Fentanyl: what Brazil can learn from US mistakes – 05/22/2023 – Health

There is no time to lose: Brazil needs to act now to avoid an opioid abuse crisis like the one in the United States. This is the main recommendation of an article signed by two researchers in the specialized journal The Lancet Regional Health – Americas.

Opioids are a class of drugs to treat pain that, if used inappropriately, can cause severe dependence.

One of the most worrying drugs in this group, according to experts, is fentanyl, which has become a public health problem in American lands and is 100 times more potent than morphine.

According to the US National Institute on Drug Abuse, overdose deaths related to opioid use jumped from 21,000 in 2010 to 80,400 in 2021 — a fourfold increase in just over a decade.

Although the Brazilian situation is quite different, the authors of the recently published text call attention to two factors that may signal an increase in the use of fentanyl in the country over the next few years: the Covid-19 pandemic and the record of the first apprehensions of the drugs in operations carried out by the police recently.

Experts therefore suggest that Brazil learn from the experience of the United States — and create public policies now, before the problem takes on greater proportions.

TWO DIFFERENT REALITIES

First of all, it is necessary to make it clear that the scenarios in Brazil and the USA are completely different.

In summary, the problem among Americans began with the improper promotion of opioid drugs as a pain treatment about 20 years ago — in the package insert and in advertisements, some companies said that analgesic drugs such as oxycodone were safe and did not cause addiction.

This, in turn, has led to an impressive increase in the number of medical indications for this treatment. According to the CDC (Center for Disease Control and Prevention) in the USA, in 2012 there were 255.2 million opioid prescriptions in the US – a historic record.

In practice, this led to dependence on millions of people — who, with greater control over the legal sale of these pills in pharmacies in recent years, had to resort to the illegal market and more potent options, such as fentanyl created in clandestine laboratories. .

In Brazil, the scenario is different both in profile and size. Psychiatrist and epidemiologist Francisco Inácio Bastos, lead author of the article published in The Lancet, explains that general practitioners in the country still have a “traditionally cautious conduct in the use of the most potent opioids”.

“But there is a second group of specialists, such as anesthesiologists, intensivists, orthopedists and professionals who deal with pain, who tend to prescribe and use more”, he differentiates.

Bastos is also one of the authors of a large survey on drug use in Brazil. The data, collected in 2015, reveal that 2.9% of Brazilians have already used opioids at least once in their lives without medical indication — and 1.4% of them have tried these substances in the last year.

“This index corresponds, more or less, to what was seen in the United States ten or 15 years ago”, estimates the specialist.

Contrary to what is observed among Americans, where men are the majority among users, here the consumption of these drugs is more common among women.

WATER DIVIDERS

Bastos draws attention to two recent factors that may contribute to the greater dissemination of opioids in Brazilian territory.

The first one is covid-19.

“The country’s response was confused and politicized. As a result, we had a very intense pandemic, with numbers of cases, hospitalizations and deaths higher than observed elsewhere”, compares the doctor, who is a researcher at FioCruz (Oswaldo Cruz Foundation). .

In this context, fentanyl has gained relevance, because it is used to intubate and place patients with extremely serious conditions on mechanical ventilation.

Let it be clear: the use of this opioid in the ICU (Intensive Care Units) has nothing wrong with it. It is in fact indicated for individuals in more critical conditions, who need breathing apparatus.

However, in a pandemic that affected millions of people in a short period of time, the demand for this substance probably skyrocketed.

Bastos clarifies that national data on the use of fentanyl during the pandemic are not yet 100% known – and varied considerably between public and private hospitals. But, according to him, it is undeniable that they rose considerably during this period.

Even before that, growth was already underway: Anvisa (National Health Surveillance Agency) recorded a 500% increase in opioid sales in the country between 2009 and 2015 (most recent number available).

The second factor that could trigger such a crisis in Brazil is the illegal market.

The psychiatrist says he received “with surprise” the news of the first seizure of fentanyl in the country — in March, the Civil Police of Espírito Santo intercepted 31 vials of the drug with dealers.

Still in the first months of 2023, the Center for Information and Toxicological Assistance at Unicamp (State University of Campinas) released an alert about cases of fentanyl intoxication identified in the interior of São Paulo.

“I follow the statistics on the hospital dispensation of opioids, so I did not expect these first signs of this substance on the illegal market”, he admits.

“Especially because Brazil does not have a strong heroin trade, as in the US and Europe, which is linked to other opioids”, he adds.

WHAT TO DO?

In the newly published article, the authors consider that the situation of opioid consumption in Brazil is not a reason for panic — but the American experience and recent evidence should be seen as a warning.

One of the specialists’ concerns is the “unpredictability of the illegal market” and “the possibility of sales of products that mix cocaine and fentanyl” in the country.

Still according to them, the good news is that the problem is just beginning, at a stage up to 15 years earlier than that observed in the US. So it’s still possible to stop it before it becomes a public health concern.

For the epidemiologist Noa Krawczyk, the second author of The Lancet text, a fundamental step is “to establish limits on the marketing of the pharmaceutical industry to doctors and patients”.

“It is necessary to create clear guidelines and limit the use of opioid analgesics only to cases in which they are absolutely necessary. When possible, other treatments for pain should be prioritized”, suggests the specialist, who is a professor at the Center for Epidemiology and Policies on University of New York Opioids, USA.

In this sense, Bastos praises a decision by Anvisa, which prohibited the commercialization of chemical products used in the illegal manufacture of fentanyl.

The FioCruz researcher also points to the need to create toxicological surveillance networks capable of detecting the presence of this and other opioids in drugs seized by the police.

CONTROL THE SUPPLY AND EDUCATE THE DEMAND

The psychiatrist argues, however, that it is no use just repressing trafficking without guiding users and addicts.

“Historically, when you squeeze supply and don’t reduce demand, the situation only gets worse,” he warns.

“During Prohibition of the United States [que proibia a venda de bebidas alcoólicas]people stopped consuming fermented products, such as beer, to drink very low-quality distillates”, he exemplifies.

“That is, when there is a very strong repression, the tendency is to look for more concentrated, potent and portable products”, concludes the doctor.

So did opium and heroin, cocaine and crack, marijuana and K-drugs, oxycodone and fentanyl…

“And you only reduce demand with education, counseling and health services”, points out Bastos.

“Brazil can now also establish protocols for the treatment of dependence on opioids, with the use of specific medications”, agrees Krawczyk.

Finally, Bastos believes that it is necessary to train all health professionals in the country so that they are able to detect an opioid overdose — and know what to do to save the lives of victims.

“Brazil is doing very poorly in this regard. I myself did not have a single class on how to deal with illicit drug abuse during my initial training”, he says.

“It is important that doctors and nurses undergo training and know what to do in such a situation”, he argues.

There is, for example, a medicine that is used in cases of overdose and can save that individual’s life.

For the psychiatrist, these actions are necessary even if the opioid crisis does not become something so big in Brazil.

“I hope that dependence related to fentanyl in our country does not gain the same catastrophic dimension as what happened in the United States”, hopes Bastos.

“But it doesn’t matter if we are talking about five or thousands of users. Our function as health professionals is to care for and save lives”, he concludes.

This text was originally published here.