CDP Summer-Fall issue 2008 article by: Fischer, et al.
06-12-09 Rev
Characterizing the
“awakening elephant” of
prescription opioid misuse in
North America: Epidemiology,
harms, interventions
BY BENEDIKT FISCHER, JUDE GITTINS
AND JÜRGEN REHM
Recent North American data suggest that the misuse of prescription
opioids (POs) has substantially increased in segments of the
general population (e.g., adults, youth, students), as well as in
specific high-risk groups (e.g. street drug users), in many instances
surpassing prevalence rates for traditional illicit drugs. Some 11
million U.S. citizens are estimated to have misused POs in 2002
alone. These misuse trends have corresponded with increases in
PO-related harms, i.e. morbidity (e.g., emergency room mentions)
and mortality (e.g., poisoning deaths). Existing data suggest that
POs for misuse are obtained from a diverse variety of sourcing
routes, many of which involve direct or indirect diversion from the
medical system, yet also include personal contacts, thefts or street
markets. The above is occurring in a recent context of massively
increased medical availability and use of POs, mainly due to
changes in pain treatment practice, with North America being the
world’s top PO consumer region. The intersecting of legitimate and
Contemporary Drug Problems 35/Summer-Fall 2008 397
AUTHORS’ NOTE: The principal author acknowledges funding support from
the Canadian Institutes of Health Research and the Michael Smith Founda-
tion for Health Research.
© 2009 by Federal Legal Publications, Inc.

illegitimate PO use poses enormous challenges for devising control
interventions that effectively address the problem of PO misuse
while not compromising adequate pain care. Current interventions
include intensified PO availability regulation by prescription
monitoring programs (PMPs). This article reviews available
(mainly North American) data describing the phenomenon of PO
misuse, while considering policy implications.
“Abuse of prescription drugs to surpass illicit drug abuse, says INCB”
—INCB PRESS RELEASE, 2007
The above headline topped a recent International Narcotics
Control Board (INCB) Press Release (2007) that went on to
say that the “abuse of prescription drugs has already sur-
passed abuse of traditional illicit drugs such as heroin and
cocaine in some parts of the world”, referring to the United
States (U.S.) as the outstanding example. Recent commen-
taries in key scientific journals have suggested a paradigm
shift (Fischer & Rehm, 2007), with prescription opioid (PO)
misuse1 increasingly outpacing or replacing misuse of heroin,
considered one of the dominant illicit drugs for many decades
(Courtwright, 1982; Musto, 1987). Even though the social
history of several illicit drugs (e.g., heroin, cocaine) began
with the non-medical uses of what originally existed as a
pharmaceutical drug (ibid.), prescription drug misuse in
many—science and policy—contexts has long lived a rather
neglected existence in the shadows of the licit and illicit
drugs. For example, the most recent Canadian Addiction Sur-
vey (CAS) did not include any question item on prescription
drug misuse (Adlaf, Begin, & Sawka, 2005), and the Cana-
dian Social Costs of Substance Abuse study also did not
include PO misuse as an explicit part of its estimations
(Rehm, Baliunas, Brochu, Fischer, Gnam, Patra, et al., 2006).
This article will examine available data on the epidemiology;
morbidity, mortality and other harm; sourcing routes; and the
398 OPOID MISUSE IN NORTH AMERICA
CDP Summer-Fall issue 2008 article by: Fischer, et al.
06-12-09 Rev