Article written by UNITE member Hon. Adrian Belîi, Member of the Parliament of the Republic of Moldova and professor of anesthesiology and intensive care.
I only found out about International Overdose Awareness Day recently, purely by chance, when I was asked to write an article on the subject for the UNITE Parliamentarians Network for Global Health), which I recently joined. The proposal caught me on a short holiday in the Carpathian Mountains in Ukraine. Usually, everything that happens is rarely purely by chance. I just finished watching a short series on Netflix called “Pain Killer” (producer – Chris Hatker, premiere – August 10, 2023). Based on true events, the movie explores the origins and consequences of the opioid crisis in the United States, highlighting the stories of perpetrators, victims and truth seekers whose lives were forever altered by the invention of OxyContin.
Memories take me back to my residency in anesthesiology and intensive care at the Chisinau Emergency Hospital, over 20 years ago. “… Adult man, poor family, drug addict, brought unconscious, with hypotension and respiratory failure….“; “…young man, golden youth profile, brought by friends from night club with hallucinations, inappropriate behavior, disoriented...”. Similar cases can be recounted by the dozens, with natural reactions of outrage, disapproval and condemnation from those who hear them. But it is also fortunate that these people arrived alive at the hospital and were subsequently discharged, if they had not managed to escape from the ward on their own by then.
Also at that time, I was looking for ways to relieve the unbearable pain of a family member caused by the advanced stages of oncology. I had seen similar torment in people close to me in my high school years. The word “morphine” induced horror among both family doctors and patients and their loved ones – “it is the last cure before death”.
The specialty of anaesthesia and intensive care has given me the skills to understand and apply in daily practice the pharmacological effects of opioid analgesics, inhalatory anaesthetics, ketamine, benzodiazepines and many other interesting molecules. Likewise – about their side effects and methods of pharmacological antagonization or life support, if necessary. Pain therapy has gradually become my clinical, academic and scientific “super-specialization”.
Working a while with the Pain & Policy Studies Group[1] from the US has reinforced my belief in the indispensability of respecting the “balance principle” between the availability and accessibility of opioid analgesics, their use in medical indications frame (mainly – for anaesthesia and relief of acute and cancer pain), and the restrictions imposed on the effective control of the illicit drug circuit. I have so far remained a supporter and promoter of the Fundamental Human Right to pain relief, of simplifying the prescription of opioid analgesics in the necessary dosage, as long as the situation requires it.
The “Opioid Crisis” or “Opioid Epidemic” (which started in 1997 and was already devastating communities in 2001) was unheard of in Moldova at the time: patients were still desperately looking for pain relief drugs. Drug users were using substances other than opioid painkillers, heroin or cocaine, because of the precarious economic situation. In fact, information about the Opioid crisis still comes “from overseas”, occasionally slipping into press articles or scientific communications at conferences. Moldovan realities are still far from ensuring an adequate level of pain control (acute, chronic, oncological) or access to opioid analgesics in oncology, especially in palliative care. It is worth mentioning, however, that the consumption of morphine (in morphine equivalent of opioid analgesics, excluding methadone) for medical indications has increased from about 0.9 mg per capita in 1992 to about 3.0 mg per capita in 2020. Today, doctors in Moldova are more readily prescribing tramadol for pain relief and are no longer frightened when they hear the word “morphine”. Compared to the overall average consumption in the health system – 12 mg of morphine equivalent per capita (year 2020), it is clear that in the Republic of Moldova we must continue to encourage doctors to fight pain, including with the help of opioid analgesics, and patients to demand respect for their fundamental rights.
Certain lessons, however, need to be learned, and not necessarily at first hand. It’s about anticipating (avoiding) an opioid epidemic of the kind that has happened in the US. For readers who are not yet up to speed, here, very succinctly, is a relevant case study. In the early 1990s, Purdue Pharma developed a new pharmaceutical preparation, called OxyContin (oxycodone extended-release capsule). Noble intention, by the way, intended to relieve intense pain in various indications. What followed, in fact, surpasses all imagination. OxyContin has been the cause of death of over 450,000 people in 20 years, 50% of whom suffer from addiction as a result of legal (!) prescription and use of the drug (Gale A., 2022). Prescriptions of the drug jumped from 670,000 to 6.2 million between 1997 and 2002. Paradoxically, 86% of prescriptions were for chronic non-cancer pain – actually, a dubious indication where the benefit of any opioid analgesic could not be demonstrated, instead the incidence of deviant behaviour and iatrogenic addiction reaches alarming heights.
It has come to the point that the share of iatrogenic addictions reached 50% of all other addictions. Although the company reports near-zero incidences of addiction risk, independent studies show that these can be as high as 50% (depending on the diagnostic criteria applied). By 2001, about 75% of methadone substitution program recipients were receiving OxyContin. Diversion, abuse and overdose increased by 830% between 1997 and 2003. The liberalization of opioids for chronic non-cancer pain has led to increases in abuse and overdose of +641% for fentanyl, +113% – for morphine, 346% – for oxycodone: increases well above those caused by heroin and cocaine combined. The year 2001 was an incendiary one in the US, with 107,000 overdose-related deaths, of which 70,000 – from opioids, up +15% from 2000.
So what runs like a “red thread” through all the exposure – are the overdose deaths from narcotic and psychotropic substances, but also from opioid painkillers, prescribed “according to law”. The number of people dying every day from opioid overdoses dwarfs the fatal overdoses of all other substances combined. See Purdue Pharma’s marketing strategy for OxyContin and it will all become clear to you.
What remains to be done? It remains to actively, openly talk about overdose deaths to find support for change. Young people in Australia began in 2001 by raising awareness among the public and officials about overdoses, overdose deaths, stigmatization of people in need and acknowledging the grieve felt by the families and friends of those left unseen. Since then, 31 August has been marked internationally as International Awareness Overdose Day and is symbolized by the silver ribbon. In the Republic of Moldova, Overdose Day was marked for the first time on September 4, 2013, at 11:00 am by some Nongovernmental Associations. It is estimated that there are about 30,000 drug users in the Republic of Moldova. Deaths related to overdose,without specifying the substance, amount to 30 per month – according to the Association for the Prevention of HIV/AIDS, as officials do not register them.
The measures taken would be to introduce appropriate health and social policies, increase the availability and accessibility of naloxone, decriminalize personal drug use, de-stigmatize sufferers and support them and their families to recover and reintegrate into society.
– Hon. Adrian Belii, Republic of Moldova
A comprehensive list of measures that can be taken is provided by a number of online platforms (e.g. https://www.overdoseday.com/campaign-resources; https://www.camh.ca).
On August 31, 2023, International Overdose Awareness Day, we commemorate those who leave unseen, in front of blind seers, with profits that trump ethics.
[1] Pain & Policy Studies Group (PPSG) refers to a World Health Organization Collaborating Center at the University of Wisconsin Paul P. Carbone Cancer Center in Madison, Wisconsin, USA. This group coordinates a program of international policy studies to identify and address barriers to opioid availability in national policy and national health care systems. PPSG provides technical assistance and monitors progress to improve the availability of opioid analgesics for pain management and palliative care.
