Are we missing the opioid consumption in low- and middle-income countries?

Igor Correia; Ney Meziat-Filho; Andrea D. Furlan; Bruno Saragiotto; Felipe J. J. Reis

doi:10.1515/sjpain-2023-0086

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Are we missing the opioid consumption in low- and middle-income countries?

Igor Correia , Ney Meziat-Filho , Andrea D. Furlan , Bruno Saragiotto and Felipe J. J. Reis

Published/Copyright: November 13, 2023

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From the journal Scandinavian Journal of Pain Volume 24 Issue 1

Abstract

Objectives

The rise in opioid prescriptions with a parallel increase in opioid use disorders remains a significant challenge in some developed countries (opioid epidemic). However, little is known about opioid consumption in low- and middle-income countries (LMICs). In this short report, we aim to discuss the increase in opioid consumption in LMICs by providing an update on the opioid perspective in Brazil.

Methods

We analyzed opioid sales on the publicly available Brazilian Health Regulatory Agency (ANVISA) database from 2015 to 2020.

Results

In Brazil, opioid sales increased 34.8 %, from 8,839,029 prescriptions in 2015 to 11,913,823 prescriptions in 2020, this represents an increase from 44 to 56 prescriptions for every 1,000 inhabitants. Codeine phosphate combined with paracetamol and tramadol hydrochloride were the most common opioids prescribed with an increase each year.

Conclusions

The results suggest that opioid prescriptions are rising in Brazil in a 5 years period. Brazil may have a unique opportunity to learn from other countries and develop consistent policies and guidelines to better educate patients and prescribers and to prevent an opioid crisis.

Keywords: opioids; opioid consumption; opioid crisis; pain

Introduction

The opioid crisis is a serious public health problem in developed countries such as the United States (U.S.) and Canada [1, 2]. In the US, opioid crisis resulted in nearly 500,000 deaths in the last 2 decades. Although the opioid crisis is recognized by cases of fatal overdoses, opioid use disorder also has social and economic impacts [3]. It has been estimated that economic costs in the U.S. associated with health care expenses, criminal justice, lost productivity and reduced quality of life topped $1 trillion with 54 % attributed to overdose deaths and 46 % to opioid use disorder in 2017 [4]. However, the opioid crisis is not exclusive to North America. The World Health Organization (WHO) has recognized opioid use disorder as an international problem and responsible for more than 8,000 opioid overdose deaths in Europe in 2017 [5]. In Australia, opioid deaths accounted for 62 % of all drug-related deaths in recent years and the total number of opioid-related deaths are increasing every year [6].

The variable rates of opioid consumption between high-income countries and low- and middle-income countries (LMICs) [7] as well as strong regulatory policies suggest that the opioid crisis is not yet a problem in LMICs [8]. However, there are compelling data showing an increase in opioid consumption in LMICs [9, 10]. A recent study reported an increase in the total consumption of strong opioids in Malaysia (increase of 993.18 %), Indonesia (increase of 530.34 %), Vietnam (increase of 170.17 %), Singapore (increase of 116.16 %) and Thailand (increase of 104.66 %) in a period of 10 years [9].

From 2009 to 2015, opioid consumption in Brazil increased from 8 to 44 sales per 1,000 inhabitants – accounting for an increase of 465 % [10]. The main consumed substance in this period was codeine representing 98 % of all sales. Our aim with this short communication is to discuss the increase in opioid consumption in LMICs by providing an update on the opioid perspective in Brazil from 2015 to 2020.

Methods

We carried out a cross-sectional study using a database from the Brazilian Health Regulatory Agency (ANVISA). ANVISA is responsible for regulating health-related products including medicines subject to bookkeeping (i.e., those that require special control due to their potential for abuse or dependence). This study was exempt from approval by the Ethics Committee since all data included in this study are publicly available on the internet.

We collected the data (June 2021) representing all opioid sold legally (i.e., after presentation of a medical prescription). Data provided by ANVISA consider all opioids sold at registered pharmacies and drugstores across Brazil. Two authors (IC and FR) independently extracted the data from the ANVISA website from 2015 to 2020. We extracted data related to sales (representing all prescriptions retained), number of units, healthcare professions responsible for prescriptions and substances over the years. All data collected for analysis were stored in an Excel spreadsheet and processed using Python language version 3.10.12 and the following packages pandas, numpy, matplotlib, seaborn and plotly. We present a descriptive data analysis. To be comparable with previous Brazilian data [10], we adjusted the opioid prescriptions sold per 1,000 inhabitants by using annual estimates of population size.

Results

We found that opioid sales in Brazil increased 34.8 % (from 8,839,029 prescriptions in 2015 to 11,913,823 prescriptions in 2020) and the number of units increased 11.9 % (from 15,167,025 in 2015 to 16,978,192 in 2020) (Figure 1A). This result represents an increase from 44 prescriptions in 2015 to 56 prescriptions in 2020 for every 1,000 inhabitants (or 5.6 prescriptions per 100,000 persons). The number of units increased from 74 units in 2015 to 80 in 2020 for every 1,000 inhabitants (or 8 units per 100,000 persons). The state of São Paulo had the highest number of prescriptions while the state of Amapá had the lowest. Figure 1B illustrates the opioids with the highest sales volume from 2015 to 2020, while Figure 1C shows the sales of strong opioids during the same period. Doctors registered with the Regional Council of Medicine (CRM) are most responsible for prescriptions, followed by dentists registered with the Regional Council of Dentistry (CRO) and veterinarians registered with the Regional Council of Veterinary Medicine (CRMV). In Brazil, only doctors, dentists, and veterinarians have the legal authorization to prescribe opioids.

Figure 1:

(A) The total opioid sales and units from 2015 to 2020. (B) The most common sold opioids in Brazil from 2015 to 2020. (C) The most common sold strong opioids in Brazil from 2015 to 2020.

Discussion

The data presented here suggest that opioid sales in Brazil continued to advance from 2015 to 2020. Our results contribute to update the data previously published by Krawczyk et al. [10]. The authors reported a higher opioid consumption rate in six years (2009–2015) representing an increase from 8.3 to 44 sales per 1,000 persons [10]. In the current study, we found an increase of 34.8 % on opioid sales representing an increase from 44 to 56 sales per 1,000 persons. Similarly, codeine products presented the largest absolute increase. The small increase observed in our study could be attributed to the broader accessibility of opioids for outpatients. However, it could also be a result of heightened awareness regarding the risks of opioid use disorders, leading to a preference for prescribing alternative treatments such as non-opioid pain medications. Although there was a drop in sales in 2020, it is possible that the decrease occurred due to the suspension of outpatient care during the COVID-19 pandemic.

The opioid epidemic has been recognized as one of the most challenging public health crisis in United States and Canada [11]. This phenomenon increased the attention for over prescribing in other countries. In the Netherlands, between 2008 and 2017, there was an increase in oxycodone users from 574 to approximately 2,500 per 100,000 inhabitants. The authors reported that the increase of opioid prescriptions was followed by increases in the number of hospital admissions related to prescription opioid intoxication, in the proportion of patients receiving addiction care for prescription opioid use disorder, and in prescription opioid-related mortality over the study period [12]. In the current study, it was not possible to investigate if the increase of opioid prescription was followed by proxies for opioid use disorders or the increase access to opioid analgesics.

LMICs face several obstacles in accessing and utilizing opioids for pain management [13]. Recently, opioid consumption was estimated for 76 countries between 2009 and 2019. Lower opioid consumption rates were observed in LMICs and upper-middle income countries from 2009 to 2019. The median opioid consumption rate in high-income countries was 345.1 morphine milligram equivalents per 1,000 inhabitants per day compared with 23.6 for upper-middle countries and 8.3 for LMICs. The highest consumption rates in 2009 were observed in South Africa, Romania, Lebanon and Ukraine. While oxycodone was the most consumed opioid in high-income countries, tramadol, codeine, tapentadol were the most consumed in LMICs and upper-middle income countries in 2019 [11]. Results from Malaysia, Singapore, Indonesia, Thailand, and Vietnam over a 10 years period, showed that the total strong opioid consumption increased in all five countries [9]. Malaysia presented the largest increase in consumption over time. Singapore presented the highest total consumption of opioids used for pain management (fentanyl, morphine, oxycodone, and pethidine), but the largest increase was noted for Indonesia [9]. Yucumá et al. [14], showed that 660,203,089 opioid units were sold in Colombia between 2012 and 2018. Tramadol was the most frequently sold opioid, followed by codeine, dihydrocodeine, and methadone.

Although the results of the current study can turn on an alarm, it may also reflect an increase in the accessibility of this treatment in Brazil. However, safe and appropriate use of opioids is crucial. The responsibility for preventing and controlling an opioid crisis relies on governments, health authorities, pharmaceutical companies, pharmacies, doctors, healthcare providers and patients. It is critical for Brazil to establish adequate national public policies and campaigns mediated by medical societies. It is important to invest in the development of adequate training for doctors, support for patients who develop opioid use disorders, and educational campaigns for the general population to prevent addiction and overdoses [15]. Empowering patients about the risks of opioid consumption and alternative options to their problems should be a priority.

The current study presents some limitations. First, it was not possible to investigate the duration of opioid use and the amount of pills dispensed. Second, there are no data about opioid use disorders or opioid-related overdoses in the database. Third, the ANVISA database has not been updated since 2020, and therefore it was not possible to have recent data. Fourth, the database did not provide information on patient profiles and risk factors for opioid use disorders, including variables such as sex, age, indications for opioid use, and mental health status. Lastly, our results should be interpreted with caution. Discrepancies may exist between the opioids sold for outpatient use and those administered within the public healthcare system and hospitals, potentially leading to an underestimation of our reported results. Unfortunately, access to this information was not attainable.

Conclusions

The results suggest that opioids sales continue to rise in Brazil in a 5 years period. Brazil may have a unique opportunity to learn from other countries and develop consistent policies through evidence-based guidelines to better educate individuals and communities and to prevent the negative consequences of opioids.

Corresponding author: Felipe J. J. Reis, Physical Therapy Department of Instituto Federal do Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil; Postgraduation Progam in Clinical Medicine – Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil; and Pain in Motion Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium, E-mail: felipe.reis@ifrj.edu.br

Research ethics: Not applicable (data are publicy available).
Author contributions: Igor Correia (data collection, data analysis and text); Ney Meziat-Filho (supervisor and final text review); Andrea D. Furlan (final text review); Bruno Saragiotto (text review); Felipe J J Reis (project, supervisor, data analysis and final text review).
Competing interests: Andrea D. Furlan - Unrestricted Educational Grant from Canadian Generic Products Association (CGPA). - Research grants: Canadian Institutes for Health Research, Health Canada, Ontario Ministry of Health, Workplace Safety and Insurance Board (WSIB of Ontario, and Certas Insurance. - Honoraria: member of the WSIB Drug Advisory Committee - Personal Royalties: Google Inc (YouTube Channel) and Book Author (Robert Rose Inc).
Research funding: There is no funding to declare.
Data availability: Data are publicy available.

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Received: 2023-06-28

Accepted: 2023-10-26

Published Online: 2023-11-13

This work is licensed under the Creative Commons Attribution 4.0 International License.

Articles in the same Issue

https://doi.org/10.1515/sjpain-2023-0086

Keywords for this article

opioids; opioid consumption; opioid crisis; pain

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