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 Louisa Degenhardt, Briony Larance, Bradley Mathers, Tasnim Azim, Adeeba Kamarulzaman, Richard Mattick, Samiran Panda, Abdalla Toufik, Mark Tyndall, Lucas Wiessing and Alex Wodak on behalf of the Reference Group to the United Nations on HIV and injecting drug use National Drug and Alcohol Research Centre UNIVERSITY OF NEW SOUTH WALES Sydney, Australia i ISBN: 978-0-7334-2707-7 This work is copyright. You may download, display, print and reproduce this material in unaltered form only (retaining this notice) for your personal, non-commercial use or use within your organisation. All other rights are reserved. Requests and enquiries concerning reproduction and rights should be addressed to the information manager, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW 2052, Australia. ii Acknowledgements This report is a product of the Reference Group to the United Nations on HIV and injecting drug use and was reviewed by the 2007 members of the Reference Group and also the Secretariat of the Reference Group. In 2007 the Reference Group members were Tasnim Azim, Mauro Guarinieri, Matthew Hickman, Adeeba Kamarulzaman, Kasia Malinowska-Sempruch, Fabio Mesquita, Azarakhsh Mokri, Olanrewaju Olusola Onigbogi, Fred Owiti, Samiran Panda, Steffanie A. Strathdee, Fayzal Sulliman, Abdalla Toufik, Jallal Toufiq, Mark Tyndall and Lucas Wiessing. In 2007 the Secretariat consisted of Richard Mattick, Louisa Degenhardt, Bradley Mathers, Benjamin Phillips, Kate Dolan and Alex Wodak. The following individuals assisted with the compilation of the literature: • Laura Kemmis, United Kingdom • Gabrielle Campbell, NDARC, University of NSW • Eva Congreve, NDARC, University of NSW • Benjamin Phillips, NDARC, University of NSW • Jessica Singleton, NDARC. University of NSW The following individuals assisted with the compilation of data, or provided comment on the report: • Reychad Abdool, UNODC, Regional Office for Eastern Africa, Nairobi, Kenya • Pavel Aksenov, UNODC, Regional Office for Russia and Belarus, Moscow, Russian Federation • Hement Bajaj, UNAIDS, New Delhi, India • Raimondo Bruno, University of Tasmania, Hobart, Australia • Jimmy Dorabjee, Centre for Harm Reduction, Melbourne, Australia • Jeremy Douglas, UNODC Regional Centre for East Asia and the Pacific, Bangkok, Thailand • Ranjan Dwivedi, UNAIDS, New Delhi, India • Wayne Hall, University of Queensland, Brisbane, Australia • John Howard, Ted Noffs Foundation, Sydney, Australia • David Jacka, WHO, Hanoi, Viet Nam • Danica Klempova, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal • Joao Matias, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal • Linda Montanari, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal • Jane Maxwell, Addiction Research Institute, The University of Texas at Austin, United States • Susannah O’Brien, NDARC, University of NSW, Sydney, Australia • Amanda Roxburgh, NDARC, University of NSW, Sydney, Australia • Graham Shaw, WHO, Phnom Penh, Cambodia • Mahshid Taj, UNODC, Tehran, Iran • Mutabara Vohidova, UNODC, Dushanbe, Tajikistan • Paul Williams, UNODC, Vienna, Austria iii Table of contents Acknowledgements ................................................................................................................................. iii Foreword ................................................................................................................................................. vi Abbreviations ......................................................................................................................................... vii Executive Summary ............................................................................................................................... viii 1.1. Introduction ......................................................................................................................... viii 1.2. Terminology ........................................................................................................................ viii 1.3. Scope of this report .............................................................................................................. viii 1.4. Findings ................................................................................................................................. ix 1.5. The use of pharmaceutical opioids outside of prescribed bounds .......................................... ix 1.6. Mechanisms of diversion ........................................................................................................ x 1.7. Clinical use of pharmaceutical opioids ................................................................................... x 1.8. Harms associated with pharmaceutical opioid injecting ........................................................ xi 1.9. Pharmaceutical opioid availability, extra-medical use, injection, and HIV ............................ xi • Eastern Europe and Central Asia ............................................................................................ xi • South Asia............................................................................................................................. xii • East and South East Asia ........................................................................................................ xii • Caribbean ............................................................................................................................ xiii • Latin America ...................................................................................................................... xiii • Oceania and the Pacific ....................................................................................................... xiii • Canada, United States and Western Europe ......................................................................... xiv • Middle East and Northern Africa ........................................................................................... xv • Sub-Saharan Africa ............................................................................................................... xv 1.10. Discussion ........................................................................................................................... xvi 1.11. Regulatory responses .......................................................................................................... xvii 1.12. Drug preparations and formulations .................................................................................. xviii 1.13. Harm reduction ................................................................................................................. xviii 1.14. HIV treatment .................................................................................................................... xviii 1.15. Future research .................................................................................................................... xix 1.16. Conclusions ......................................................................................................................... xix 2. Introduction ..................................................................................................................................... 2 2.1. Scope of this report ................................................................................................................. 2 2.2. Terminology ........................................................................................................................... 3 2.3. Pharmaceutical opioids .......................................................................................................... 4 2.4. Dependence ........................................................................................................................... 5 2.4.1. The concept of “dependence liability” ............................................................................... 6 3. The use of pharmaceuticals outside of prescribed bounds – “extra-medical” use ............................. 8 3.1. Why does extra-medical use occur? ....................................................................................... 8 3.2. Do all opioids carry the same risk of extra-medical use and diversion?................................... 8 3.3. How does “diversion” occur? ............................................................................................... 10 4. Clinical use of pharmaceutical opioids .......................................................................................... 13 4.1. Treatment of acute pain ........................................................................................................ 13 4.1.1. Risks for misuse and diversion .......................................................................................... 13 4.2. Treatment of cancer pain ...................................................................................................... 13 4.2.1. Risks for misuse and diversion .......................................................................................... 14 4.3. Palliative care for HIV/AIDS .................................................................................................. 15 4.3.1. Risks for misuse and diversion .........................................................................................