Responding to the opioid crisis in North America and beyond: Recommendations of the Stanford–Lancet Commission

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Responding to the opioid crisis in North America and beyond: Recommendations of the Stanford–Lancet Commission

Keith Humphreys, Chelsea L. Shover, Christina M. Andrews, Amy S. B. Bohnert, Margaret L. Brandeau, Jonathan P. Caulkins, Jonathan H. Chen, Mariano-Florentino Cuéllar, Yasmin L. Hurd, David N. Juurlink, Howard K. Koh, Erin E. Krebs, Anna Lembke, Sean C. Mackey, Lisa Larrimore Ouellette, Brian Suffoletto, Christine Timko

Executive Summary

The Stanford–Lancet Commission on the North American opioid crisis was formed in response to soaring opioid-related morbidity and mortality in the USA and Canada over the past 25 years. The commission is supported by Stanford University and brings together diverse Stanford scholars and other leading experts across the USA and Canada, with the goals of understanding the opioid crisis, proposing solutions to the crisis domestically, and attempting to stop its spread internationally. Unlike some other Lancet commissions, this one focuses on a long-entrenched problem that has already been well characterized, including in several reviews by the National Academies of Sciences, Engineering, and Medicine. This commission therefore focused on developing a coherent, empirically grounded analysis of the causes of, and solutions to, the opioid crisis.

The North American crisis emerged when insufficient regulation of the pharmaceutical and healthcare industries enabled a profit-driven quadrupling of opioid prescribing. This prescribing involved a departure from long-established practice norms that prevailed before the mid-1990s—particularly in the expanded prescribing of extremely potent opioids for a broad range of chronic, non-cancer pain conditions. Hundreds of thousands of individuals have fatally overdosed on prescription opioids, and millions more have become addicted to opioids or have been harmed in other ways, either as a result of their own opioid use or someone else’s (e.g., disability, family breakdown, crime, unemployment, bereavement). In response to the large pool of people who became addicted to prescription opioids, heroin markets expanded, which further increased morbidity and mortality. As heroin markets became saturated with illicit synthetic opioids, such as fentanyl, an already dire situation became a public health catastrophe, which has only worsened since the onset of the COVID-19 pandemic. Since 1999, more than 600,000 people have died from opioid overdoses in the USA and Canada, and the current rate of mortality in each country exceeds even that of the worst year of the HIV/AIDS epidemic.

The first wave of the opioid crisis began in the 1990s, when the long-acting opioid OxyContin and other high-potency opioids were prescribed to an extremely wide array of patients. The first wave inflicted the most harm on white and Indigenous people in both the USA and Canada. An unusually high number of middle-class people and people living in selected rural areas (e.g., Appalachia in the USA, the Yukon in Canada) were affected in this wave of the crisis compared with previous epidemics of opioid addiction and overdose. The second wave, as heroin markets became resurgent in response to demand from people addicted to prescription opioids, began around 2010 and led to rapidly rising mortality among African Americans in the USA, and more generally in urban areas in the USA and Canada. These demographic shifts persisted into the third wave of the crisis, which began around 2014 and was characterized by rising addiction and fatal overdoses linked with synthetic opioids such as fentanyl. In 2020, fatal opioid overdoses continued to rise dramatically, exacerbated by the COVID-19 pandemic.

Published Online February 2, 2022

Department of Psychiatry and Behavioral Sciences

(Prof K. Humphreys PhD, Prof A. Lembke MD, Prof C. Timko PhD), Stanford Center for Biomedical Informatics Research

(J. H. Chen MD), Division of Hospital Medicine (J. H. Chen), and Department of Emergency Medicine (B. Suffoletto MD), Stanford University School of Medicine, Stanford, CA, USA;

Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA (Prof K. Humphreys, Prof C. Timko); Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA (C. L. Shover PhD); Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA (C. M. Andrews PhD); Department of Psychiatry and Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA (A. S. B. Bohnert PhD); Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA (A. S. B. Bohnert); Department of Management Science and Engineering, Huang Engineering Center, Stanford University, Stanford, CA USA (Prof M. L. Brandeau PhD); Heinz College, Carnegie Mellon University, Pittsburgh, PA, USA (Prof J. P. Caulkins PhD); Stanford Law School, Stanford, CA, USA (M.-F. Cuéllar JD, Prof L. Larrimore Ouellette PhD); Addiction Institute, Icahn School of Medicine, New York, NY, USA (Prof Y. L. Hurd PhD)