Dynamic Thinking Approach of Non-medical Use of Pharmaceutical Opioids

Document Type : Research article


1 Department of Phamaeconomics, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

2 Department of Industrial Management, School of Management and Economics, Tarbiat Modares University, Tehran, Iran.

3 Department of Pharmacoeconomics and Pharmaceutical Management,,School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.


The unsteady increase in using pharmaceutical opioids is a phenomenon that has existed in human societies for a long time. Furthermore, the ever-growing trend of addiction to opioids affects communities in various economic, social, and cultural aspects. Since abusing pharmaceutical opioids is a complex dynamic problem, it is extremely difficult to recognize the factors influencing this abuse. Thus, applying such dynamic models as system dynamics (SD) plays an important role in addressing these complex dynamic problems. System dynamics model falls in two categories of qualitative and quantitative system dynamics.
In this paper, causal loop diagrams (CLDs), which are conceptual qualitative stages were applied, and variables were elicited from literatures; then, the initial CLDs were generated, and afterward, some experts were interviewed in order for the CLDs model to be evaluated. Ultimately, a meeting was held for discussing the variables and validating the diagrams. In this study, variables are connected by causal relationships called reinforcing and balancing. Then, the CLD model clearly depicted how the variables interact with one another in different stages of the process. The CLDs model is a fundamental issue in developing quantitative system dynamic, assisting policymakers in forecasting the process of non-medical use of pharmaceutical opioids and finding some measures to reduce their usage.


Main Subjects

Fartookzadeh H, Moazzez H and Rajabi Nohouji M.
Strategies and Policies of Drug Abuse Control in Iran.
Social Welfare (2013) 13: 171-99.
Laxmaiah Manchikanti M, Sairam Atluri M and Hans
Hansen M. Opioids in chronic noncancer pain: have
we reached a boiling point yet? Pain Physician (2014)
17: E1-E10.
Davis WR and Johnson BD. Prescription opioid use,
misuse, and diversion among street drug users in New
York City. Drug Alcohol Depend. (2008) 92: 267-76.
Compton WM and Volkow ND. Abuse of prescription
drugs and the risk of addiction. Drug Alcohol Depend.
(2006) 83: S4-S7.
Quigley C. Hydromorphone for acute and chronic
pain. The Cochrane Library (2002).
Højsted J and Sjøgren P. Addiction to opioids in
chronic pain patients: a literature review. Eur. J. Pain
(2007) 11: 490-518.
Eriksen J. Opioids in chronic non‐malignant pain. Eur.
J. Pain. (2001) 5: 231-2.
Warner M, Chen LH, Makuc DM, Anderson RN and
Miniño AM. Drug poisoning deaths in the United
States, 1980-2008. NCHS Data Brief (2011) 1-8.
Judin J. Risk Evaluation and Mitigation Strategy
(REMS) for extended-release and long-acting opioids.
J. Pain. Palliat. Care Pharmacother. ( 2012), 26:136-
Nelson LS and Perrone J. Curbing the opioid epidemic
in the United States: the risk evaluation and mitigation
strategy (REMS). JAMA (2012) 308: 457-8.
Chou R, Ballantyne JC, Fanciullo GJ, Fine PG and
Miaskowski C. Research gaps on use of opioids for
chronic noncancer pain: findings from a review of the
evidence for an American Pain Society and American
Academy of Pain Medicine clinical practice guideline.
J. Pain (2009) 10: 147-59. e15.
Sterman JDJD. Business dynamics: systems thinking
and modeling for a complex world, McGraw-Hill
Education (2000).
Moosivand A, Rajabzadeh Ghatari A and Rasekh
HR. Supply Chain Challenges
in Pharmaceutical Manufacturing Companies: Using
Qualitative System Dynamics Methodology. Iran. J.
Pharm. Res. (2019) 18:1103-16.
Toole TM. A project management causal loop diagram.
in Proceedings of the 21st Annual Conference of
the Association of Researchers in Construction
Management (2005).
Chang DT, Saidel GM and Anderson JM. Dynamic
systems model for lymphocyte interactions with
macrophages at biomaterial surfaces.CMBE (2009)
2: 573-90.
Jones AP, Homer JB, Murphy DL, Essien JD,
Milstein B and Seville DA. Understanding diabetes
population dynamics through simulation modeling and
experimentation. Am. J. Public. Health (2006) 96:
Wakeland W, Schmidt T, Gilson AM, Haddox JD
and Webster LR. System dynamics modeling as a
potentially useful tool in analyzing mitigation
strategies to reduce overdose deaths associated with
pharmaceutical opioid treatment of chronic pain. Pain
Med. (2011) 12: S49-S58.
Homer JB and Hirsch GB. System dynamics modeling
for public health: background and opportunities. Am.
J. Public Health (2006) 96: 452-8.
Albin S, Building a system dynamics model part 1:
Conceptualization. Road Maps: A Guide to Learning
System Dynamics, MIT System Dynamics in Education
Project. Massachusetts Institute of Technology,
Cambridge, USA (1997).
Alasad R, Motawa I and Ougunlana S. A System
Dynamics-Based Model For Demand Forecasting In
PPP Infrastructure Projects–A Case Of Toll Roads.
OTMCJ (2013) 5: 791-798.
Minato T. Representing causal mechanism of defective
designs: a system approach considering human errors.
Construction Management and Economics. (2003) 21:
Brailsford SC. System dynamics: What’s in it for
Dynamic Thinking Approach of Non-medical
healthcare simulation modelers. in 2008 Winter
Simulation Conference. IEEE (2008).
Vennix JA and Gubbels JW. Knowledge elicitation in
conceptual model building: A case study in modeling
a regional Dutch health care system. Eur. J. Oper. Res.
(1992) 59: 85-101.
Doyle JK and Ford DN. Mental models concepts for
system dynamics research. Syst. Dyn. Rev. (1998) 14:
Forrester JW. Policies, decisions and information
sources for modeling. Eur. J. Oper. Res. (1992) 59:
Cicero TJ, Surratt H, Inciardi JA and Munoz A.
Relationship between therapeutic use and abuse
of opioid analgesics in rural, suburban, and urban
locations in the United States. Pharmacoepidemiol.
Drug Saf. (2007) 16: 827-40.
Potter M, Schafer S, Gonzalez-mendez E, Gjeltema
K, Lopez A, Wu J, Pedrin R, Cozen M, Wilson R and
Thom D. Opioids for chronic nonmalignant pain J.
Fam. Pract. (2001) 50: 145-51.
Joranson DE, Gilson AM, Dahl JL and Haddox JD.
Pain management, controlled substances and state
medical board policy: a decade of change. J. Pain
Symptom. Manage. (2002) 23: 138-47.
Pradel V, Frauger E, Thirion X, Ronfle E, Lapierre V,
Masut A, Coudert C, Blin O and Micallef J. Impact of
a prescription monitoring program on doctor‐shopping
for high dosage buprenorphine. Pharmacoepidemiol.
Drug Saf. (2009) 18: 36-43.
Gilson AM, Ryan KM, Joranson DE and Dahl JL. A
reassessment of trends in the medical use and abuse
of opioid analgesics and implications for diversion
control: 1997–2002. J. Pain Symptom. Manage.
(2004) 28: 176-88.
Aldworth J. Results from the 2007 national survey
on drug use and health: National findings. DIANE
Publishing (2009).
Schmidt T, Wakeland W and Haddox JD. A System
Dynamics Model of Pharmaceutical Opioids: Medical
Use, Diversion, and Nonmedical Use. (2011).
Collett BJ. Chronic opioid therapy for non‐cancer
pain. BJA (2001) 87: 133-43.