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The opioid overdose epidemic in North America remains among the most challenging public health issues of recent times. Sadly, all evidence points to a worsening of the epidemic,1 2 despite growing investment in responses that span policy and legislative changes, scale-up of evidence-based overdose interventions, and the implementation and evaluation of novel interventions. This has prompted concerns about what is and what is not being done to address this epidemic that has resulted in reductions in life expectancy in both the USA and Canada.
Given the well-described problem of the overprescribing of opioids for pain, governments and medical bodies have sought to reduce opioid prescribing through guideline development, physician education and monitoring efforts. While the rate of prescribing in the USA dropped from a high of 81.3 per 100 persons in 2012 to 58.5 per 100 persons in 2017,3 the death rate attributable to opioids continues to rise, and prescription opioid misuse has remained fairly stable since 2010.3 While this result may seem unexpected, it is not entirely surprising given observed transitions from prescription opioid to heroin use in the USA, as well as evidence from Canada indicating that many individuals acquire heroin or diverted opioids from drug markets when denied opioids from physicians.4 These dynamics are consistent with evidence from a range of settings indicating that when access to one substance is restricted, most individuals will transition to using an alternative, which in many cases will be more dangerous than standardised doses of prescription opioids.
While many have attributed the overdose crisis to opioid prescribing, this is an obvious oversimplification of this epidemic. There is now clear evidence of an increasing role of illicitly manufactured opioids, such as fentanyl and related analogues, in the continued rise in overdose deaths. In the USA, overdose deaths attributable to …
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