Problem drug use – conceptual and methodical considerations Rehm, J.1,2,3,4 1Technische Universität Dresden 2 Centre for Addiction and Mental Health, Toronto, Canada 3 WHO Collaboration Centre at the Research Centre for Public Health and Addiction, Zurich, Switzerland 4Dala Lana School of Public Health, University of Toronto

A birds eye view General observation on global monitoring of alcohol and global monitoring of drugs Worlds apart! Different concepts Different agencies Different indicators

Monitoring of illicit drugs In 1998, the General Assembly gave the United Nations Office on Drugs and Crime (UNODC) a monitoring mandate: to assembly and to publish "comprehensive and balanced information about the world drug problem in recognition of the importance of factual and objective information in international drug control as a basis for policy and other interventions

What is monitored and what not? Production (opioids, coca/crack/cocaine, cannabis, amphetamines and stimulants, other drugs) Seizures (in the same categories) Prices (again for the same categories, wholesale and street-level prices as well as purity levels) Consumption (estimated annual prevalence and treatment demand) Drug attributable harm is NOT monitored.

Global monitoring of alcohol Global Information System on Alcohol and Health (GISAH) as first step But not as clearly defined and developed as illicit drug monitoring But: Word Health Assembly has called for a strengthening of the Secretariats capacity to provide support to Member States in monitoring alcohol- related harm and to reinforce the scientific and empirical evidence of effectiveness of policies. (WHA, 2005). [1] (contrast to monitoring of illicit drugs, where only supply and use are to be monitored) [1] 2008 WHA part of global strategy

Main differences Monitoring of use indicators vs. monitoring of consequences indicators Global monitoring of alcohol with a clear mandate to have one summary indicator per country to judge: increase, decrease, stable trend of alcohol related harm. The country indicators are not necessarily the same

EMCDDA concept of PDU Problem opioid users Problem cocaine users Problem amphetamine users Injecting drug users

EMCDDA: Methods and definitions: problematic drug use population Problem drug use is defined by the EMCDDA as injecting drug use or long duration/regular use of opioids, cocaine and/or amphetamines. This definition specifically includes regular or long-term use of prescribed opioids such as methadone, but does not include their rare or irregular use, nor the use of ecstasy or cannabis. Existing estimates of problem drug use are often limited to opioid and polydrug use. As a reaction to a growing stimulants problem, as well as a growing number of cannabis-related treatment demands, the EMCDDA is currently examining the possibilities of breakdowns by main drug, as well as the best way of estimating the population of intensive and/or long-term, possibly dependent or problematic, users of cannabis.

Problem, intensive and polydrug use discussed Problem opioid users Problem cocaine users Problem amphetamine users Heavy/long-term cannabis users e.g. Intensive, long-term or otherwise harmful cocaine users (ILH) And, and, and… Injecting drug users

How to measure PDU? a simple multiplier method using police, treatment, mortality or HIV/HCV data; capture–recapture methods; extrapolation via multivariate indicator methods Indirectly, PDU is measured via harm or costs.

Example Cannabis: Mortality attributable to alcohol, illegal drugs and tobacco by age and sex, Canada 2002

Hospitalizations or policy activity as indirect indicator for PDU Different picture with hospitalizations: 16% of all acute care hospitalizations in Canada for illegal drugs are due to cannabis only, 12% of all psychiatric hospitalizations for illegal drugs, and a higher proportion in specialized treatment centres. If we take police activity, the majority of police activity in the area of illegal drugs in Canada 2002 is for cannabis. Different harm as basis, different conclusion!

INCB Report 2007 Abuse of prescription drugs to surpass illicit drug abuse, says INCB [INCB Press Release, 01 March 2007]

14 The rise of prescription opioids in North America In Canadian studies, in most cities prescription opioids have replaced heroin as main opioid (e.g. OPICAN). Canadian coroners autopsies: more than 25% of overdose deaths involve prescription opioids Annual Number of New Abusers of Psychotherapeutics in the US: ; NSDUH, cf. Compton & Volkow, 2006

Increasing deaths from opioid analgesics in the United States Leonard J. Paulozzi MD, MPH 1 *, Daniel S. Budnitz MD, MPH 2 and Yongli Xi MS 3 1 Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA 2 Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA 3 Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA SUMMARY Purpose Since 1990, numerous jurisdictions in the United States (US) have reported increases in drug poisoning mortality. During the same time period, the use of opioid analgesics has increased markedly as part of more aggressive pain management. This study documented a dramatic increase in poisoning mortality rates and compared it to sales of opioid analgesics nationwide. Methods Trend analysis of drug poisoning deaths using underlying cause of death and multiple cause of death mortality data from the Centers for Disease Control and Prevention and opioid analgesic sales data from the US Drug Enforcement Administration. Results Unintentional drug poisoning mortality rates increased on average 5.3% per year from 1979 to 1990 and 18.1% per year from 1990 to The rapid increase during the 1990s reflects the rising number of deaths attributed to narcotics and unspecified drugs. Between 1999 and 2002, the number of opioid analgesic poisonings on death certificates increased 91.2%, while heroin and cocaine poisonings increased 12.4% and 22.8%, respectively. By 2002, opioid analgesic poisoning was listed in 5528 deathsmore than either heroin or cocaine. The increase in deaths generally matched the increase in sales for each type of opioid. The increase in deaths involving methadone tracked the increase in methadone used as an analgesic rather than methadone used in narcotics treatment programs. Conclusions A national epidemic of drug poisoning deaths began in the 1990s. Prescriptions for opioid analgesics also increased in this time frame and may have inadvertently contributed to the increases in drug poisoning deaths. Copyright# 2006 John Wiley & Sons, Ltd. key wordspoisoning; mortality; opioid; analgesic; narcotic; methadone; oxycodone; fentanyl

What does it all mean for PDU? How do other areas handle it? Again, there is a need for one summary indicator which will be become relevant for policy (e.g., DALY for measuring health state of a nation, or life expectancy for measuring mortality of a nation, or GDP for measuring economic output) Even though the illegal drug area is not that important in the overall scheme of things, there is a plethora of indicators, with the consequence of an arbitrariness of judgement about the characterizing trend for a nation

Basic considerations: national summary indicator for alcohol within global monitoring The indicator has two constituents: Levels of alcohol exposure (indirect indicator of alcohol-attributable harm) Alcohol-related health burden Both alcohol consumption and alcohol-related health burden can only be measured with considerable measurement error (Gmel & Rehm, 2004; Lopez et al., 2006). Given this situation, an or operator between the two constituents of the indicator is preferable.

Basic considerations for a summary indicator of PDU Conceptually and methodologically PDU is linked to harm and measured indirectly by harm category There should be a distinction between mortality and morbidity/social harm indicators, which may be later partly combined into DALYs or the like (main decision: and or or link; DALY = YLD + YLL; but harmful use of alcohol = use-derived indicator or health consequences)

Important distinctions Mortality vs. morbidity/social harm based estimates Substance classes including polydrug users Source: prescription opioids vs. illicit opioids (may be related to different harm) Injection vs. non injection

Main challenges How do we bring all together into one comparable indicator? How do we compare backwards with the PDU tradition?

Tentative solution with two indicators combined by or Introduce mortality as one key indicator from the harm side, and differentiate between overlapping substance class where possible Develop PDU further by more systematically including treatment based estimates (i.e., bringing in cannabis, polydrug), and differentiate by overlapping substance class where possible Result: differentiated description (profile), but still one indicator for political discussion and policy (i.e., trend increased/decreased/stable)