Relevance to Developing Countries
Much of the epidemiological research on illicit opioid dependence, its disease burden, and its societal harm comes from Australasia, Europe, and the United States. The major exception is research on the role of injecting drug use in HIV transmission in developing countries (see, for example, Beyrer and others 2000; Yu and others 1998). In addition, research on the effectiveness and cost-effectiveness of interventions for illicit opioid dependence has been conducted primarily in developed countries (Ward, Hall, and Mattick 1998), with the exception of studies of the effectiveness of methadone treatment in Hong Kong, China (see, for instance, Newman and Whitehill 1979), and in Thailand (Vanichseni and others 1991), both of which showed comparable effectiveness to that found in developed countries (W. Hall, Ward, and Mattick 1998).
Translating findings on interventions for opioid dependence in developed countries into disease control priorities for opioid dependence in developing countries presents three major challenges. First, countries differ in the scale of illicit opioid use and in the resulting disease burden. This variation reflects the effects of differences in the prevalence of injecting and noninjecting opioid users; the dependent opioid users' access to treatment and health services for overdoses, blood-borne viruses, and other complications of drug use; the access to needle and syringe programs; the extent to which illicit opioid use is concentrated in socially disadvantaged minority groups; and the capacity of public health services to monitor and respond to emerging infectious disease and drug-use epidemics. The burden is likely to be greatest in settings where the primary route of administration is injecting and where public and personal health services are poorly developed, as appears to be the case in Asia and in Eastern Europe.
Second, societal wealth and health care infrastructure affect the capacity of developing societies to treat illicit opioid dependence. A country's capacity to provide opioid substitution treatment will be affected by the cost of oral opioid drugs, such as methadone, LAAM, and buprenorphine, and the existence of specialist drug treatment centers; trained medical, nursing, and pharmacy staff; and a drug regulatory system, which are required so as to deliver opioid substitution treatment safely and effectively. Few developing countries possess this infrastructure. However, examples exist of apparently successful drug substitution programs, using such tools as sublingual buprenor-phine, that have been conducted with minimal resources in extremely poor settings (Crofts and others 1998).
Third, in societies with a sizable illicit opioid dependence problem, cultural attitudes and beliefs will affect societal responses, especially attitudes toward illicit opioid use and dependence (Gerstein and Harwood 1990). A critical determinant of the social response will be the relative dominance of moral and medical understandings of drug dependence in general and opioid dependence in particular. A moral model of addiction sees addiction as largely a voluntary behavior, in which case it is seen as an excuse for bad behavior that allows drug users to continue to take drugs without assuming responsibility for their conduct (Szasz 1985). In this view, drug users who offend against the criminal code should be imprisoned (Szasz 1985). This model is the dominant one in many developed societies, which imprison drug users at high rates without any effect on the prevalence of drug abuse. Countries that adopt punitive policies toward drug users are reluctant to embrace harm reduction measures, such as needle and syringe programs and opioid maintenance treatment (Ainsworth, Beyrer, and Soucat 2003). A medical model of addiction, by contrast, recognizes that dependent opioid users require specific treatment if the sufferer is to become and remain abstinent (see, for example, Leshner 1997).
These competing views will affect the societal acceptability of opioid maintenance and abstinence-oriented approaches to the treatment of opioid dependence (Cohen 2003). Those who have a moral view of addiction will tend to prefer drug-free and self-help approaches toward treatment. Supporters of medical models of addiction will favor some form of opioid substitution treatment and the provision of clean needles and syringes to reduce the transmission of bloodborne viruses by injecting opioid and other drug users. Stronger advocacy by international organizations and agencies is needed for the adoption of such harm reduction measures as needle and syringe programs and agonist substitution programs.
