Thoughts from the void: The Opioid Pandemic Behind the Mask of Covid19

Opening Quotes
Fatalities Attributed to Covid 19
The Opioid Class of Pharmaceutical Drugs
Common Uses of Opioids
Side Effects of Commonly Used Opioids
Opioid Fatalities – The Rising Tide of Death
Similarities between Covid 19 and Opioid Fatalities
Global Opioid Demand and Usage
Region-wise Opioid Demand and Usage
Leading Opioid Trading and Consuming Countries
Demand, Supply and Consumption of Selected Opioids
Key Issues
Recommendations
Closing Quotes
Sources

Opening Quotes

'Prohibition [of ganja] might lead to the use of dhatura or other intoxicants worse than ganja [such as alcohol and opium].'
- [Evidence of] (21) Mr. Jenkins, Collector. (46) Ganendra Nath Pal, Deputy Collector. (62) Kanti Bhushan Sen, Deputy Collector of Excise. (161) Maharaja Girijnath, Roy Bahadur. (164) Raja Surja Kanta Acharjya, Bahadur. (167) Radha Balav Chaudhri, Rai Bahadur. (233) Secretary, Rajshahi Association. (217) Biprodas Banarji, Pleader, &c. Assam. (6) Mr. Stoker, Commissioner of Excise, (15) Mr. Ferard, Collector. (28) Mr. Bruce, Assistant Collector. (51) Thakur Tukman Singh, Deputy Collector. (76) Babu P. C. Chatterji, Judge, Chief Court. (10) Mr. A. Anderson, Deputy Commissioner. (18) Rai Bahadur Bhagwan Dass, Extra Assistant Commissioner. (39) Thakur Das, Rai Bahadur, Assistant Surgeon. (27) Muhammad Barkat Ali Khan, Khan Bahadur, retired Extra Assistant Commissioner. (86) Lachman Dass, Merchant. (1) Mr. Neill, Judicial Commissioner. (9) Mr. Drake-Brockman, Officiating Excise Commissioner. (39) Dr. Prentie, Civil Surgeon. (64) Rao Sahib Balwantrao Govindrao Bhuskute, Jagirdar. (23) Mr. Campbell, Sub-Collector.(1) Hon'ble T. D. Mackenzie, Commissioner of Abkari, etc. (6) Mr. Sinclair, Collector. (53) Mr. Vincent, C.I.E., Officiating Commissioner of Police. (49) Yashvantrao Nilkanth, Superintendent, Office of Survey Commissioner. (62) Rao Sahib Pranshankar, Inspector of Police. (102) Ramchandra Krishna Kothavale, Inamdar. (109) Secretary, Arya Samaj, Bombay.

- Report of the Indian Hemp Drugs Commission, 1894-1895, https://digital.nls.uk/74464868

'Total prohibition of the cultivation of the hemp plant for narcotics, and the manufacture, sale or use of the drugs from it is neither necessary nor expedient in consideration of their ascertained effects, of the prevalence of the habit of using them, of the social and religious feeling on the subject, and of the possibility of its driving the consumers to have recourse to other stimulants or narcotics which may be more deleterious [such as opium, dhatura or alcohol] (Chapter XIV, paragraph 553 to 585)'

- Conclusions of the Commission, Report of the Indian Hemp Drugs Commission, 1894-1895, https://digital.nls.uk/74464868

Fatalities Attributed to Covid 19

The Opioid Class of Pharmaceutical Drugs

“Opioids” is a generic term that refers both to opiates and their synthetic analogues
Opiates are naturally occurring alkaloids found in the opium poppy, such as morphine, codeine and thebaine, as well as their semi-synthetic derivatives, such as heroin, hydrocodone, oxycodone and buprenorphine.
The term “opioids” also includes synthetic opioids, which are structurally diverse substances. Some are used in medicine mainly for the management of pain resulting from conditions such as trauma, surgery and cancer, and are thus also referred to as pharmaceutical opioids, indicating their medical use
Most pharmaceutical opioids are controlled under the Single Convention on Narcotic Drugs of 1961 with the exception of some, such as buprenorphine, which are controlled under the Convention on Psychotropic Substances of 1971.
All opiates are controlled under the Single Convention on Narcotic Drugs of 1961, except for buprenorphine, which is controlled under Schedule III of the Convention on Psychotropic Substances of 1971.
Tramadol is an example of a pharmaceutical opioid that is currently not controlled under the drug conventions.

Common Uses of Opioids

Pharmaceutical opioids are used for the management and control of acute and chronic pain that can result from physical trauma and post-surgical care, and for palliative therapy for cancer and other chronic conditions

Side Effects of Commonly Used Opioids

Respiratory depression is the most serious adverse reaction associated with opioid use. Some opioids show toxicity with single use while others display toxicity build up over a period of time with chronic use

Opioid Fatalities – The Rising Tide of Death

In 2017, the use of opioids accounted for 110,000 (66 per cent) of the 167,000 deaths attributed to drug use disorders. The actual extent of global drug abuse and fatalities remain largely unknown

Similarities between Covid 19 and Opioid Fatalities

Covid chain of death - acute respiratory distress/respiratory failure, pneumonia, death – WHO

Underlying cause of all viral fatalities – reduced immunity

Global Opioid Demand and Usage

In 2017, some 53.4 million people worldwide had used opioids in the previous year, 56 per cent higher than the estimate for 2016.
Among those people, 29.2 million had used opiates such as heroin and opium, 50 per cent higher than the 2016 estimate of 19.4 million
Combined, the three subregions (East and South-east Asia, Eastern and south-eastern Europe, North America) account for almost two thirds (60 per cent) of the global number of PWID.

Three countries – China, the Russian Federation and the United States – account for 27 per cent of the global population aged 15–64 but are home to almost one half (43 per cent) of persons who inject drugs (PWID) worldwide.
The strong increases in the amounts available for consumption included oxycodone (tenfold growth), hydromorphone (fivefold growth), hydrocodone (threefold growth), oxy-morphone (46,000-fold growth), methadone (threefold growth), buprenorphine (11-fold growth), fentanyl (ninefold) over the period 1998–2010

Over the period 2013–2017, opioids accounted for the largest increase in the quantities of a drug seized: the quantities doubled over that period, reflecting, among other things, the current opioid crisis in North America.
Accounting for 62 and 36 per cent, respectively, of the total quantity seized, tramadol and codeine dominated global seizures of pharmaceutical opioids over the period 2013–2017.
Expressed in S-DDD, as defined by INCB, 164 seizures of pharmaceutical opioids were, however, dominated by fentanyl and its analogues in both 2016 and 2017 (over 80 per cent in 2017), followed by tramadol (11 per cent).
UNAIDS estimates that injecting drug users are 22 times more likely than the general population to be infected with HIV.
Pharma-cological maintenance therapy, such as methadone and buprenorphine, is recommended by WHO and has become the mainstream treatment for opioid dependence in many countries.

Region-wise Opioid Demand and Usage

Overall

North America

Overall, North America continues to be the subregion with the highest annual prevalence of opioid use, with 4.0 per cent of the population using opioids
Nearly 47,600 opioid overdose deaths in the United States in 2017, an increase of 13 per cent from the previous year. This is nearly 68 per cent (47,600) of all overdose deaths (70,237) corresponding to a rate of 14.6 deaths per 100,000 population

Those deaths were largely attributed to synthetic opioids (fentanyl, its analogues) which were involved in nearly 50 per cent more deaths than in 2016. It increased from over 19,000 overdose deaths in 2016 to over 28,000 in 2017.
In Canada, nearly 4,000 opioid-related deaths were reported in 2017, a 33 per cent increase from the 3,000 overdose.
The illicit market for non-medical use of opioids is dominated by fentanyl in North America

The major opioids of concern in North America remain pharmaceutical opioids, hydrocodone, oxycodone, codeine and tramadol, which are used for non-medical purposes.
A large number of persons who inject drugs (PWID) reside in North America (16 per cent of the global total).

Europe

Estimated prevalence of opioid use in Europe in 2017 was at 3.8 million opioid users. In Western and Central Europe, with an estimated 2 million opioid users, it is dominated by heroin use. However, in recent years methadone, buprenorphine and fentanyl have increased
Men represent the majority of drug-related deaths in Europe (78 %)

In recent years, an ageing cohort of opioid users, who are likely to have contact with treatment services, has been identified.
A large number of persons who inject drugs (PWID) also reside in Eastern and South-Eastern Europe (16 per cent of the global total).

The proportions of the populations aged 15–64 who inject drugs are relatively high in Eastern and South-Eastern-Europe with rates that are almost four times higher (3.6) than the global average
The prevalence of HIV among PWID in Eastern and South-Eastern Europe, with rates at 1.8 times the global average. It also has higher than average proportions of injecting drug users.

France, Germany, Italy, Spain and the United Kingdom, which account for some 60 per cent of the population of the European Union, are estimated to account for three quarters of the estimated high-risk opioid users in the European Union.
It is estimated that at least 8238 overdose deaths occurred in the European Union in 2017. This rises to an estimated 9461 deaths if Norway and Turkey are included.
As in previous years, the United Kingdom (34 %) and Germany (13 %) together account for around half of the EU total number of drug-related deaths in 2017.

Asia

The size of the population of the region means that more than half of global opioid users reside in Asia (29 million past-year opioid users).
35 per cent of the global opioid users and almost half of all opiate users worldwide reside in South Asia.
Within Asia, the Near and Middle East and South-West Asia have a total of almost 8.5 million past-year opioid users in those two subregions combined.

The illicit market for non-medical use of opioids is dominated by codeine in Asia.
In India, a total of 23 million people, are estimated to be past-year opioid users (2018). Among opioids, heroin is the most prevalent substance, the past-year use of opioids is much higher among men in general (4 per cent of the male population) than women (0.2 per cent of the female population).
Of the total 23 million past-year opioid users in India, roughly one third, or 7.7 million people, are considered to be suffering from opioid use disorders in India.
The proportions of the populations aged 15–64 who inject drugs are relatively high in Central Asia and Transcaucasia, with rates that are almost four times higher (3.4) than the global average.
In terms of the actual numbers of PWID, most reside in East and South-East Asia (28 per cent of the global total), even though the prevalence of injecting drug use is relatively low in that subregion.
The prevalence of HIV among persons who inject drugs (PWID) is the highest by far in South-West Asia with rates that are 2.3 a the global average. This subregion also has higher than average proportions of injecting drug users.

In the Islamic Republic of Iran, at the clinic of the Iranian National Centre for Addiction Studies in Tehran, opioids and stimulants are the predominant drugs of concern among new treatment admissions. Opioid use disorders (opium in particular) is the most common type of drug use disorder in the country, estimated at 1.8 per cent among people aged 15–64 in 2011.

India's Tramadol: Running wild in Africa, Middle East and West Asia

Most tramadol seized worldwide over the period 2013–2017 seems to have originated in India. In 2017, only India was reported to have been a country of origin of internationally trafficked tramadol.
Most of the tramadol seizures in India in 2017 and 2018 were reported in the western part of the country, in particular in three locations: the State of Gujarat, India, which accounts for a third of the total turnover of that country’s pharmaceutical sector; in locations near the coast and in the city of Mumbai (suggesting substantial trafficking in tramadol by sea); and in New Delhi, in particular at its airport.
Based on recent seizure data, the main destinations of illegal tramadol shipments are countries in West and Central Africa (including Benin, Cameroon, the Central African Republic, Chad, Côte d’Ivoire, Ghana, Guinea, the Niger, Senegal, Sierra Leone and the Sudan) and Northern Africa (mostly Egypt and, to a lesser extent, Libya), from which some tramadol is further smuggled to countries in the Near and Middle East (including Jordan and Leba-non).(including in parts of Libya, Nigeria and the Syrian Arab Republic, as well as in the Sahel)
In 2017, Nigeria intercepted the largest quantity worldwide (96 tons), followed by Egypt (12 tons in weight equivalents) and the United Arab Emirates (9 tons in weight equivalents).
Malta reported million tramadol tablets seized in three seizure cases in 2016, all originating in India and destined for Libya, as well as a further 117 million tablets seized in four seizure cases in 2017.
Another major seizure of tramadol tablets took place in Genoa, Italy, in May 2017 The seizure consisted of 37 million tablets, which had originated in India and been sold to an importer based in Dubai, United Arab Emirates
A cluster of tramadol seizures occurred in the Middle East in various countries in the Gulf region, from Kuwait to Oman, most notably along the coast of the United Arab Emirates.
Malta reported million tramadol tablets seized in three seizure cases in 2016, all originating in India and destined for Libya, as well as a further 117 million tablets seized in four seizure cases in 2017.

Africa and South America

West and Central Africa is also a subregion with a high prevalence of non-medical use of opioids (1.9 per cent or an estimated 5 million opioid users), which is dominated by the non-medical use of pharmaceutical opioids, in particular of tramadol.
In Nigeria, for example, the prevalence of pharmaceutical opioids in 2017 was estimated at estimated 4.6 million past-year users), most of which can be attributed to the non-medical use of tramadol
The illicit market for non-medical use of opioids is dominated by tramadol in Africa.
Based on recent seizure data, the main destinations of illegal tramadol shipments are countries in West and Central Africa (including Benin, Cameroon, the Central African Republic, Chad, Côte d’Ivoire, Ghana, Guinea, the Niger, Senegal, Sierra Leone and the Sudan) and Northern Africa (mostly Egypt and, to a lesser extent, Libya), from which some tramadol is further smuggled to countries in the Near and Middle East (including Jordan and Leba-non).(including in parts of Libya, Nigeria and the Syrian Arab Republic, as well as in the Sahel)
In 2017, Nigeria intercepted the largest quantity worldwide (96 tons), followed by Egypt (12 tons in weight equivalents) and the United Arab Emirates (9 tons in weight equivalents).
Malta reported million tramadol tablets seized in three seizure cases in 2016, all originating in India and destined for Libya, as well as a further 117 million tablets seized in four seizure cases in 2017.

Leading Opioid Trading and Consuming Countries

Demand, Supply and Consumption of Selected Opioids

Key Issues

Licit market, not illicit market, driving widespread drug proliferation and abuse
Dozens of varieties of opioids, benzodiazepines, amphetamines, NSAIDs, etc constantly emerging from the chemist's lab. Pharmaceutical companies, legal and illegal, churning out vast numbers of chemical drugs for profit
Abuse of licit drugs is underestimated and abuse of illicit drugs is largely unknown. Only in the last two-three years has the extent of prescription and synthetic drug abuse started to emerge. Global estimates are not available in many areas
Main drugs of addiction and abuse appear to be analgesics, anxyliotics, anti-inflammatory drugs and anti-depressants.
Opioids appear to be main culprits, both the ones used for abuse as well as those used in treatment for recovering from abuse

Large amounts of drug enforcement resources directed towards cannabis and other natural drugs while harmful synthetic drugs are rampant
World drug control bodies such as UNODC and INCB appear to be working in silos without a complete view of licit and illicit market for pharmaceutical drugs
WHO's list of Essential Medicine contains highly toxic and addictive chemical drugs
Scheduling and controlling of pharmaceutical drugs is not working as huge numbers of humans are now addicted to freely available prescription drugs. Many dangerous drugs not on list
Doctors, pharmaceutical companies, governments, black markets all working together to fuel the world's drug habit and profit from it
Comorbidity factors such as HIV, multi-organ failure, pneumonia, cardiac arrests, hepatitis C and tuberculosis not taken into consideration when considering damage from drug abuse
Diversion of pharmaceutical drugs from licit to illicit market takes place in various ways: - purchase of pharmaceutical opioids – often in preparations (such as codeine cough syrups) – for non-medical purposes in drug stores/pharmacies, subsequently re-sold on the black market; theft from hospitals or pharmacy stocks; diversion of shipments from licit trade at the wholesale level or at import/export level when crossing borders mainly by false declarations; individuals accessing substances through doctor shopping, that is, obtaining prescriptions from several different doctor

Recommendations

Re-organization of WHO into two bodies - the World Pharmaceutical Drugs Control Board (WPDCB) and the World Diseases Control Organization (WDCO)
Merger of World Pharmaceutical Drugs Control Board (WPDCB) with International Narcotics Control Board (INCB) and United Nations Organization for Drug Control (UNODC)
Focus of WPDCB on synthetic drugs emerging from the chemists lab world wide, both licit and illicit, including global manufacture, imports, exports, consumption and stocks
Inclusion in scope of WPDCB of all pharmaceutical drugs and novel psychoactive substances currently not in the list
Removal of natural medicine such as cannabis, opium, psilocybin, coca from all controlled lists and schedules such as Single Convention on Narcotic Drugs of 1961 and Convention on Psychotropic Substances of 1971.

New Narcotic Drugs Convention to be drafted, if required , that only has chemical and synthetic drugs in scope considering current realities. Removal of all natural plants and medicine from the new convention. Redrawal of all international treaties, international and national laws on the basis of new convention.

Redirection of drug enforcement focus and resources completely from cannabis and other natural drugs towards more harmful and addictive synthetic pharmaceutical drugs
Shift towards long-term goal of replacing all pharmaceutical analgesic, anxyliotic and anti-inflammatory drugs with natural cannabis plant

Removal of all restrictions on the cultivation, distribution and consumption of cannabis, opium, psilocybin, coca in natural form
Shift from pharmaceutical drugs to natural medicine as main focus of global health and drug policy. Medical industry to reduce usage of pharmaceutical medications
Ban on development of any newer synthetic pharmaceutical drugs, legal and illegal.

Closing Quotes

569. Out of the total of 1,193 witnesses, 575 have expressed a decided opinion on the question of prohibition [of cannabis]. Of these only 99 advocate it in their answers. The remainder are against it. Thus, not only is there a very large preponderance of opinion against prohibition, but the preponderance is specially marked among superior Civil officers.

- Report of the Indian Hemp Drugs Commission, 1894-1895, https://digital.nls.uk/74464868

462. In connection with the therapeutics of hemp drugs, one of the commonest uses is for the relief of pain, the drugs being used either as local or general anodynes. Thus bhang poultices are frequently mentioned as soothing local applications to painful parts; and poultices are used for inflamed piles and over the seat of pain in liver and bowel diseases, and to check inflammation and erysipelas. Fumigation with the smoke from burning ganja or bhang is also used as a local sedative in piles. A small fragment of charas is placed in a carious tooth to relieve toothache. And the use of the drugs is also referred to for the relief of protracted labour pains, dysmenorrhœa, pain in the stomach, cramps, and neuralgia. One witness states that hemp drugs are used as a substitute for opium. In cases of circumcision the drugs are used as anæsthetics, and a witness mentions that native doctors on rare occasions substitute ganja for chloroform in operations. The tincture of Cannabis has been used as a local anæsthetic in extracting teeth (British Journal of Dental Science).

- Report of the Indian Hemp Drugs Commission, 1894-1895, https://digital.nls.uk/74464868

'kurigalu sir, kurigalu' – sheep sir, sheep – Nisar K Ahmed

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The Opioid Pandemic Behind the Mask of Covid19

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