Pakistan has remained a major transit country for opioids originating in neighboring Afghanistan
By Nazarul Islam | USA
The opioid crisis has devastated human beings globally. In United States, this has been more than any other country, and the epidemic is getting worse. While opioid prescriptions have decreased by more than 40% from its peak in 2010, unfortunately, opioid-related overdose deaths have not declined but continued to increase.
Historically, one of the key players Pakistan has remained a major transit country for opioids originating in neighboring Afghanistan—which has traditionally been the world’s primary opium producer. However, in late 2024 and 2025, a significant shift has occurred: following the Taliban’s strict ban on opium poppy cultivation in Afghanistan, Pakistan is reportedly emerging as the leading hub for global opium production.
Role in Production
Historical Context: Pakistan successfully reduced its domestic opium cultivation significantly by the early 2000s through robust government efforts and international assistance, achieving near “poppy-free” status in some areas.
Recent Resurgence (2024-2025): The situation changed dramatically after the 2022 Afghan opium ban. Afghan farmers, expertise, and capital have migrated across the border into Pakistan, particularly into the remote and lawless Balochistan province. This has led to a significant increase in poppy cultivation in Pakistan, with some reports indicating unrestrained farming on a large scale.
Current Status: With the dramatic fall in Afghan production, some security analysts and experts suggest that the opium crop in Pakistan in 2025 will exceed that of Afghanistan, making it the new leading producer.
Role in Smuggling
Primary Transit Route: Pakistan has consistently been a vital part of the “southern route” for smuggling Afghan opiates to international markets, including the Gulf States, Africa, China, and Europe. An estimated 40% of drugs from Afghanistan traditionally routed through Pakistan.
Logistics: The long, porous border between Afghanistan and Pakistan, especially in regions like Balochistan and the former Federally Administered Tribal Areas (FATA), facilitates this illicit movement.
Infrastructure: Drug cartels and transnational criminal groups within Pakistan are involved in processing raw opium into heroin and then smuggling it through various means, including land routes to Iran and container ports like Karachi.
Impact: The illicit drug trade funds criminal and potentially terrorist groups, posing significant security and health challenges for Pakistan, which has a high rate of domestic opioid addiction.
The World Drug Report highlights developments across the global drug market to explain the factors that drive the world’s consumption, production and trafficking of illicit drugs. The report presents a comprehensive analysis of key drug markets, namely opium/heroin, coca/cocaine, amphetamine-type stimulants and cannabis. For each of these drug types, the report analyses trends in production, consumption, trafficking and prices.
Drug markets and drug usage patterns change rapidly, requiring measures to stop them to adapt promptly too. Thus, for the international community to be better prepared to respond to new challenges, this report has been an attempt at ensuring the availability of comprehensive and up to date data.
Pakistan’s geographic location makes it vulnerable to the threat of drug usage and trafficking. Afghanistan produces 90 percent of the world’s opium. The fact that poppy growing Afghan provinces (Helmund, Kandahar and Nimroz) neighbour Pakistan, makes it a lucrative trafficking route for Afghan opiates.
Jeremy Douglas, Representative UNODC stressed “Pakistan is particularly vulnerable to the trafficking of Afghan opiates and this poses a burden on public health, criminal justice and security systems.
Currently, Afghanistan is producing almost 90% of the total world opium and heroin, of which almost 40% trafficked through Pakistan or over 35% of the global total. During transition, these drugs are also consumed in the local market and, therefore, are a source of increasing addiction in our country. These drugs also benefit criminal groups along drug trafficking routes. Afghan opium production has resulted in negative social, health and economic consequences for Pakistan – which has claimed to be a victim country.
The World Drug Report highlights developments across the global drug market to explain the factors that drive the world’s consumption, production and trafficking of illicit drugs. The report presents a comprehensive analysis of key drug markets, namely opium/heroin, coca/cocaine, amphetamine-type stimulants and cannabis. For each of these drug types, the report analyses trends in production, consumption, trafficking and prices.
Drug markets and drug usage patterns change rapidly, requiring measures to stop them to adapt promptly too. Thus, for the international community to be better prepared to respond to new challenges, this report is an attempt at ensuring the availability of comprehensive and up to date data.
Pakistan’s geographic location makes it vulnerable to the threat of drug usage and trafficking. Afghanistan produces 90 percent of the world’s opium. The fact that poppy growing Afghan provinces (Helmund, Kandahar and Nimroz) neighboring Pakistan, makes it a lucrative trafficking route for Afghan opiates. Jeremy Douglas, Representative UNODC.
Pakistan is particularly vulnerable to the trafficking of Afghan opiates and this poses a burden on public health, criminal justice and security systems.”
Mr. Iftikhar Ahmed stated “At present, Afghanistan is producing almost 90% of the total world opium and heroin, of which almost 40% trafficked through Pakistan or over 35% of the global total.
During transition, these drugs are also consumed in the local market and, therefore, are a source of increasing addiction in our country. These drugs also benefit criminal groups along drug trafficking routes. Afghan opium production has resulted in negative social, health and economic consequences for Pakistan – we are a victim country.
The Government of Pakistan, in collaboration with international partners like the United Nations Office on Drugs and Crime (UNODC), is engaged in counter-narcotics efforts, including law enforcement operations and border control measures, to combat both cultivation and trafficking.
With greater scrutiny on prescription opioids, many users around the globe have switched to the cheaper and more readily available heroin that drove up heroin-related overdose deaths from 2010 to peak in 2016, being overtaken by the spike in synthetic opioid (mostly fentanyl)-related overdose deaths.
The surge in fentanyl-related overdose deaths since 2013 is alarming as fentanyl is more potent and deadly. One thing is certain the opioid crisis is not improving but has become dire with the surge in fentanyl-related overdose deaths. Evidence-based strategies have to be implemented in the U.S. to control this epidemic before it destroys more lives.
Other countries, including European countries and Canada, have invested more in harm reduction strategies than the U.S. even though they (especially Europe) do not face anywhere near the level of crisis as the U.S.
In the long-run, upstream measures (tackling the social determinants of health) are more effective public health strategies to control the epidemic. In the meantime, however, harm reduction strategies have to be employed to mitigate the harm from addiction and overdose deaths.
Being the global leader, United States is facing an opioid epidemic that is worse than anywhere else in the world. Mortality data from drug overdoses of 13 member countries in the Organization for Economic Co-operation and Development show that the U.S. has more than twice the drug overdose death rates than any other country.
Preliminary data released by the National Center for Health Statistics indicate that in 2020, during the pandemic, the U.S. witnessed the largest alarming increase in drug overdose deaths and opioid-related overdose deaths in particular—drug overdose deaths increased by 29.4%, led by opioid-related overdose deaths increasing by 36.8%. During 2020, there were 93,331 drug overdose deaths, of which 69,710 (74.7%) were related to opioids.
Overdose death is only the tip of the iceberg of a much larger underlying drug addiction and drug misuse problem. The opioid crisis is a culmination of a multitude of factors, ranging from laxity in opioid prescriptions and addictiveness of opioids to failed policy in prevention and treatment.
Staying on the same course is not a viable option that witnessed the spiraling out-of-control devastation of lives, and the pandemic year only dealt a further blow to the dire situation. The U.S. has to adopt a different approach to the opioid crisis to stem and turn the tide.
In the 1990s, Purdue Pharmaceuticals marketed the extended-release oxycodone (OxyContin) as an analgesic with low abuse potential. There was a push for physicians to treat pain adequately. Consequently, the first wave of the epidemic saw opioid prescription rates increase to 81.2 prescriptions per 100 persons in 2010, enough to medicate every American adult around the clock for a whole month.
Opioid prescribing rates have since declined by more than 40% to 46.7 prescriptions per 100 persons in 2019.3Prescription opioid-related overdose deaths climbed from 3,442 in 1999 to peak at 17,029 in 2017, stabilizing at over 14,000 and accounting for over 28% of all opioid-related deaths in 2019.
Heroin use surged in the second wave as many prescription drug abusers switched to the cheaper and more easily available heroin.
Heroin-related overdose deaths increased from 3,036 in 2010 to peak at 15,469 in 2016, stabilizing at over 14,000 and accounting for over 28% of all opioid-related deaths in 2019.
The opioid crisis is worsening as the third wave is driven by synthetic opioids, particularly fentanyl and its analogues, which are more lethal due to their higher potency. Synthetic opioid-related overdose deaths rose from 3,105 in 2013 to more than 36,000 in 2019, accounting for nearly 73% of the opioid overdose deaths in 2019. Overall opioid overdose deaths increased from 2018 to 2019 by over 6%, driven by an increase of over 15% in fentanyl-related overdose deaths.
This review emphasizes the public health approach to opioid addiction, supporting evidence based harm reduction strategies that have been underutilized in this country but have gained a greater foothold in other developed countries.
STRATEGIES
Past practices in controlling the opioid epidemic have failed as evidenced by the worsening opioid crisis. In 2017, Health and Human Services launched a five-point strategy to combat the opioid crisis, emphasizing science- and evidence-based practices. Importantly, it advocates for greater access to addiction prevention, treatment, and recovery services.
The public health approach to opioid addiction moves away from law enforcement and the criminalization of addiction to treating it as a disease and emphasizing harm reduction strategies. Other developed countries, including Europe and Canada, have invested more than the U.S. in harm reduction strategies and provided more patient-centered services (e.g., safe injection sites and medication-assisted treatment dispensed through pharmacies that are not found in the U.S.).
Role of Naloxone
Naloxone is a competitive mu-opioid receptor antagonist used to reverse an opioid overdose. Naloxone (Narcan) nasal spray, approved in 2015, is easy to use, even by laypersons. In a study of first responders and community-based organizations, naloxone nasal spray, containing 4 mg dose per device, was found to be successful in the reversal of opioid overdose in 98.8% of cases, most of which were heroin overdoses.
The majority of the cases had a response within 5 minutes of naloxone administration and required no more than two units of the naloxone spray.8 One opioid that is relatively resistant to the effective reversal by naloxone is buprenorphine that has a high affinity to mu-opioid receptors.
The Surgeon General and health organizations in the US call for the distribution of naloxone to laypersons as drug overdoses are often witnessed by bystanders. In recent years, fentanyl and fentanyl analogs were involved in the majority of opioid overdose deaths.
Due to its high potency, opioid-reversing drug has to be administered at a high enough dose and quickly. On April 30, 2021, the U.S. Food and Drug Administration approved a higher dosage (8 mg) naloxone nasal spray. Additionally, distributing naloxone kits to laypersons such as family members and friends, including other drug users, so that they are easily accessible and readily available, becomes more pressing.
Opioid prescription rates vary substantially from state to state; hence, the need for clinical practice guidelines. Higher prescription rates are found in rural, impoverished counties, and among Medicaid populations. In response to the opioid crisis, in 2016, the CDC issued opioid prescribing guidelines for chronic non-cancer pain, excluding cancer treatment, palliative treatment, and end-of-life care.
Among the recommendations are preferring non-pharmacological and non-opioid pharmacological therapy over opioid therapy for long-term pain management; prescribing at the lowest effective dose; reviewing the prescription drug monitoring programs; limiting the duration of opioid therapy; and offering or arranging for evidence-based treatment (e.g., medication-assisted treatment) for patients with opioid use disorder.
A study on the impact of the CDC guidelines found that after their implementation, the amount of post-surgery opioids prescribed—and consumed—for elective laparoscopic cholecystectomy decreased from 250 mg to 75 mg and from 30 mg to 20 mg, respectively.
The CDC guidelines might have saved more lives if they were made earlier when prescription opioid misuse was on the rise from at least 1999. Nevertheless, any reduction in opioid prescriptions would have a positive impact to the extent that prescription opioids are the “gateway drugs” to illicit drug use.
Opium Laws
Pill mill laws were introduced in some states as a result of the proliferation of pain clinics (pill mills) where opioids were irresponsibly prescribed in large quantities, often for cash. In mid-2000s, Florida was the epicenter of the prescription opioid epidemic and the metacenter for the prescription opioid trade.
In 2010 and 2011, medication laws were introduced in Florida that impose strict regulations on pain clinics, requiring medical examinations and follow-ups when prescribing opioids for chronic pain, among other requirements.
Before the intervention, Florida had higher prescription opioid and total opioid overdose death rates than North Carolina. However, after the intervention, both prescription opioid and total opioid overdose death rates decreased in Florida but they stabilized and increased, respectively, in North Carolina.
Additionally, while heroin overdose death rates increased in both states, reflecting national trends, the increase was lower in Florida than North Carolina. Medicine production laws have the potential of slowing down the opioid epidemic.
Prescription Drug Monitoring Program
All states, with the exception of Missouri, have statewide prescription drug monitoring programs. They are electronic databases that track duplicate prescriptions obtained through doctor shopping and pill mills. PDMP requirements vary from state to state, such as mandatory vs. voluntary use, real-time vs. periodic query, and types of providers and other professionals granted access to records in PDMP.
A study of 16 states in the US reflects
Differential impact of PDMP in reducing prescription opioid overdose in different communities. In counties with greater access to opioids through the medical system, as opposed to the non-medical or illicit routes, PDMP produced a bigger reduction in prescription opioid overdose with a smaller increase in heroin overdose.
Safe Injection Sites
Safe injection sites—also known as safe consumption sites and supervised injecting facilities—are public facilities that allow individuals to consume drugs in a supervised setting. They are found in Canada, Australia, and Western Europe but not in the U.S.
They were found to decrease opioid overdoses and overdose deaths, hospitalizations, use of emergency medical services, and facilitate entry into treatment for substance use disorders.
A national survey of the U.S. adults shows that the majority were not in favor of legalizing such consumption sites due to the stigma toward people who use opioids.15Nevertheless, some cities, including Denver, Ithaca, Philadelphia, San Francisco, and Seattle, are considering opening such sites. Future studies on the impact of such sites on the community would help to shape public opinion and guide policy.
Medication-Assisted Treatment
The Food and Drug Administration (FDA) has approved methadone, buprenorphine, and naltrexone for the treatment of opioid addiction. Extensive research has shown that medication-assisted treatment is superior in treatment outcomes to non-medication-based therapies in reducing opioid use, overdoses and overdose deaths, and improving social functions and quality of life.
In a study of 699 adults randomized to either methadone or buprenorphine/naloxone and followed for at least 5 years, only 20.7% of them were abstinent from heroin and other opioids during the preceding 5 year period.
Relapse rates were high. However, opioid use disorder as a “chronic disease” is not unique among medically managed chronic diseases, including hypertension, diabetes, and asthma, to suffer sub-optimal adherence to medications and less than optimal treatment outcomes.
Medicated-assisted treatment may need to be lifelong and “recovery” defined as retention in treatment, reduction in illicit drug use, and improvement in quality of life.
New Buprenorphine Practice Guidelines
One of the barriers faced by health care practitioners in providing treatment for opioid use disorder is the certification requirement related to training and the provision of counseling and ancillary services (i.e., psychosocial services) to qualify for a waiver to prescribe buprenorphine for treatment.
Effective April 28, 2021, to expand access to treatment, Health and Human Services issued new buprenorphine practice guidelines that exempt all eligible practitioners—physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives—from the certification requirement for prescribing buprenorphine for opioid use disorder for up to 30 patients.
Extended-release Oxycodone (OxyContin) Reformulation
Extended-release oxycodone (OxyContin) contains higher doses of oxycodone than the immediate-release oxycodone. The extended-release formulation could potentially, unless tampered with, reduce abuse through the delay in opioid absorption.
OxyContin was reformulated in 2010 to be resistant to crushing or dissolving to deter abuse. After the reformulation, among those who had previously misused OxyContin specifically relative to those who had misused other prescription pain relievers (mostly opioids), there was greater reduction in prescription pain reliever misuse and smaller increase in new heroin use.
Drug overdoses are often witnessed by other drug users who may be hesitant to call 911 due to fear of arrest. Good Samaritan laws protect bystanders calling 911 when witnessing an overdose. However, a survey of persons who inject drugs in Baltimore found that only 18.8% knew about the Good Samaritan law.
CONCLUSION
As a public health strategy, long-term interventions with upstream measures will be more effective in controlling the epidemic. Naloxone- and medication-assisted treatment reduce harm from drug misuse and addiction but do not get at the root causes of the problem. Nevertheless, in the meantime, evidence-based harm.
It is difficult to live without opium after having known it because it is difficult, after knowing opium, to take earth seriously. And unless one is a saint, it is difficult to live without taking earth seriously.
Perhaps there is always a need for intoxication: China has opium, Islam has hashish, the West has woman. Andre Malraux It is not opium which makes me work but its absence, and in order for me to feel its absence it must from time to time be present. Antonin Artaud Under the pressure of the cares and sorrows of our mortal condition, men have at all times, and in all countries, called in some physical aid to their moral consolations—wine, beer, opium, brandy, or tobacco.
Read: Pornography Addiction in Society
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The Bengal-born writer Nazarul Islam is a senior educationist based in USA. He writes for Sindh Courier and the newspapers of Bangladesh, India and America. He is author of a recently published book ‘Chasing Hope’ – a compilation of his articles.
