The opioid-driven public health crisis in North America has reached alarming proportions, contributing in 2016 to an estimated 64,000 deaths from drug overdoses in the US (more American deaths than lost in entire Vietnam War), and some 2,500 in Canada. The members of the Global Commission on Drug Policy, several of whom faced similar crises while occupying the highest levels of government in their own countries, have shared in a position paper their views and recommendations on how to mitigate this epidemic.

Since 1999, more than half a million Americans have died of drug overdoses. Recent data shows the trend accelerated in 2016, when 63,600 people were killed by overdoses and the rate of Americans dying increased by 21%.

America’s opioid epidemic began more than a century ago – with the Civil War. An estimated two million people abused opiates during the war, after using drugs disseminated by healthcare providers, doctors and nurses to stem pain. “I freely admit that I did not expect another wave of medical opiate addiction in my lifetime,” said David Courtwright, a professor of history at the University of North Florida, and an expert on the history of drug use in the US.

History, Courtwright said, offers some “grounds for optimism”. Beginning in the 1890s, physicians began to criticize colleagues who reached for the prescription pad when patients had aches and pains; pharmacists refused to sell heroin or cocaine (then both legal); and in 1906 muckraking journalists and campaigners successfully argued for reforms to end the sale of patent medicines.

By 1915, Courtwright argues in the New England Journal of Medicine, “the Harrison Act closed the barn door after the horse was back in”. Problematically, the Harrison Act also became the first law to criminalize drug use and opiate maintenance therapies, such as methadone and buprenorphine.

That stigma stuck. Despite double blind clinical trials showing the efficacy of methadone, abstinence-based 12-step programs are still much more common in the US, and politicians have so far failed to find the courage to fund such evidence-based treatments. 

Media and government attention has primarily focused on the supply through doctors. The fact that most addictions start with diverted supplies rather than among pain patients has been largely ignored. Policymakers have also failed to address the role of economic upheaval, unemployment, inequality, and other systemic sources of despair in increasing the risk for addiction and decreasing the odds of recovery. Health systems were completely unprepared and treatment is still dominated by abstinence-focused programs, where no regulatory standards have to be met. Furthermore, among other factors, prejudice against the most effective treatments for opioid addiction—opioid substitution therapy (OST)—has translated into lack of treatment for those in need. Opioid substitution therapy has proven effective in treating addictions to heroin and should be offered to those dependent on or addicted to prescription opioids.