problem Abuse Treatment, Prevention, and Policy volume 16, Article number: 12 (2021) cite this post


Background

Global opioid consumption increased multifold post-2000, disproportionately in high-income countries, com severe mortality/morbidity consequences. Latin estados unidos da america features comparatively low opioid availability; Brazil, the region’s many populous country, provides an amazing case pesquisar concerning opioid use/harms. In this an extensive overview, we aimed to identify e summarize medical and non-medical data and indicators the opioid availability and use, regulation/control, and harm outcomes in Brazil because 2000.

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Methods

We searched multiple scientific databases to identify relevant publications e conducted additional ‘grey’ literature searches to determine other pertinent information.

Results

Despite some important indicators, opioid-related data ~ ~ limited para Brazil. Encontro indicate that population-level availability of prescription opioids represents only a small fraction of use in comparison to high-income countries. However, within latin America, Brazil ranks mid-level ao opioid consumption, indicating reasonably moderate consumption compared to bordering jurisdictions. Brazil has imposed restrictive regulation to opioid prescribing e is taken into consideration ‘highly restricted’ for opioid access. Codeine remains a major opioid analgesic utilized, but stronger opioids such as oxycodone ser estar becoming an ext common. Expert knowledge about medical opioid use e effects shows up limited. Nacional surveys indicate increases in non-medical use of prescription opioids, albeit lower than it was observed in north America, while illicit opioids (e.g., heroin) ~ ~ highly uncommon.

Conclusions

Overall population-level opioid availability and corresponding levels of opioid-related harms in Brazil stay substantially reduced than prices reported for North America. However, ns available surveillance and analytical encontro on opioid use, policy/practice, e harms in Brazil ~ ~ limited and insufficient. Because existing e acute (e.g., pain-related) needs para improved opioid utilization and practice show up to it is in substantiated, boosted indicators for e understanding of opioid use, practice, e harms in Brazil are required.


The worldwide use of opioids has actually substantially enhanced post-2000. Based on international Narcotics Control borda (INCB) data, global consumption that opioid analgesics (in characterized daily quantia for statistical functions per million inhabitants per day) has risen by 250 %, from approximately 5 million S-DDD in 2000 to about 13 million S-DDD in 2014, yet has plateaued because <1>. The global prevalence that non-medical opioid use among persons aged 15–64 was estimated to have increased são de 0.7 % (approximately 35 million people) in 2015 come 1.2 % (approximately 58 million) in 2018 <2, 3>. Ns majority (80–90 %) of globais opioid consumption, and recent associated increases, have been focused in high-income areas of north America, Western/Central Europe, e Oceania <1, 4>. Globally, a total of 109,500 opioid-related deaths to be estimated ao 2019 <5>.

The highest intake of opioids wake up in North américa (e.g., a United States and Canada), whereby opioid ease of access exponentially increased, reaching a highest levels globally (~ 31,000 S-DDD) by ns period 2011-13 <4, 5>. More recently – following a implementation of system-level restrictions (e.g., opioid restrictions, prescription monitoring e guidelines, enforcement) – opioid usage levels have actually inverted e decreased by 20–50 % in North america from optimal levels till 2018 <6–8>. Yet, in 2016-18, North estados unidos da america alone tho accounted ao about 60 % of a world’s venenoso opioid usage <1>. Post-2000, and fueled by ns persistently high opioid accessibility described, North estados unidos da america has experienced steep increases in population-level opioid-related harms, consisting of opioid-related morbidity e mortality (e.g., acute poisoning deaths) <9–11>. Ao example, a total of 47,600 opioid-related deaths developed in the United claims in 2018, com proportionally semelhante rates, e a rude of 4,398 opioid-related deaths in Canada <12–14>. However, complying with policy restrictions e availability reductions, mortality resulting são de prescribed opioids has steadily decreased. Additionally, there have been recent boosts (60–80 %) in illicit/synthetic opioid usar (e.g., fentanyl, heroin) end time, considerably driving opioid-related mortality <10, 15, 16>. In phia băc America, high levels of opioid-related deaths negative impact vida expectancy in the visão global population <17–20>.

While comparative data ser estar scarce, the context of opioid use e harms in Latin estados unidos da america differs são de that in North estados unidos da america <21>. In latin America, there are significantly lower amounts of medically prescribed opioids, especially when contrasted to high-income nations <4>. Medical opioid intake in Central/South américa from 2016 to 18 (S-DDD/1,000,000/day) amounted to about 2 % of ns world’s total, or 1>. Some Latin americano countries only agora report the levels that opioid usar (about 20 mg morphine equivalents/capita) uncovered in North américa decades ago <22>. This is despite ns fact the chronic pains – a main indication para opioid medications usar – is very prevalent in latino America, with mean approximates ranging são de 26 come 37 % <23, 24>. However, accessibility to efficient pain treatment including opioid pharmacotherapy is minimal or insufficient in many Latin american countries <23, 25–27>. Similarly, a prevalence of non-medical opioid usar in South américa was estimated to it is in 0.1–0.2 % from 2015 to 2017, in compare to roughly 4 % reported in North estados unidos da america <2, 28>.

In a specific Latin americano context, Brazil features a relatively low pervasiveness of opioid use and harms, especially when contrasted to high-prevalence settings like north America. However, this instance does no compromise ns need e utility of comprehensively analyzing related indicators, especially in a spirit of to compare study. Rather, and given that opioids offer both medical (e.g., pharmacotherapeutic) value, para example porque o pain treatment, too as ~ ~ the reasons of substantial (e.g., mortality/morbidity) harm, e no generally embraced ‘optimum’ use levels exist, the is same worthwhile to estude ‘low-use/harm’ jurisdictions as it is to study others, including a possibility to ascertain system or prática barriers to use, components of reduced harms, e so forth. In this privado context, Brazil represents a most populous country while still gift representative of the opioid context in latin America, e so all at once offers naquela unique case study in regard come opioid use, harms, and regulations <4, 23>. Furthermore, Brazil functions distinctly alto levels of other psychoactive substance usar (e.g., problem drinking, psychostimulant, or benzodiazepines use) <29, 30>. ~ above this basis, us aimed come identify e summarize available indicators e data top top (medical and non-medical) opioid availability e use, control/regulations, hurts (e.g., morbidity or mortality outcomes), e associated determinants in Brazil because 2000.


In the context of limited availability of (especially peer-reviewed journal based) dia but with ns aim to comprehensively consider e present information on opioid use, availability, harms, and regulations/policy in Brazil, we relied on der combination of find strategies and approaches to recognize relevant indicator data e information. First, we developed an easy search state (e.g., “opioid(s) or opiate(s) or morphine or heroin” and “Brazil or latino America,” combined com subtopic-specific added terms, e.g., use, mortality, morbidity, pain, policy, control) e electronically searched key scientific databases, including MEDLINE (PubMed), web of Science, Scopus, Embase, CINAHL (EBSCO), LILACS, e SciELO porque o relevant publications. The focus foi ~ on originais studies or other publications, in English or Portuguese, originating são de Brazil that consisted of relevant encontro towards the scope of the present outline as defined, for the equipe period em ~ 2000 to 2020. Possibly relevant publications figured out were title- and abstract-screened and selected porque o inclusion/exclusion principally through the primeiro author (LOM), com consultation with ns co-authors in instance of ambiguity. Second, we manually scanned related bibliographies e conducted Internet-based searches (e.g., by google Scholar, Google) porque o additional studies and indicator data, consisting of ‘grey literature’ (e.g., surveys, databases, organizational or technical or mass médio reports) in connection with to ns topic the interest. Tudo de data and indicator products of relevance were extracted, thematically e topically structured and organized, e subsequently narratively summarized e presented. Given ns specific e combined dia search e identification approach, a present summary is non-systematic while comprehensive e narrative in nature; hence, also enquanto formal análise reporting sistema (e.g., PRISMA) or related data is presented.


Medical opioid usar in Brazil

Data são de national/international databases

The INCB encontro indicate that the nacional level that opioid intake (moving averages ao three-year periods) in Brazil increased from 172 S-DDD/1,000,000/day (2000-02) to 384 S-DDD/1,000,000/day (2009-11) e to 512 S-DDD/1,000,000/day (2016-18) <1, 31, 32>. While these indicator dia represent considerable proportional increases, opioid usage remains substantially smaller (1>. These intraregional indications ao population-level opioid usar in Latin américa are reflect by various other data. Porque o instance, a highest opioid ease of access (in log-distributed opioid morphine equivalents) in 2014 was reported in argentina (34 mg/capita), followed by chile (14 mg/capita), Panama e Brazil (about 10 mg/capita each), while beach Rica, Peru, Mexico, and Bolivia report levels ≤ 5 mg/capita in the same year <22>.

Longitudinal dia from insurance cases showed that 2.2 % that Brazilian patient of any type of condition (n = 1,057,033) e 24.4 % that cancer patient (n = 9,873) covered by exclusive health treatment plans obtained opioid therapy in between 2004 and 2007 <33>. Naquela study using the nacional System para the monitoring of regulated Substances discovered that ns largest portion of opioid prescriptions by Brazilian dentists dispensed in 2012 (n = 141,161 prescriptions) was para codeine combination (i.e., together com paracetamol or various other non-opioid analgesics) and singular formulations (86.7 %), followed by tramadol only/combined (12.6 %), oxycodone (0.3 %), morphine, fentanyl, and hydromorphone (34>. Another study using ns same database showed naquela 465 % boost in ns number that codeine, fentanyl, e oxycodone prescriptions dispensed through Brazilian dentists from 2009 (1.6 million) to 2015 (9 million), with codeine representing > 98 % that the total prescriptions and representing a largest rate rise (8.2 come 43.4 prescriptions/1,000 people); oxycodone had ns largest relative increase, rising more than ten-fold (0.07 to 0.8 prescriptions/1,000 people), when fentanyl had ns smallest absolute e relative increase (from 0.02 come 0.05 prescriptions/1,000 people) <35>.

Cross‐sectional pesquisa de opinião data

Opioid analgesics usar was report by 2.2 % and 2.6 % of chronic pains participants from two population-based family surveys performed in a Brazilian municipalities of eles são Luís/MA (2009-10; n = 1,597) and Botucatu/SP (2016; n = 416), dong <36, 37>. Studies surveying specific disease-related populaces reported comparatively higher prevalence that opioid use. Naquela study com 280 outpatient cancer treatment patients of an oncology hospital in Curitiba/PR uncovered that 30 % and 16 % that patients got weak or solid opioids porque o pain relief in 2015, dong <38>.

Among 307 neuropathic ache patients treated in three visão global hospitals/pain clinics based in a Brazilian municipalities of saint André/SP or Salvador/BA, a prevalence that opioid-therapy within a last seis months era 39 % (median: 32.8 %, range: 0.0 %-39.3 %), post-surgical neuropathic ache (39 %) e chronic lower earlier pain with naquela neuropathic component (34 %) as the most regular conditions ao which opioid prescriptions were issued <39>.

In naquela nationally representative household inspeção (n = 41,433) performed in 2013-14, 0.5 % the respondents report opioid analgesics use to treat ache associated with chronic diseases (current constant use: 29 % of those who had reported use) or acute diseases/events (occasionally within a last 15 days: 71 %). Among respondents indicating any medical analgesic use (n = 13,054), 1.7 % used opioids, of whom 39 % provided codeine, 31 % papaverine, and 26 % tramadol. Opioids were predominantly provided in combination formulations (e.g., codeine-paracetamol), consisting of non-opioid analgesics (e.g., paracetamol, metamizole) (1.7 %), non-steroidal anti-inflammatory drugs (NSAIDs 0.4 %), or both (0.4 %). The prevalence of medical opioid usar in the general population era significantly higher among human being aged 60 years or larger (0.8 %) compared to the 20–59 years-of-age group (0.5 %) <40>.

Contextual e regulatory determinants related to medical opioid usar in Brazil

Regulation of prescription opioids

The Brazilian national Health Surveillance company (ANVISA) is component of a Brazilian national Health System, in fee of protection e regulation (e.g., approvals) of health and wellness products e services, including prescription medications/opioids. Opioid analgesics estão scheduled as “narcotic substances” (List “A1”, including morphine, buprenorphine, pethidine, methadone, hydrocodone, oxycodone, fentanyl, and others) or “narcotics that which use is permitted só in unique concentrations” (List “A2”, consisting of codeine, tramadol, dextropropoxyphene, nalbuphine, e others), adhering to the normal division right into ‘strong opioids’ e ‘weak opioids’ from the who ‘pain ladder’ <41>. Only medical physicians and dental surgeons ~ ~ permitted to prescribe reserved opioids, based on naquela special registration são de the local health monitoring service. Further, pharmacists ser estar not allowed to accept emergency call prescriptions ao opioids or to correct technical errors (e.g., misspelling, lacking values) on naquela prescription in order to dispense the medication <25, 42>. In enhancement to der duplicated one-of-a-kind prescription form, prescribers have to provide der document termed “Prescription Notification” containing a prescriber, patient, and provider identifications; each type covers increase to naquela maximum of 30 dia of prescription supply for treatment. Der prescriber’s created justification is required ao longer periods. Dispensing entities (i.e., pharmacies, drugstores) must é registrado dispensing through the national System ao the administration of regulated Substances operation by ANVISA and forward todos Prescription Notifications monthly to local Health Authorities, i m sorry retains uma copy and returns the other to the dispensing reality after confirmation <42, 43>. Currently, opioids scheduled e available porque o outpatient use in Brazil encompass codeine, morphine, tramadol, methadone, buprenorphine, oxycodone, and fentanyl <44>. Codeine and morphine estão included in the nacional list of vital medicines provided within the público health sistema and, so consequently, do up the majority of opioid prescriptions dispensed <45>.

Medical and patient education

A pesquisa in porto Alegre/RS (2011-12) entailing 122 physicians, pharmacists, physiotherapists, nurses, and nursing technicians/assistants working in oncology e intensive care pediatric units from naquela general hospital reported that fifty percent (51 %) had no decorrer prior pain monitoring training; 82 % were unclear around or perplexed opioid-related withdrawal, tolerance, e dependence symptoms; 20 % thought that patients’ asking porque o higher opioid bondade is indicative the addiction; 42 % thought opioid-related respiratory depression to be common; 47 % assumed that opioids ought not to be supplied upon unknown reasons of pain <46>. Among 126 nurses at one oncology centro in rio de Janeiro/RJ, half (48 %) believed that opioids injury patients, while the belief that opioids dá not cause harm (52 %) was associated com adequate expertise on cancer pain administration <47>. Amongst 257 opioid-prescribing dental surgeons em ~ the state of minas Gerais, nearly two-thirds (62 %) reported absence of understanding of Brazilian opioid-related regulation legislation, e legislation knowledge era associated com higher prescription frequency <48>.

A prospective pesquisar (2005 come 2009) in naquela São Paulo/SP private hospitais evaluated pethidine e morphine prescription quantities after ns implementation of an educação protocol informing prescribing physicians about toxicity the pethidine and suggesting its instead of by morphine. Results found naquela significant decrease (72 %) in pethidine prescriptions (in milligrams/year), also as naquela significant rise (42 %) in morphine prescriptions over the pesquisar period <49>.

A patient-focused study conducted in one oncology hospitais in Curitiba/PR verified that somente 41 that 280 (15 %) cancer patients appropriately classified morphine as an opioid analgesic, while 19 % would refuse acquisition morphine also if prescribed by their doctors as result of fear of seeks (65 %), tolerance (30 %), or adverse reactions (35 %), 68 % thought that opioid use is directly related to worsening disease outcomes and 41 % that opioid use means that death is closer <38>.

Socioeconomic factors

The typical expenditure by patients on naquela single opioid prescription foi ~ calculated to be 5 % (Brazilian realmente 33.27) of a Brazilian minimum wage (R$678.00) in 2013, com codeine being the lowest (R$29.59) and oxycodone the highest (R$300.08 ) mean price per prescription <50>. Accordingly, high-income says showed greater opioid dispensing rates, with 87 % of tudo de prescriptions dispensed in 2012, mostly concentrated in South and Southeast Brazilian states. This variations substantially correlated com socioeconomic estado (e.g., poverty, human advance index, education) e health-related (e.g., prescriber access) signs of ns corresponding jurisdictions <34>.

Non‐medical opioid use

Prescription opioids

Results em ~ national household surveys (2005 and 2015) suggest that amongst Brazilians aged 12–65 years there was an boost in non-medical opioid analgesic use, defined as non-prescribed use. Equivalent rates increased from 1.9–2.9 % para lifetime use, 0.5–1.4 % for past-year use, e 0.3–0.6 % ao use in the past-month, back these distinctions have not been assessed statistically <28, 51, 52>. In 2015, the annual pervasiveness of non-medical opioid usar (1.4 %) era substantially reduced than the corresponding use rates ao alcohol (43 %) or tobacco (17 %), but semelhante to a use pervasiveness of three (2.5 %), benzodiazepine (1.4 %), or cocaine (0.9 %) e amphetamine (0.3 %) <51>. The majority the individuals quem have offered opioids in the past-month reported restricted use; for instance, persons would usar infrequently – 1–2 days per month (35 %) or 3–5 days per month (27 %) <28>. Women’s non-medical opioid usar was greater than the of men both in 2005 (1.6 % vs. 0.9 %) e 2015 (1.8 % vs. 1.0 %) <28>. In addition, a 2015 nacional survey discovered that male sex (prevalence ratio: 0.53 <0.36–0.78>), younger lei (10–24 years contrasted to 45–65) (PR: 0.56 <0.34–0.92>), monthly família income that R$1,501-3,000 (PR: 0.59 <0.38–0.92>) or higher than R$3,000 (PR: 0.64<0.42–0.98>) contrasted to the lowest income grupo (up to R$750), and being unemployed (PR: 0.65 <0.46–0.92>) were tudo significantly associated (p p > 0.05) <28>.

A national survey among college students from Brazilian state capitalistas cities (2009) reported ubiquity of non-medical (non-prescribed) opioid use, with findings as follows: 5.5 % (lifetime use), 3.8 % (use in a past-year), e 2 % (use in a past-month). As soon as comparing outcomes by sex, women showed significantly higher prevalence that lifetime use (6.3 % vs. 4.4 %), past-year usar (4.8 % vs. 2.2 %), and past-month use (2.7 % vs. 1.0 %) of opioids non-medically, and higher ubiquity (1.3 % vs. 0.4 %) the hazardous opioid use (i.e., “moderate risk”) together assessed by a World health and wellness Organization Alcohol, Smoking, and Substance joining Screening check (ASSIST-WHO) <53>. In addition, a separate nacional survey conducted among high-school student in Brazilian state capitalista cities estimated a prevalence of lifetime non-medical (non-prescribed) opioid usar at 0.3 % in 2004 e 0.6 % in 2010, without statistics difference in between men and women <54, 55>.

When considering opioid dependence (DSM-IV criteria), ns 2015 nacional household inspeção reported der 0.1 % (or about 208,000 people) prevalence among people age 12–65 years. These approximates were higher (not statistically tested) among respondents aged 25–34 years (0.3 %) and 35–44 (0.2 %), e among ladies (0.2 %), as compared to males (51>. Alto levels of opioid involvement to be reported by a survey of medical professionals (n = 198) receiving outpatient service treatment for substance dependence across Brazil (2000 come 2005). Prescription opioids were ns second-most typical substance abused (23 %), following alcohol (49 %) but comparable to cocaine (21 %) <56>. Among der sample that anesthesiologists (n = 57) who sought outpatient treatment ao substance use disorders in São paul between 2002 and 2009, opioid abuse era most typically reported by 34 (60 %) respondents, and almost all of i beg your pardon (88 %) showed consumption patterns consistent com dependence symptom <57>. It foi ~ estimated that around 30,000 Brazilians age 12–65 years to be receiving therapy (mainly psychosocial or psychiatric) porque o opioid-related usar problems in 2015 <51>.

Heroin

Other than in north or Central american regions, the use of heroin or various other illicit opioids is uncommon in Brazil, e data ser estar correspondingly scarce. National household surveys have estimated ns prevalence of lifetime heroin usar of 0.1 % in both 2001 e 2005 <52, 58>, 0.2 % in 2012 <59>, and 0.3 % in 2015 <28, 51>. Ns prevalence the past-year use was estimated at 28, 52>. In der national pesquisa conducted across Brazilian state capitalista cities (2003) assessing street-involved/homeless youth (9–18 years), 122 of 2,807 (4.3 %) respondent reported life time injecting drug use; however, ns type of drugs used foi ~ not specified. The study highlighted ns use that psychostimulants without clearly noting heroin <60>. Similarly, ns use the non-specified injecting drug use was reported by 10 the 330 (61>.

Despite ns scarcity of scientific data, select média reports have defined sporadic occurrences of heroin distribution e usage in local areas of são Paulo, Brazil’s largest urban centro characterized by illegal drug usar (‘cracolandias’) in i m sorry psychostimulants (e.g., crack-cocaine), alcohol, and cannabis ser estar the primary drugs of consumption <62>. Heroin usar in this sub-locales occurs greatly by inhalation e smoking (similar to a use that crack-cocaine) rather of injecting. However, com the high cost and limited accessibility of heroin, this practice is unusual <63, 64>. Media reports and police investigations show sporadic heroin use in settings like eles são Paulo. These occurrences ser estar irregular e are thought to be mostly a partir de West african importation e then spread to end-users by african migrants and asylum seekers <64>. Other choose heroin seizures have been reported in ns media: in 2003, 15 kg that heroin a partir de Colombia foi ~ seized through the comunidade Police in the north region (Amapá State), adding up to almost 100 kg seized between 2001 e 2003 <63>. Further, in 2018, Brazilian customizeds seized 100 kg that heroin at fluviais de Janeiro/RJ airport, imported a partir de Hong kong concealed as der licit chemistry (fluticasone) ao medication manufacturing by a Brazilian certain <65>. Otherwise, there estão virtually durante indications of recurring opioid use in Brazilian drug use scenes.

Opioid‐related morbidity/mortality

In 2007, there were 138,585 hospitalizations tape-recorded by the Brazilian público health system (through the hospitais Information sistema SIH-SUS) together ‘mental and behavioral disorders because of psychoactive substance use.’ of these, 2,232 (1.6 %) were associated with opioid-related disorders, although a reason for hospitalization (e.g., acute intoxication, physics or mental complications from harmful use, dependence/craving symptoms) foi ~ not reported. This price is substantially lower than para alcohol (69 %), multiple medicine (23 %), or cocaine (5 %) but higher than for cannabinoids (0.8 %) or sedatives/hypnotics (0.5 %) <66>.

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Similarly, mortality data are scarce e limited in specificity. Data from ns Mortality Information sistema (SIM), run by a Health security Secretariat of to adjust of Health, exposição 44,326 deaths associated com psychoactive substance-related obstacle (reason unspecified) são de 2001 to 2007, com 24 (0.1 %) regarded opioids; a substantially reduced proportion 보다 alcohol (86.6 %), tobacco (6.3 %), multiple drugs (0.7 %), or cocaine (0.4 %), but similar to cannabinoids (0.1 %), sedatives/hypnotics (0.1 %), or inhalants (i.e., solvents) (0.1 %) <66>. Para the duration 1998 come 2018, 111 deaths (0.08 %) lado de fora of tudo psychoactive substance-related deaths (n = 141,218) were reported together associated com opioids, of i m sorry 72 (65 %) e 39 (35 %) involved male e female decedents, respectively <67>. São de 2010 to 2015, 2642 (67 %) poisoning deaths (i.e., accidental, intended (suicide), or undetermined intent) were associated with ‘narcotics and psychodysleptics ’, and 1060 (27 %) were associated with acute alcohol intoxication (n = 3,927) <68>. However, these general e unspecific substance-categorizations wailer it difficult to ascertain a actual number of opioid-related poisoning deaths in Brazil.