Introduction

The prescription Opioid crisis ravaged communities across the globe, leaving a trail of devastation in its wake.^1,2 This was particularly true in the United States, where an absurd “knee-jerk reaction” has resulted in profound opiophobia, which has been associated with tremendous harms in its own right and represents a clear ethical imbroglio.^3–5 While the United States struggled to combat this epidemic, Italy has emerged as a remarkable exception. Estimates of rates of misuse in patients prescribed opioids in the United States vary dramatically, as there is no universally accepted definition of “misuse”. For the purposes of this analysis, we will use the estimate of prevalence of misuse from the Vowles et al systematic review and data synthesis of 21–29%.⁶ We were unable to find any reliable data on the incidence of prescription opioid abuse in Italy, although a 2019 publication from the European Monitoring Centre for Drugs and Drug Addiction⁷ reported an incidence rate of all high-risk opioid use (licit and illicit) of only 0.006%, with the authors of a 2018 report on Italian prescriptions in pain management concluding that, “Our analysis showed that neither a risk of addiction nor an indication to limit opioid therapy in these patients seems to exist” (p. 373).⁸ As a result of Italy’s unique social, family, and church dynamics, Italy has managed to evade the overwhelming burden that has plagued many other nations, with opioid analgesia still considered a central aspect of pain management. In this editorial, we explore the factors contributing to Italy’s success in mitigating the prescription opioid crisis and attempt to elucidate valuable lessons for the international community.

Strong Social Connections

Italian society is characterized by a deep sense of community and interconnectedness.

Social solid bonds foster a support system that plays a crucial role in preventing the proliferation of opioid abuse and addiction. Italians prioritize personal relationships, relying on friends, neighbors, and community members to provide emotional support and guidance.⁹ This tight-knit social fabric appears to serve as a safety net, ensuring that individuals facing challenges, including substance abuse, receive the help they need before it spirals out of control.¹⁰ In contrast, in the United States, “social distress” has been identified as a “likely upstream explanatory factor” for its opioid abuse crisis,¹¹ with an oft-cited 2017 National Academy of Science report identifying “eroded social capital” as a root cause of the misuse of opioids and other substances.¹²

Family Cohesion

Family plays a central role in Italian culture, with a focus on unity, solidarity, and mutual care.

We posit that the close-knit nature of Italian families acts as a protective shield against opioid abuse. Parents and siblings are often keenly aware of each other’s struggles, and the familial support network provides a strong deterrent to substance abuse.¹³ Open lines of communication and a sense of responsibility toward one another create an environment in which individuals feel secure, loved, and understood, reducing the likelihood of turning to opioids as an escape. Specifically, data indicate that Italian familial disapproval of deviance serves a protective role against substance abuse.¹⁴ Further, family cohesion (ie, the extent to which family members are emotionally bonded) has long been considered a buffer against substance abuse and to have a prophylactic effect against relapse.^15–18 In Italy, family cohesion is extremely strong. In a 1998 study by Claes,¹⁹ the author hypothesized that Italian parents organize their families and behave in a manner that fosters family closeness. Data from a 2016 study indicate that of the 15 countries considered, more Italian young adults still lived with their parents than the young adults of any other nation.²⁰ However, in the United States, family stability has been determined to be progressively deteriorating.²¹ Even among immigrant groups in the United States, for whom family cohesion is initially high, a significant diminution of cohesion rapidly occurs with acculturation.²² Although we do not believe that differences in levels of family cohesion between Italy and the United States offer a sole explanation for the differences in prescription opioid abuse between the 2 nations, strong family cohesion in Italy in contrast to weak cohesion in the United States likely contribute to the dramatically lower levels of prescription opioid abuse that have been experienced in Italy.

The Influence of the Church

Italy has remained, to a great extent, a “Catholic nation”, with 2018 data suggesting that 78% of the population identifies as Catholic.²³ Italy’s historical ties to the Catholic Church have significantly influenced its societal norms and values. Even if many Italians are not observant, the Church plays a central role in Italian communities, providing spiritual guidance, moral education, and a sense of purpose.²⁴ We opine that the emphasis on compassion, forgiveness, and empathy (all aspects of confession)²⁵ has the potential to help prevent and reduce the severity of substance abuse and offer support and redemption to those who may have fallen victim to addiction. The Church’s presence provides access to a moral compass, reinforcing the values necessary to mitigate potential abuse of prescription opioids. In the United States, on the other hand, there is no centralized church, with considerably more religious diversity than is the case in Italy. Furthermore, the Catholic church in the United States has been rocked by thousands of child sexual abuse scandals, with allegations against priests dating back to at least 1983.^26,27 Certainly, the Catholic church in the United States is not the only religious institution plagued by numerous types of scandals.²⁸ These scandals have contributed to religious institutions’ loss of social capital,²⁹ contributing to decreased religious participation and charitable giving.²⁷ Consequent differences in levels of moral authority between the Church in Italy and religious institutions in the United States can explain, to a degree, why the Church has a more powerful role in mitigating opioid abuse in Italy than do religious institutions in the United States. As Storm has noted,³⁰ when religious institutions lose their moral authority, the state becomes the overseer of the populace’s behavior. Regarding opioid abuse, the United States government’s effort to reduce aberrant opioid use has been an abject failure, at best.^31,32

Lessons for the International Community

Italy’s success in avoiding the full brunt of the opioid crisis offers valuable lessons for other nations grappling with this epidemic:

1. Strengthening social ties: Encouraging and nurturing strong community bonds can create a supportive environment that prevents substance abuse.
2. Promoting family values: Fostering strong family structures and nurturing open lines of communication within households can serve as a protective factor against addiction.
3. Leveraging faith-based organizations: Collaborating with religious institutions to disseminate education, awareness, and support programs can potentially have a significant impact in curbing the opioid crisis. Respect for religious institutions needs to be high if they are to exert the optimal influence on prescription opioid abuse.

Conclusion

We are not sufficiently naïve to suggest that social, family, and church differences between the United States and Italy fully explain why the former experienced an epidemic of prescription opioid abuse and overdose deaths while the latter has gratefully been able to avoid such. However, we believe that Italy’s ability to avert the devastating consequences of the opioid crisis stands as a testament to the power of social, family, and church differences, even though other important differences have also contributed to this discrepancy. By fostering strong social connections, emphasizing resilient family values, and leveraging the influence of religious institutions, Italy has created a society that continues to be more resilient to the opioid epidemic. As other nations continue to grapple with this crisis, we believe that it would be prudent to study Italy’s success and consider how these cultural strengths can be cultivated and adapted within their own cultures.

Disclosure

Dr Michael Schatman is a research consultant for Modoscript and Collegium Pharma; is part of the advisory committees for Syneos Health, outside the submitted work. The authors report no other conflicts of interest in this work.

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