the opioid epidemic with drug courts, 12 step rehabs, and even medications like Vivitrol. However, seven other countries have overcome a huge drug overdose crisis very cheaply using technology which is more than 50 years old. Their secret? They have made methadone, an extremely cheap drug which costs less than a dollar a day for a maintenance dose, readily available to everyone who needs it. Rather than mandating expensive and stigmatizing methadone clinics, they allow any patients who need methadone to take their doses in their doctors’ offices or even at pharmacies... for free!

In order to find out what works and what doesn't work in fighting an overdose crisis, I looked at data from 33 countries which have published detailed data about drug dependence, overdose, and treatment responses over a long period of time. A major overdose crisis was defined as more than 2.0 drug poisoning deaths per 100,000 person years. Long term success was defined as a greater than 40% reduction in overdose deaths for a minimum of nine years. Seven countries were successful at greatly reducing overdose deaths: Australia, Germany, Greece, Italy, Luxembourg, Norway, and Switzerland (Full details of my analysis can be found at http://hams.cc/overdose).

The Seven Biggest Successes

Why were these seven countries successful when the US has failed so miserably? The overwhelming commonality was that all seven countries had extremely good access to opioid substitution therapy (OST). The majority of clients take their dose of methadone or buprenorphine in pharmacies or doctors' offices instead of methadone clinics in five of these countries: Australia, Germany, Luxembourg, Norway, and Switzerland. Only in Greece are clients required to come to a specialized clinic to dose, although in Italy clinic dosing is the norm and pharmacy dosing is the exception. However, Greece and Italy have clinics everywhere so that it is no hardship to get to the local clinic to dose; a solution which is impractical in a country with a population as dispersed as the US.

Importantly, opioid substitution therapy (OST) is essentially free to patients in six out of seven of these countries, Australia being the exception. OST is available for anyone who needs it, and there are generally no wait times, so patients are not in danger of overdose while they wait for treatment. Also, patients are not kicked out of treatment if their urine tests positive for other drugs: treatment is the priority, not punishment.

In Australia, Germany, Luxembourg, and Switzerland OST can be initiated in doctors' offices. Greece, Italy, and Norway require that OST be initiated at a specialized treatment center. Once OST is initiated, however, it is usually continued by doctors in office practice in Australia, Germany, Luxembourg, Norway, and Switzerland. Only Greece requires attendance at a specialized treatment clinic (OTP) to continue OST.

Some of these countries also have instituted other initiatives to reduce overdose deaths; however, none of these are as widespread and long established as OST.

Drug consumption rooms (DCRs), sometimes called safe injection facilities, undoubtedly save lives but there just aren't enough of them yet. Australia has one DCR (opened 2001), Germany has 24 (the first opened in the early 1990s and they became legally sanctioned in 2000), Luxembourg has one (since 2005), Norway has one (since 2005), and Switzerland has 12 (since 1986). There are none in Greece or Italy. DCRs alone could not have been the factor which turned around the overdose crisis in these countries, although they are extremely important lifesaving programs.

Heroin assisted treatment (HAT) is another lifesaving measure, but out of the seven countries under discussion, only Germany and Switzerland currently allow HAT. Housing first initiatives aimed at reducing homelessness also undoubtedly decrease drug use and drug overdose deaths, but rates of homelessness in the seven successful countries vary greatly. Take home naloxone (THN) programs are also successful at combating overdose, but they are only found in four of the seven successful countries. The one common factor in the success of all seven at beating the overdose crisis is easily available OST.

The evidence suggests that cheap or free and easy access to OST is the most fundamental building block needed to reverse an opioid crisis. Once that foundation is in place, countries will benefit by adding drug consumption rooms, heroin assisted treatment, take home naloxone, and housing first programs to it. But without affordable and accessible OST these other programs alone are insufficient. The way to make OST affordable and accessible in the US is with office based prescribing and pharmacy dosing of methadone. This costs less than a dollar a day for the medication itself and is much less stigmatizing than waiting in line at a methadone clinic.

The Five Biggest Failures… And We’re Number One!

In five of the countries that failed to overcome a major overdose crisis, the death toll is spiraling out of control. Unfortunately, the USA is the biggest failure at combating opioid overdose death.

USA

The USA is the worst of any country investigated in this article in terms of overdose deaths. The rate of opioid overdose death in the USA increased 255% between 1999 and 2015. The number of opioid overdose deaths (T40.0-.4,.6) went from 8,050 (2.88 per 100,000) in 1999 to 33,091 (10.3 per 100,000) in 2015. As Jones et al. (2015) have noted in detail, OST coverage is quite inadequate in the US. For many people, OST is not covered by insurance and patients are forced to pay hundreds of dollars out of pocket.

The regulations for initiation and dosing of methadone in the US are completely different from those for buprenorphine, unlike most countries in the world which treat these two substitution medications the same. Buprenorphine is far more accessible because it is far more expensive and results in huge profits for pharmaceutical companies, while methadone is cheap.

The US has no drug consumption rooms and no HAT. The homelessness rate is fairly low (0.18%) and several housing first initiatives have been put in place. Tiny harm reduction agencies do an excellent job of distributing take home naloxone, but it is not enough. Naloxone has been made over-the-counter in 14 states, but that leaves 36 states where you can only get naloxone with a prescription.

The federal government needs to change the laws to allow office-based methadone initiation and pharmacy-based methadone dosing, and to subsidize OST so that it is free for all. This is proven to be a best practice by the seven countries that have been successful at reversing the opioid crisis: the US should put aside outdated ideology and adopt the policy that saves lives.

Sweden

Sweden is the second worst country for overdose deaths. Sweden’s percentage of increase is essentially the same as that in the US, but the current death rate (6.3 per 100,000 for all drugs) is much lower. The rate of overdose death in Sweden increased 256% between 1999 and 2014. Sweden has a 'zero tolerance' policy for the use of illicit drugs while on OST, so many patients are kicked out of treatment, putting them at greater risk for overdose. There has been a decline in the number of clients in OST since 2011. Clients must go to a specialized OTP clinic to dose and to initiate treatment with both methadone and buprenorphine; there is no office-based or pharmacy-based dosing or initiation of either.

Sweden has no drug consumption rooms, no take home naloxone, and no HAT. Sweden has high rates of homelessness (0.36%) and inadequate drug user housing. It should come as no surprise that Swedish overdose deaths are out of control.

UK (England and Wales)

The opioid overdose death rate increased 35% in England and Wales between 1999 and 2015. More shockingly, it increased 51% between 2012 and 2015 and the rate for all drug overdose deaths increased even more over this period. In 2010 the government of the United Kingdom decided to replace the highly effective harm reduction approach to drug use which had been in place for decades with a more politically popular "recovery" approach focused on abstinence, and in so doing precipitated a major public health crisis.

Given the resounding failure of abstinence-based US drug policy, it is tragic that these policies have been imported to the UK. Prior to 2010, the UK did a relatively successful job of reducing or at least containing overdose deaths. It has the mechanisms in place such as pharmacy dosing and office prescription of OST, as well as take home naloxone and HAT. The UK should return to the policy of allowing people to stay on OST as long as necessary, rather than trying to force them off methadone and buprenorphine as is current policy.

Lithuania

Drug overdose death rates increased 183% in Lithuania between 1999 and 2014. The number of deaths went from 37 (1.0 per 100,000) in 1999 to 87 (3.0 per 100,000) in 2014. OST in Lithuania, whether methadone or buprenorphine, can only be dispensed at specialized clinics. OST coverage is poor. A 2007 report estimated there were 5,458 problem opioid users in Lithuania; in 2014 only 585 clients were in OST. This is less than 11% of those in need of OST. 95% of opioid treatment admissions in Lithuania are for heroin. In 2014 in Lithuania 479 OST clients (82%) were receiving methadone and 106 (18%) were receiving buprenorphine.

Finland

Drug overdose death rates increased 40% in Finland between 1999 and 2014. The number of deaths went from 119 (2.3 per 100,000) in 1999 to 176 (3.2 per 100,000) in 2014. Rates actually peaked in 2012 when there were 213 deaths (3.9 per 100,000) and then fell 18% in the following two years; however, there don't seem to have been any major policy or treatment changes which account for this drop.

Although pharmacy dosing of methadone is legal in Finland, only about 7% of people in OST have been given a pharmacy contract and the other 93% must go to a specialized clinic to dose. It is estimated that there were 13,836 problem opioid users in Finland as of 2012, but as of 2014 only 3,000 were in OST, giving a rate of coverage of only 22%. Overall, access to OST in Finland is poor.

Countries Where Overdose Has Leveled Off, or That Have Had Short Term Success

Denmark and Ireland have seen a leveling off of overdose death rates. This can be largely attributed to easier access to OST.

Austria, Estonia, Malta, Croatia and Slovenia have seen short term reductions in overdose deaths. For more information on countries where overdose has leveled off or that have seen short term success, please see my full article at http://hams.cc/overdose/.

Conclusion and Recommendations

Cheap and easy access to OST has repeatedly proven effective at stemming or reversing an opioid overdose crisis. The cheapest, least stigmatizing way to reach the most people is with pharmacy-based dosing of methadone. This costs less than a dollar a day. And yet, the “solutions” pushed by drug courts, mental health professionals and popular culture are the worst possible approaches: 28 day rehab or incarceration. Both 28 day rehab and incarceration raise the odds of overdose death exponentially. Graduates of 28 day rehabs are 30 times more likely to die of overdose than active heroin users.

Meanwhile, OST with methadone is cheap, effective, and could cut down on stigma if pharmacy dosing were available. In 2007 a pilot study of office-based prescribing and pharmacy-based dosing of methadone was conducted in the US. Patients, pharmacists and doctors alike were extremely satisfied. The solution that worked in the seven most successful countries can be implemented here in the US.

People on methadone can lead productive lives even while being treated. More people would accept treatment if they knew they could access the medication they need in a non-stigmatizing environment like a pharmacy.

Cheap and easy access to methadone is the bedrock that must be in place so that drug consumption rooms, heroin assisted treatment, take home naloxone programs, and housing first initiatives can have a firm foundation. Only once the US follows the example of the seven most successful countries and implements pharmacy dosing of methadone will we stem the tide of the opioid overdose epidemic.