Department of Psychiatry, University of São Paulo, São Paulo, Brazil; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Department of Medical Psychology, School of Medical Sciences, National University of Asuncion, San Lorenzo, Paraguay; Department of Neuroscience, Medical School, FMABC University Centre, Santo André, Brazil.
Department of Psychiatry, University of São Paulo, São Paulo, Brazil.
Lancet Psychiatry. 2023 Feb;10(2):85-97. doi: 10.1016/S2215-0366(22)00339-X.
South America's substance use profile, poverty, income inequality, and cocaine-supplier role make it a unique place for substance use research. This study investigated the burden of disease attributable to amphetamine use disorder, cannabis use disorder (CAD), cocaine use disorder, and opioid use disorder (OUD) in South America from 1990 to 2019, on the basis of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.
GBD 2019 estimated the incidence, prevalence, mortality, years of life lost (YLL), years of life lived with disability (YLD), and disability-adjusted life-years (DALYs) due to substance use disorders in each of the 12 South American countries (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, and Venezuela). Data were modelled using standardised tools (ie, the Cause of Death Ensemble model, spatio-temporal Gaussian process regression, and disease modelling meta-regression) to generate estimates of each quantity of interest by sex, location, and year. The analysis included comparisons by sex and country, and against regional and global estimates.
In 2019, the highest amphetamine use disorder burden per 100 000 population in South America was in Peru (66 DALYs). CAD DALY rates per 100 000 in South America were stable between 1990 and 2019, except in Chile and Colombia, which had the highest rates in 2019 (19 DALYs for Chile and 18 DALYs for Colombia). OUD DALYs per 100 000 increased during the period in Brazil and Peru, which in 2019 had the highest rates in South America (82 DALYs for Brazil and 70 DALYs for Peru). In 2019, Brazil had the highest cocaine use disorder DALYs per 100 000 (45 DALYs), nearly double its rate in 1990. DALY rates were higher in males than females for each substance use disorder, except in Paraguay. The overall burden of substance use disorders was higher in males than in females, mainly because of cocaine use disorder and CAD, whereas for amphetamine use disorder, the difference between sexes was minimal, and for OUD there was no difference. For males and females, the highest rate of substance use disorders DALYs per 100 000 was for OUD except in Argentina (in males, 58 DALYs for cocaine use disorder vs 52 DALYs for OUD) and in Paraguay (in females, 77 for amphetamine use disorder vs 50 for OUD). CAD DALY rates were generally the lowest among the substance use disorders for males and females. Amphetamine use disorder YLD rates were reasonably stable throughout the period and were highest in Peru, Paraguay, and Uruguay (>40 YLD per 100 000). For CAD, YLD rates were stable in all countries except Chile and Colombia. Cocaine use disorder YLD rates per 100 000 for the top four countries (Argentina, Uruguay, Chile, and Brazil) increased from 1990 to 2010 (eg, from 19 to 33 in Brazil), but decreased between 2010 and 2019 (eg, from 36 to 31 in Chile). For OUD, YLD rates showed a slight increase in most countries apart from Brazil, which increased from 52 in 1990 to 80 in 2019 and was top among the countries. Amphetamine use disorder YLL rates per 100 000 were highest in Suriname and Peru during the period, although in Suriname it increased from 2·7 in 2010 to 3·2 in 2019, whereas in Peru it decreased from 2·1 to 1·7. The highest YLL rate for cocaine use disorder was in Brazil, which increased from 3·7 in 1990 to 18·1 in 2019. Between 2000 and 2019, Chile and Uruguay showed the highest OUD YLL rates (11·6 for Chile and 10·9 for Uruguay). A high incidence of CAD was found in Chile, Colombia, Guyana, and Suriname. There were high incidences of amphetamine use disorder in Paraguay, cocaine use disorder in Argentina, and OUD in Ecuador. A decrease in annual prevalence for substance use disorders during the period was observed in Venezuela (amphetamine use disorder, CAD, and OUD), Brazil (CAD and amphetamine use disorder), Colombia (amphetamine use disorder and cocaine use disorder), Peru (amphetamine use disorder and cocaine use disorder), Chile and Suriname (amphetamine use disorder), Uruguay (CAD), and Bolivia (OUD). Overall, the cocaine use disorder burden stabilised then decreased. OUD was less prevalent than other substance use disorders but its burden was the highest.
The decrease in the burden of cocaine use disorder probably reflects the success of national standardised treatment programmes. Programmes for amphetamine use disorder, CAD, and OUD management should be improved. We did not find an increase in CAD burden in Uruguay, the country with the highest degree of cannabis decriminalisation in the region. Countries in South America should improve monitoring of substance use disorders, including regular surveys to provide more accurate data on which to base policy decisions.
The Bill & Melinda Gates Foundation.
南美洲的物质使用状况、贫困、收入不平等以及作为可卡因供应方的角色，使其成为物质使用研究的独特之地。本研究根据 2019 年全球疾病、伤害和危险因素研究（GBD）调查了 1990 年至 2019 年期间，南美洲与苯丙胺使用障碍、大麻使用障碍（CAD）、可卡因使用障碍和阿片类物质使用障碍（OUD）相关的疾病负担，包括 12 个南美国家（阿根廷、玻利维亚、巴西、智利、哥伦比亚、厄瓜多尔、圭亚那、巴拉圭、秘鲁、苏里南、乌拉圭和委内瑞拉）。使用标准化工具（即死因综合模型、时空高斯过程回归和疾病建模荟萃回归）对 GBD 2019 进行建模，以生成每个国家/地区每年、每个性别和地点的物质使用障碍发病率、患病率、死亡率、寿命损失年（YLL）、失能生命年（YLD）和伤残调整生命年（DALY）的估计值。该分析包括按性别和国家进行比较，并与区域和全球估计值进行比较。
2019 年，南美洲每 10 万人中苯丙胺使用障碍负担最高的国家是秘鲁（66 DALY）。1990 年至 2019 年期间，除智利和哥伦比亚外，CAD 的 DALY 率保持稳定，这两个国家的 DALY 率在 2019 年最高（智利为 19 DALY，哥伦比亚为 18 DALY）。2019 年，巴西和秘鲁的 OUD DALY 率有所上升，这两个国家的 OUD 负担在 2019 年是南美洲最高的（巴西为 82 DALY，秘鲁为 70 DALY）。2019 年，巴西的可卡因使用障碍 DALY 率最高（45 DALY），几乎是 1990 年的两倍。除了巴拉圭，每个物质使用障碍的男性 DALY 率都高于女性。总体而言，男性的物质使用障碍负担高于女性，主要是因为可卡因使用障碍和 CAD，而苯丙胺使用障碍则相反，男性和女性的差异最小，阿片类物质使用障碍则没有差异。在男性和女性中，除了阿根廷（男性可卡因使用障碍的 DALY 率为 58，阿片类物质使用障碍为 52）和巴拉圭（女性阿片类物质使用障碍的 DALY 率为 77，可卡因使用障碍为 50）外，OUD 的 DALY 率最高。在男性和女性中，CAD 的 DALY 率通常是物质使用障碍中最低的。苯丙胺使用障碍的 YLD 率在整个期间相当稳定，在秘鲁、巴拉圭和乌拉圭最高（超过 40 个 YLD/10 万）。除智利和哥伦比亚外，所有国家的 CAD 的 YLD 率都保持稳定。2010 年至 2019 年期间，前四个国家（阿根廷、乌拉圭、智利和巴西）的可卡因使用障碍的 YLD 率（如巴西从 19 增加到 33）有所上升，但随后在 2019 年下降（如智利从 36 下降到 31）。2019 年，除巴西外，大多数国家的 OUD 的 YLD 率略有上升，巴西从 1990 年的 52 增加到 2019 年的 80，居各国之首。1990 年至 2019 年期间，在苏里南和秘鲁，苯丙胺使用障碍的 YLL 率最高，尽管在苏里南，这一比率从 2010 年的 2.7 增加到 2019 年的 3.2，而在秘鲁则从 2.1 减少到 1.7。可卡因使用障碍的 YLL 率最高的国家是巴西，从 1990 年的 3.7 增加到 2019 年的 18.1。2000 年至 2019 年期间，智利和乌拉圭的 OUD YLL 率最高（智利为 11.6，乌拉圭为 10.9）。智利、哥伦比亚、圭亚那和苏里南的 CAD 发病率较高，巴拉圭的苯丙胺使用障碍发病率较高，阿根廷的可卡因使用障碍发病率较高，厄瓜多尔的阿片类物质使用障碍发病率较高。委内瑞拉（苯丙胺使用障碍、CAD 和 OUD）、巴西（CAD 和苯丙胺使用障碍）、哥伦比亚（苯丙胺使用障碍和可卡因使用障碍）、秘鲁（苯丙胺使用障碍和可卡因使用障碍）、智利和苏里南（苯丙胺使用障碍）、乌拉圭（CAD）以及玻利维亚（OUD）的物质使用障碍的年度患病率在此期间有所下降。总体而言，可卡因使用障碍的负担稳定后有所下降。阿片类物质使用障碍的流行率低于其他物质使用障碍，但负担最重。
可卡因使用障碍负担的下降可能反映了国家标准化治疗方案的成功。应加强苯丙胺使用障碍、CAD 和 OUD 管理方案。我们没有发现乌拉圭（该地区大麻合法化程度最高的国家）的 CAD 负担增加。南美洲各国应加强物质使用障碍的监测，包括定期进行调查，以提供更准确的数据来支持决策。
比尔及梅琳达·盖茨基金会。
