Is Brazil brewing an opioid crisis of its own?

. Jun 26, 2018
oxycodone opioid crisis brazil Opioid consumption has sharply risen in Brazil. Photo: Cindy Shebley

Back in October 2017, The New Yorker published an article about how one family—the Sackler dynasty—planted the seeds of what became, years later, the worst addiction epidemic in American history. The Sacklers are the people behind Purdue Pharma, known for its prescription painkiller OxyContin—a drug that uses “a chemical cousin of heroin which is up to twice as powerful as morphine,” as the magazine describes it.

With aggressive marketing strategies that changed the prescribing habits of American doctors, Purdue built a multi-billion dollar empire—all the while creating a legion of addicts. Since 1999, opioid overdoses killed roughly 200,000 Americans – 64,000 in 2016 alone. U.S. President Donald Trump even declared it a public health emergency. Now, as the U.S. tries to slash the consumption of opioids, Purdue Pharma sets its eyes on several other markets—notably Brazil.

A big emerging market for opioids

In Brazil, the Sackler family operates through Mundipharma, a company that has tried hard to help doctors overcome “opiophobia.” For Dr. Tim Ives, a pharmacy professor at the University of North Carolina, however, “[the pharmaceutical industry] is pulling in Brazil the same tricks and lies as they used in the U.S. years ago.” He says that even the term “opiophobia” was coined by drug producers. “Before handing off opioids,” he continues, “doctors must review the literature and make proper physical examinations of patients.”

</span></p> <p><span style="font-weight: 400;">While &#8220;few drugs are as dangerous as the opioids,&#8221; according to what a former Food and Drug Administration agent told </span><i><span style="font-weight: 400;">The New Yorker</span></i><span style="font-weight: 400;">, Mundipharma Brazil is, unsurprisingly, trying to convince doctors of the perks of their drugs. Campaigns urge doctors to &#8220;bring more to life&#8221; and help manage pain. They are also holding various seminars, in which painkillers are portrayed as a modern approach endorsed by leading experts in the U.S.</span></p> <p><span style="font-weight: 400;">In 2016, the company sent out a </span><a href=""><span style="font-weight: 400;">press release</span></a><span style="font-weight: 400;"> baiting journalists with the title &#8220;One in three Brazilians suffer from chronic pain,&#8221; in which the company defines as &#8216;chronic&#8217; any pain which persists for at least three months. The document also says that opioid analgesics are one of the solutions for &#8220;moderate and intense pain,&#8221; while stating that Brazil figures among the ten countries with the lowest opioid prescription rates in the world, partially due to &#8220;prejudice&#8221; from many doctors.</span></p> <p><span style="font-weight: 400;">Dr. Ives, however, points out that &#8220;chronic pain&#8221; is too vague of a term, and that Mundipharma downplays the addictive potential of opioids &#8211; similarly to what Purdue Pharma did back in the U.S. Patients can develop tolerance to the drugs in a matter of five days. According to American authorities, 115 people </span><a href=""><span style="font-weight: 400;">die</span></a><span style="font-weight: 400;"> in the U.S. every day from abusing these substances.</span></p> <p><span style="font-weight: 400;">(Mundipharma was contacted for this story, but hasn&#8217;t responded.)</span></p> <h3>The rise of opioid use in Brazil</h3> <p><span style="font-weight: 400;">There are no studies measuring opioid </span><a href=""><span style="font-weight: 400;">use</span></a><span style="font-weight: 400;"> in Brazil. However, a group of researchers has analyzed sales of these drugs in the country, according to Brazil&#8217;s National System for the Management of Controlled Substances. </span></p> <p><span style="font-weight: 400;">Between 2009 and 2015, opioid consumption in Brazil has jumped by 465 percent, according to a study recently </span><a href=""><span style="font-weight: 400;">published</span></a><span style="font-weight: 400;"> by the </span><i><span style="font-weight: 400;">American Journal of Public Health</span></i><span style="font-weight: 400;">. The study monitored products based on three active ingredients: codeine, fentanyl, and oxycodone (which is used in OxyContin). </span><i><span style="font-weight: 400;">&#8220;Data were limited to records from officially registered pharmacies and did not account for other opioids (e.g., tramadol) or opioids obtained through other sources (e.g., Internet, black market).&#8221;</span></i></p> <p><span style="font-weight: 400;">Sales from prescribed opioids jumped from 1.6 million in 2009 to over 9 million six years later. And while codeine remains by far the most consumed of the three, oxycodone (which is more heavily regulated) increased its &#8216;market share&#8217; from 0.8 to 1.8 percent.</span></p> <p><span style="font-weight: 400;">“Our research shows that we need to be cautious in Brazil and other places that are seeking increased opioid sales,” said Noa Krawczyk, one of the authors of the study. She adds: &#8220;Brazil needs to make sure they’re monitoring the use of opioids and regulating how they’re being used to avoid a situation where more people are getting addicted.&#8221;</span></p> <div id="attachment_5345" style="width: 1034px" class="wp-caption alignnone"><img aria-describedby="caption-attachment-5345" class="size-large wp-image-5345" src="" alt="oxycodone opioid crisis brazil" width="1024" height="683" srcset=" 1024w, 300w, 768w, 610w, 2048w" sizes="(max-width: 1024px) 100vw, 1024px" /><p id="caption-attachment-5345" class="wp-caption-text">&#8220;They’re over-prescribing,&#8221; says Dr. Tim Ives</p></div> <h3>A difficult balance</h3> <p><span style="font-weight: 400;">Despite their hike in recent years, opioid prescriptions in Brazil remain at a lower rate when compared to North America and Europe &#8211; 4.43 prescriptions for every 100 Brazilians in 2015. We cannot say that Brazil is experiencing an opioid crisis &#8211; especially when compared to the U.S., where 20 percent of people had access to these drugs in 2015 -, but the numbers show a cause for concern.</span></p> <p><span style="font-weight: 400;">Francisco Inacio Bastos, a researcher at the State University of Rio de Janeiro and a co-author of the study on opioid sales, points out that historically, the country has had limited access to opioids. While that lowers risks of dependence, it can also be detrimental to patients who actually endure colossal levels of pain. </span></p> <p><span style="font-weight: 400;">“Prescribe too much, you create lots of addicts,” Bastos says. But go to the other extreme, and “people will suffer.”</span></p> <p><span style="font-weight: 400;">Opening the floodgates to heavier </span><a href=""><span style="font-weight: 400;">drugs</span></a><span style="font-weight: 400;"> often leads to abuse, as the U.S. case shows. Dr. Tim Ives comments that many patients will cite arthritis for chronic pain, in which opioid analgesics could be prescribed. However, “oftentimes over-the-counter drugs such as acetaminophen or ibuprofen will do the trick,” he said. “Sometimes even cancer patients don’t fit the standards for getting opioids.”</span></p> <p><span style="font-weight: 400;">&#8220;In the U.S.,&#8221; Dr. Ives says, &#8220;doctors don’t know when to say no. Once they have already given the patient opioids, they are compelled to give them more. They’re over-prescribing.&#8221;</span></p> <p><span style="font-weight: 400;">Brazil has an additional problem: there is no such thing as a prescription drug monitoring program in the country. &#8220;That&#8217;s risky,&#8221; says Dr. Krawczyk. &#8220;Electronic health records aren’t necessarily implanted into the whole healthcare system. A patient that receives a prescription in one facility may not show up in [the records of] another facility.&#8221; The lack of specialists also makes it easier for physicians to work without much oversight.</span></p> <p><span style="font-weight: 400;">The experts heard for this story say that it is still hard to predict the long-term implications of the rise in opioid usage in Brazil. One thing is certain, though: there isn&#8217;t enough information on what the opioids are being used for. Brazil must pay attention to the silent growth of these drugs &#8211; before we have a crisis of our own.

Austin Andru

Austin works as an intern, under the supervision of Gustavo Ribeiro.

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