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Next Billion-Dollar Startups: Truepill’s Dose Of Digital Disruption To The $400 Billion Pharmacy Industry

I was barely getting any sleep,” Umar Afridi, cofounder and CEO of Truepill, says of the tech-enabled pharmacy company’s early days. From 9 a.m. to 4:30 p.m. each day, he worked at Truepill’s distribution center in Hayward, California. Then he drove to his job as a pharmacy manager at a 24-hour CVS in East San Jose. On the side, he studied for a dozen state pharmacy exams so that Truepill, which at the time had no other pharmacists on staff, could legally ship to those states. “It was a pretty crazy first year,” he says with characteristic understatement.

That craziness has paid off for Afridi, 37, and his cofounder, Sid Viswanathan, 35, who hope to upend the staid, heavily regulated pharmacy business with technology. Truepill, which is based in San Mateo, California, shipped its first prescriptions in 2016. Last year its revenue reached $48 million, helped by the fast growth of direct-to-consumer customers like Nurx, which sells birth control, and Hims, which focuses on remedies for hair loss, erectile dysfunction and acne. This year Truepill could double its revenue to $100 million, as it expands its customer base beyond direct-to-consumer medications to prescriptions that treat more serious illnesses.

Those revenue numbers gained Truepill a spot on Forbes’ Next Billion-Dollar Startups list this year, despite its having raised just $13 million in venture funding led by Initialized Capital at a valuation of $80 million in its last round. That valuation makes Truepill an outlier on the list, as does the fact that Afridi and Viswanathan own the majority of the business and plan to continue to do so after raising the next round of capital, expected before the year’s end.

Afridi and Viswanathan—and their investors—are betting that Truepill will see a big payoff as consumers move away from in-person doctor visits and to a new model of telemedicine. “This is the building block of digital health and the future of healthcare,” says Initialized managing partner Garry Tan.

Pharmacy is a roughly $400 billion business in the United States, yet only recently have entrepreneurs begun tackling the market. In 2013, two young founders launched PillPack, a retail pharmacy startup that was acquired by Amazon last year for around $750 million. Other newcomers followed, including New York City’s Capsule, which grabbed $270 million in funding to do same-day prescription delivery refilled via text.

Truepill’s difference: Its business-to-business model makes it a behind-the-scenes player, invisible to retail customers, who will never have reason to know its name. That’s by design, and it allows Truepill to sign agreements with drugmakers and pharmacy benefit managers, those industry intermediaries that sit between insurers and drugmakers, without directly competing with them. “We’re not a traditional mail-order pharmacy,” Afridi says. “We’re way more than that.”

Afridi was born in Salt Lake City and grew up in Manchester, England, where his mother’s family was from. He studied pharmacy at the University of Manchester and worked as a relief pharmacist, filling in for those who went on vacation, in England. After passing the tests to practice in the United States, he took a job at Fred Meyer near Seattle. Unlike the typical pharmacist, Afridi always had an entrepreneurial side gig. During college, he imported performance cars, like the Mazda RX-7 and the Mitsubishi Evo 5, from Japan and sold them at a profit.

                              

While working as a pharmacist, he taught himself computer programming and began playing around with the idea of an on-demand pharmacy. His goal: to ease customers’ frustrations with waiting in line to pick up medications and to cut back the phone calls and faxes required for pharmacists to do their job. “I’ve always had a passion for technology, and every time I see a problem, I think, ‘How can technology fix this?’” he says.

Viswanathan, an Indian immigrant, had worked at Johnson & Johnson, then cofounded CardMunch, a business-card scanning app. In 2011, LinkedIn bought the startup for a reported $3 million. Viswanathan stayed at the larger company after the deal, and when LinkedIn went public the stock he owned made him wealthy for the first time. “It was fairly life-changing coming from no money to having some,” he recalls. After nearly four years at LinkedIn, he was ready to leave and work on another startup. “My only criterion was what do I want to spend the next 10 years of my life on,” he says.

While he was pondering what to do next, he stumbled upon Afridi’s profile on LinkedIn—where Afridi had changed his header to “startup founder, pharmacist”—and messaged him cold to talk about healthcare. Soon the two were meeting regularly and brainstorming ideas for a business to start together.

By then, other startup pharmacies, like PillPack, were making inroads with retail customers. Rather than compete in what had become a crowded space vying for retail customers, Afridi and Viswanathan figured they could operate in the background, using technology to build an extremely efficient pharmacy distribution center. “Truepill is what you get when you put together a pharmacist and a software engineer,” Viswanathan says.

“This is the building block of digital health and the future of healthcare,” says Initialized Capital’s Garry Tan.

Their idea coincided with the rise of new direct-to-consumer health brands that needed a distributor that could follow all the pharmacy regulations. To consumers, these Instagrammable health products don’t look like drugs, and often their subscription boxes contain a mix of both prescription and over-the-counter products. But if there’s even one vial of prescription pills going out in the mail, the startup sending it needs a pharmacy to fulfill the order. In talking with Nurx, Viswanathan says, “we came to find out they were literally picking up the phone to mom-and-pop pharmacies in different states.” They gained a customer by offering a better way.

In 2017, Andrew Dudum cofounded Hims, the fast-growing direct-to-consumer therapeutics startup for men, and he, too, signed up with Truepill. “We knew from the beginning we were going to grow very fast,” Dudum says. “We expected 30 to 50 orders per day, and that was the scale we communicated to Umar and Sid that we needed to be prepared for. In the first week, we were getting 500 orders per day.” Today, Hims, which is valued at $1.1 billion, does thousands of orders per day and is one of Truepill’s largest customers. “They figured out a way to scale with us,” Dudum says.

At Truepill’s Hayward distribution center, all orders come in electronically. When Hims sends a prescription for finasteride, the male hair-loss treatment, for example, it goes through electronic vetting and then a robotic machine pulls the 1-milligram tablets from custom-made 1,000-count bottles into a small pill vial that gets labeled with Hims branding. That automation allows Truepill to work more efficiently than a traditional retail pharmacy. So, too, does its focus on a small number of medications: Ten medications, including finasteride and the erectile-dysfunction drug sildenafil, represent 80% of its volume. Its scale in those allows Truepill to turn over its inventory every few days and gives it the power to negotiate prices with drug manufacturers and pharmacy benefit managers on those products.

“Truepill is what you get when you put together a pharmacist and a software engineer,” says cofounder Sid Viswanathan.

For Afridi and Viswanathan, direct-to-consumer medications are just the beginning. They are starting to sign agreements with drugmakers and pharmacy benefit managers, though they won’t name those larger partners yet. This shift comes none too soon, as Hims has announced that it would open its own pharmacy in Ohio to shift a portion of its distribution in-house—a move that Viswanathan says will begin to impact Truepill in 2021. “Hims is a large part of the business in quantity, but not in revenue,” he says, noting that medications reimbursed by insurance are higher cost than lifestyle meds that consumers pay for out of pocket. Truepill currently has two distribution centers and is adding another five.

Afridi and Viswanathan’s next step: building a nationwide network of doctors in every state that will enable their pharmacy startup to play a bigger role in the shift to telemedicine. Those doctors will allow it to work directly with makers of specialty medications, say, so that they can distribute their medications to consumers more easily. Over time, Truepill figures its orders could rise from 5,000 to 10,000 per day to 100,000.

“Lifestyle and ED [erectile dysfunction] medications have allowed us to build the infrastructure to all these other areas,” Afridi says. “There is a lot of innovation that needs to happen in the space.”

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I’m a senior editor at Forbes, where I cover manufacturing, industrial innovation and consumer products. I previously spent two years on the Forbes’ Entrepreneurs team. It’s my second stint here: I learned the ropes of business journalism under Forbes legendary editor Jim Michaels in the 1990s. Before rejoining, I was a senior writer or staff writer at BusinessWeek, Money and the New York Daily News. My work has also appeared in Barron’s, Inc., the New York Times and numerous other publications. I’m based in New York, but my family is from Pittsburgh—and I love stories that get me out into the industrial heartland. Ping me with ideas, or follow me on Twitter @amyfeldman.

Source: Next Billion-Dollar Startups: Truepill’s Dose Of Digital Disruption To The $400 Billion Pharmacy Industry

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Hi, I’m Garry Tan, venture capitalist and cofounder at Initialized Capital. We were earliest investors in billion dollar startups like Coinbase and Instacart, and we’re spending time with some of our best founders to learn the secrets of their success and see the future they’re building. Today I sat down with Sid Viswanathan, cofounder of Truepill, an API for all needs for telemedicine. Telemedicine has the potential to bring down costs and make high quality care more accessible for every person on the planet. We’re headed to Hayward, California, their west coast HQ and fulfillment center out of which they provide pharmacy services for dozens of telemedicine startups and practices large and small, shipping to all 50 states. Come learn about how as a founder, you need to choose a problem space that you could want to work on for 10 years or more. Please like this video and subscribe to my channel if you want to see more videos like this with top founders. Find Sid on Twitter at https://twitter.com/sidviswanathan Find Garry on Twitter at https://twitter.com/garrytan Learn more about Truepill at https://truepill.com Learn more about the companies we fund, and how we work with them at https://initialized.com

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The Health Risks of Supplements & Alternative Medicine

A few weeks ago, a patient came to me complaining of nausea, muscle weakness and fatigue. Her urine was tea-colored despite drinking loads of water. A middle-aged woman, she seemed worried she had cancer or some deadly disease. Her lab tests revealed significant liver dysfunction. But her symptoms were not due to liver cancer, hepatitis or other disease. It turned out she had liver toxicity from a green tea supplement that she’d heard was a “natural” way to lose weight.

When she stopped taking the supplement at my suggestion, her liver tests gradually normalized and she felt better over the course of a few weeks

I’ve seen the green tea issue in patients before and often witness the real-life pitfalls of eschewing traditional medicine, science and facts in favor of supplements, herbs and cleanses in the name of “natural” healing.

In an effort to be healthy, patients can easily become ensnared in the potential dangers of alternative medicine or homeopathy.

Let’s be clear: Nature has a lot to offer patients.

The Greek physician Hippocrates is said to have reported on the use of St. Johnswort, a flowering plant, for mood disturbances in the 5th century B.C. Digoxin, a well-studied medicine used to treat heart failure, is derived from the foxglove plant. Parkinson’s patients are often commonly treated with the medication L-dopa, which comes from the plant Mucuna pruriens. Moreover, research repeatedly shows that consuming fruits and vegetables, getting adequate sleep and regular exercise, and spending time outdoors have myriad health benefits.

But nature isn’t always so well-intended.

Spoiler alert: Arsenic, cyanide, asbestos and snake venom derive from nature. Refined sugar, a naturally occurring substance and one that lives in most Americans’ pantries, is in large part responsible for our country’s obesity epidemic. Simply because a substance comes from nature does not mean it is good for us.

An important key to health is using nature appropriately.

And in the case of my patient, she was able to lose weight when we made a clear plan to alter her basic human behaviors. Before she started taking the green tea extract, she was skipping breakfast, drinking the equivalent of two Venti coffees before noon, eating takeout meals for lunch, washing down her late-night dinner with two glasses of wine, sleeping restlessly, and spending too much time sitting and indoors.

Green tea extract was never going to be the quick fix that she — and other patients I have seen — had hoped. It may be attractive as a natural cure for extra body fat, but this promise has not been shown in any studies, according to the National Center for Complementary and Integrative Health at the National Institutes of Health. The key to helping my patient was pretty basic: looking at her lifestyle, her stress, and creating some structure and accountability for important lifestyle changes.

While she wasn’t able to eat like Gwyneth Paltrow would recommend (who can eat Pinterest-perfect meals like that as a mere mortal?), my patient took my advice to heart that she begin eating breakfast, packing healthy leftovers for lunch at work, cutting back the wine to weekends only, and getting more exercise on weekends.

As a result, she started sleeping better and feeling more energetic. Eventually, the weight started coming off, too.

Particular patients seem to be more susceptible to the lure of “naturopathic” medicine or homeopathy. Patients who have vague symptoms that do not fit tidily into a box, for example, are often the ones combing the Internet for answers to their health woes and spending hundreds of dollars on unproven and insufficiently regulated supplements and herbs.

According to the 2012 National Health Interview Survey (NHIS), which included a comprehensive poll on the use of complementary health approaches by Americans, 17.7 percent of American adults had used a dietary supplement other than vitamins and minerals in the past year. That number is probably larger now: The total sales of herbal and dietary supplements in the United States were estimated to be more than $8 billion in 2017, the 15th consecutive year of sales growth, according to a market research report. And women were more likely than men to use these products — as well as people with more education.

Scientific data is often not the reason patients are drawn to herbal or “natural” supplements, Harvard School of Public Health researchers said. Of supplements users surveyed in 2001, 72 percent said they would continue using supplements despite a negative government scientific study. Patients reported getting much information about herbs from family, friends, advertisements and the Internet.

My patients often consider herbal remedies to be free of side effects, but many “natural” products can lead to toxicity and can dangerously interact with prescription medications.

Compounding the problem is that herbal and dietary supplements are not subject to the same strict regulatory standards as prescription drugs. On it’s website, NIH’s Office of Dietary Supplements says the products “are not required to be reviewed by the FDA for their safety before they are marketed because they are presumed to be safe based on their history of use by humans.”

Last year, another patient came in to see me complaining of fatigue, joint pains and abdominal bloating. She had seen a naturopath for these symptoms, who told her she had “chronic Lyme” disease and gave her multiple rounds of antibiotics and a bag full of daily herbal supplements. She said she didn’t feel any better.

When we met, she told me she was certain she had Lyme disease that wasn’t being adequately treated. In fact, the antibiotics she had been given had only worsened her abdominal issues and caused a new problem: an intestinal infection that causes bad diarrhea.

After 10 days of appropriate antibiotic treatment, her diarrhea was gone but she was back to her tired and achy self. At my recommendation, she stopped the supplements, and her fatigue abated somewhat.

When we discussed her situation further, she revealed to me she suffered from a love-hate relationship with sugar.

Like many of my patients, when she was stressed out she binged on sugar. For most people, ingesting sugar provides a quick hit of the pleasure hormone dopamine, and for some people that rush of dopamine and the accompanying instantaneous boost of energy can become addicting.

The problem is that a high sugar load causes a surge in the hormone insulin, which then results in a sudden drop in blood sugar — which can promote fatigue, weakness and irritability, among other symptoms. If consumed in excess over time, such dietary sugar can cause abdominal distress, bloating and joint aches. This is what was probably causing my patient’s symptoms.

So we made a plan for her to not only cut back on sugar but also fill her diet with healthy stuff to get ahead of hunger and avoid binges. I also recommended she work with a therapist to deal with stress-eating. Her joint aches went away and her energy improved after about two weeks, and she continues to see a therapist for stress-eating issues.

Food — and added support to use it properly — was the fix.

Symptoms such as fatigue, headaches, joint pains and irregular bowel movements are some of the most common complaints I see in my office. They can be challenging for physicians to figure out, largely because they require careful and attentive listening by the doctor.

And since more than 40 percent of patients do not tell their doctors about their use of complementary or alternative medicine (including 25 percent who take supplements and/or herbs), physicians can be bewildered when trying to pin down a root cause for a patient’s complaints. Indeed, these patients are not easily diagnosed after a single lab test — and they are not easily fixed with a supplement.

Occasionally, it takes time with the patient, careful attention to the patient’s story, and asking the right questions to get to the bottom of the problem. Often, the solution is right under our nose.

Nature is indeed wonderful, but it doesn’t always come in a pill.

Lucy McBride is an internist based in the District.

Source: The health risks of supplements and alternative medicine – The Washington Post

John Oliver outlines what, exactly is problematic about Dr. Oz and the nutrition supplement industry. Then he invites George R.R. Martin, Steve Buscemi, the Black and Gold Marching Elite, and some fake real housewives on the show to illustrate how to pander to an audience without hurting anyone. Connect with Last Week Tonight online… Subscribe to the Last Week Tonight YouTube channel for more almost news as it almost happens: www.youtube.com/user/LastWeekTonight Find Last Week Tonight on Facebook like your mom would: http://Facebook.com/LastWeekTonight Follow us on Twitter for news about jokes and jokes about news: http://Twitter.com/LastWeekTonight Visit our official site for all that other stuff at once: http://www.hbo.com/last-week-tonight-…

How Serial Entrepreneur Keith McCarty Is Building Tech Solutions For The Cannabis Industry

Keith McCarty was two years into his Snoop Dogg-backed cannabis startup when he knew it was time for a change. Eaze, nicknamed the Uber for Weed as it serves as a delivery platform connecting cannabis dispensaries and their customers in legalized areas, was hitting its stride. It was 2014, and the company was on the eve of closing on a $40 million Series B round. What’s more, Eaze’s home state of California had just voted to legalize recreational use of marijuana, serendipitously expanding the company’s services beyond medical use clientele. But connecting clients and dispensaries came with multiplying constraints of the scattered commercial supply chain. So for McCarty, it was time to go.

McCarty, a serial entrepreneur, a founding team member of social media startup Yammer, saw an opportunity in the excruciating pain points between cannabis brands and dispensaries. In August, three years after his departure from Eaze and with $5 million in seed funding, McCarty launched Wayv, a B2B version of Eaze.“With more legalization comes more regulation and causes more friction in the supply chain,” McCarty told Forbes. That’s why he’s doubling down on his bet that tech solutions will help smooth out the logistical kinks through Wayv’s Amazon fulfillment model, in which brands can list their products and retailers can place bulk orders for next day delivery.

Like soda or cigarettes, the cannabis business is emerging with multiple brands, and each has its fans. It’s in the interest of every dispensary to carry the brands its customers prefer, but because of byzantine and contradictory state and federal laws, outlets can’t order multiple brands from a single outlet. Adding to the complication is the fact that nobody in the supply chain, not the growers, processors, distributors or retailers, can use banks to make it all happen as facilitating the sale of cannabis is against federal law.

Each cannabis brand begins with growers, processors and state-mandated laboratory tests before it hits the distributor, which gets the brand product to the warehouse before it’s ready to hit dispensary shelves. Together, cannabis brands bear the operational brunt of marketing, sales and processing transactions, and retailers can’t buy brands in bulk but have to deal with each individually.

“Today, the process retailers have to go through is sending emails, text messages and make calls to 30 to 50 brands to even place the order,” McCarty said. “This is one of the biggest white spaces in the industry and one of the most unsolved aspects.” In California, Wayv is greasing the cannabis distribution track, offering a “seed to sale” e-commerce compliance and distribution platform. For 80% of California’s licensed retailers using Wayv’s services, access to live inventory and brands beyond their geographical market means consistent and diverse product selection for dispensary customers. For a 15% fee, Wayv replaces the door-to-door salesman model for brands to get their products on store shelves and offloads the delivery and payment exchange—which is mainly cash-based.

Beboe, a high-end vape and edibles company, uses Wayv as a marketing tool and credits the platform for an uptick in sales. “Last year there was such a supply and demand issue because there was no data before,” said Kiana Anvaripour, Beboe’s VP of marketing. “Wayv has helped us be nimble and quick—it’s a way for you to be able to show your brand digitally.”

Brands, retailers and the distributor can all track the status of the order through Wayv’s platform and app, which helps avoid unwanted issues such as ordering the wrong product or amount—cannabis products legally come with a nonreturnable policy upon delivery.

Wayv also addresses one of the biggest pain points for brands, the inability to access  traditional lines of credit. To alleviate the cash flow part of the supply chain, Wayv offers an initial credit line and takes on delinquency and default for brands to help them keep up with market demand. “We understand that brands don’t want to be a distributor or tech company. Both of those are provided for a 15% fee, and that’s lower than your fully weighted distribution cost,” McCarty said.

McCarty remains the majority shareholder of Eaze, which he launched with his Yammer cofounders, Jim Patterson, Aleksey Klempner and Roie Edery. He spent a year at Microsoft after it purchased Yammer for $1.2 billion in 2012 before moving into cannabis. As research, McCarty interviewed 150 medical marijuana patients at the San Francisco medical dispensary Sparc. The biggest problem with the plant, McCarty cleared, was lack of easy access. Hence, Eaze.

“Eaze was pushing the limits of what’s required by brands to be able to participate, and very quickly you start to realize there’s a supply constraint about to happen,” said McCarty. He reemerged on the cannatech scene last summer with the launch of Wayv and $5 million in seed funding from Yammer cofounder David Sacks, his first investment in a cannabis business.

While there are a handful of cannabis POS startups, one thing Wayv has over one of its competitors is partnerships with a licensed distributor and lab. McCarty says one of the biggest hurdles brands face is getting their product into the dispensaries. The average mom-and-pop brownie business doesn’t have the funds to hire a delivery driver, so Wayv deploys a third-party distributor, Indus, to fulfill pickups for brands and drop-offs for retailers. Wayv also offers the option to offload state-mandated testing requirements by partnering with a licensed lab that conducts product batch testing adjacent to Indus’ warehouse.

Because Wayv is not vertically integrated, it’ll be easy to expand outside of California, but McCarty cautions that scaling is a race against time. “This is a very complex part of the supply chain,” he says. “People could probably do it over time, but the industry doesn’t have time.”

Follow Samar on Twitter at @HellaSamar or email her at smarwan[at]forbes.com.

Samar Marwan is the West Coast-based assistant editor of technology at Forbes. Marwan’s coverage of women run startups and the MENA tech scene has gone into defining

Source: How Serial Entrepreneur Keith McCarty Is Building Tech Solutions For The Cannabis Industry

The Global Drug Industry Putting Your Life At Risk – Srinath Perur

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In late 2012, 60 people died in two cities in Pakistan after drinking cough syrup to get high. Syrups from two separate manufacturers were involved. It was found that both were using an active ingredient — dextromethorphan, a synthetic morphine-like compound — imported from the same manufacturer in India. Indian drug authorities put a halt to production while they investigated. Tests in Pakistan revealed that the medicines seemed to contain the correct amount of active ingredient. But further tests revealed something that was not supposed to be there……..

Read more: http://digg.com/2018/fake-drugs-global-industry

 

 

 

 

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Are Supplements Safe & Do They Work – Dr Carter

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The story of a man who ended up needing a liver transplant after taking green tea capsules has brought the topic of dietary supplements back into the news. What are some of the dangers of supplements and what are the health benefits? When Jim McCants started taking green tea pills he had hoped he was giving his health a shot in the arm. Instead, it appears the pills caused such serious damage to his liver that it required an urgent transplant……..

Read more: https://www.bbc.com/news/health-45992725

 

 

 

 

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Marijuana Madness: This Is How CBD Oil Can Cause A Failed Drug Test – Mike Adams

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Cannabidiol, otherwise referred to as CBD is considered by a growing number of Americans to be the best thing since sliced bread. Not only does this non-intoxicating component of the cannabis plant provide people with relief from conditions ranging from anxiety to chronic pain, but it’s also mostly overlooked by law enforcement, in spite of its outlaw status in the eyes of the federal government. But people are being told that they can consume CBD on a daily basis and never have to worry about failing a drug test……

Read more: https://www.forbes.com/sites/mikeadams/2018/10/18/marijuana-madness-this-is-how-cbd-oil-can-cause-a-failed-drug-test/#1f76c92713bb

 

 

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We May Finally Know Why Marijuana Helps People With Chronic Gut Problems — ESIST

Your daily selection of the latest science news! According to Popular Science (This article and its images were originally posted on Popular Science August 13, 2018 at 06:22PM.) As John Mayer tells us (and tells us, and tells us), your body is a wonderland. When it comes to microbial life, this holds especially true for […]

via We may finally know why marijuana helps people with chronic gut problems — ESIST

 

 

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These Everyday ‘Drugs’ Cause More Harm Than the Illegal Ones, Study Says

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Worldwide, alcohol and tobacco cause much more death, disability and addiction than illegal drugs, according to a new review.

The review analyzed data from 2015 on global drug use — both overall and in 21 different regions — using data from the World Health Organization, the United Nations Office on Drugs and Crime, and the Institute for Health Metrics and Evaluation, as well as other sources. The researchers examined both the prevalence of drug use as well as the “health burden,” in the form of death and disability tied to drugs.

The researchers found that, worldwide, an estimated 18 percent of people reported “heavy” alcohol use in the last month (heavy use corresponds to more than 60 grams of alcohol, or about four standard drinks, on one occasion). In addition, 15 percent reported daily tobacco smoking, 3.8 percent reported marijuana use in the past year, 0.77 percent reported amphetamine use in the past year, 0.37 percent reported non-medical opioid use in the past year and 0.35 percent reported cocaine use in the past year.

Some of the highest levels of alcohol consumption were in Central, Eastern and Western Europe, where the per-capita consumption was 11 to 12 liters (about 3 gallons) of pure alcohol a year, compared with about 6 liters (1.5 gallons) a year per capita worldwide. These regions also had the highest levels of daily tobacco smoking, with around 21 to 24 percent of those populations reporting daily smoking, according to the review. [Here’s How Much Alcohol Is OK to Drink in 19 Countries]

Regarding addiction, an estimated 63 million people worldwide were dependent on alcohol in 2015, with about 843 cases of  alcohol dependence per 100,000 people. For comparison, about 20 million people were dependent on marijuana (260 cases per 100,000 people) and 17 million were dependent on opioids (220 cases per 100,000 people) in 2015.

However, the rates of marijuana and opioid dependence were almost threefold higher in the United States and Canada (a region called “high-income North America” in the report) than in the rest of the world, with an estimated 749 cases of marijuana dependence and 650 cases of opioid dependence per 100,000 people.

Tobacco smoking was tied to the greatest rate of death. For every 100,000 deaths in 2015, 110 were tied to tobacco, while just 33 were related to alcohol and seven to illegal drug use.

The researchers also calculated how many years of life were lost by people who died from drug use, or who were living with disability from drug use (which together were called “disability-adjusted life years,” or DALYs). They found that tobacco smoking cost the human population 171 million DALYs, compared with 85 million DALYs for alcohol and 28 million DALYs for illegal drug use.

“Alcohol use and tobacco smoking are far more prevalent than illicit substance use, globally and in most regions,” the researchers wrote in the May 11 issue of the journal Addiction.

And tobacco smoking accounted for most of the health burden due to drugs, they said. Still, the health toll of illegal drugs may be underestimated because available data on these drugs is limited.

For example, some countries and regions (including Africa, the Caribbean, Latin America and Asia) have little or no data on substance use and its associated health burden, the researchers said.

“Better standardized and rigorous methods for data collection, collation and reporting are needed to assess more accurately” the disease burden from substance use worldwide,” the researchers said.

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