Epidemiology

Opioid use disorder is a significant public health concern worldwide. The global prevalence of people aged 15 to 64 years using opioids has almost doubled since 2010, rising from approximately 0.6% to 1.2% in 2019.[4] This equates to an estimated 62 million users as of 2019.[4]

The number of opioid prescriptions began to expand significantly in the US in the 1990s, driven by aggressive marketing, increased clinical focus on pain management, and the launch of a sustained-release formulation of oxycodone.[5] Prescription of opioids for acute and chronic pain, and subsequent opioid use disorders, quickly became widespread, establishing an opioid crisis.[5] This was followed by a resurgence in the heroin market in around 2010, driven by an increase in demand from people addicted to prescription opioids.[6] The third wave of the crisis began in 2014, characterised by further increases in addiction and fatal drug overdoses linked to synthetic opioids like fentanyl.[6]

Over the past decade, opioid use has somewhat stabilised in the US, with prevalence decreasing from around 2.3% in 2010 to approximately 1.7% in 2019.[4] This is possibly attributable to the implementation of stricter prescribing regulations. However, despite the slight decrease in users, overdose deaths attributable to fentanyl and its analogues (e.g., carfentanil) continue to escalate.[4] Alarmingly, the rate of overdose deaths in the US involving synthetic opioids (excluding methadone) increased by 56% between 2019 and 2020.[7] Opioid overdose deaths in the US and Canada affect mostly men and young- to middle-aged people.[6] Studies prior to 2016 estimated that over 25% of opioid-related deaths in the US also involved benzodiazepines.[8][9][10] Updated US Centers for Disease Control and Prevention guidelines advising against concurrent opioids and benzodiazepines led to a decrease in co-prescription; however, whether this translates to a decrease in mortality is not yet clear.[10]

In Europe, opioid usage has remained fairly stable since 2016, with a prevalence of 0.7% reported in 2019.[4] Countries in Europe with the greatest levels of high-risk opioid use include Italy and Austria, whereas overdose deaths are highest in Germany and the UK.[4] Fentanyl and its analogues are less established in Europe than in the US, with heroin remaining the most commonly used opioid.[4] Heroin is also responsible for the vast majority of drug overdose deaths in the region.[4][11]

Regarding other world regions, non-medical use of tramadol, a synthetic opioid, has partly driven a three-fold increase in prevalence of opioid use in parts of Africa from 2010 to 2019.[4] Tramadol misuse is particularly high in Egypt, where it was reported among approximately 3% of the adult population in 2016.[4] Opioid use has been steadily declining in Australia, in part due to stronger regulation of codeine-containing medications coming into effect in 2018.[4] Use of heroin remains highly prevalent in India and Pakistan, whereas opium is the most commonly used opioid in Afghanistan and Iran.[4]

In parallel with increasing worldwide prevalence among the general population, an increase in opioid use has been observed in pregnancy.[12] According to 2019 US data, approximately 7% of women reported use of prescription opioid analgesics during pregnancy, with 1 in 5 of these reporting misuse.[13] Frequency of opioid use during pregnancy in Europe, Canada, and Australia is around 5%.[14]

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