Annotated Bibliography:

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Belzak, L., & Halverson, J. (2018). Evidence synthesis. The opioid crisis in Canada: a national perspective. Health Promotion and Chronic

     Disease Prevention in Canada, 38(6). https://doi.org/10.24095/hpcdp.38.6.02

 

     This review examines national data regarding opioid relate deaths and harms as of December 2017.  Risk factors were explained, especially sex and age.  It was found that most of the deaths occurred among individuals ages 30-39.  Males were more at risk than females.  First Nations communities were considered to be vulnerable populations and had disproportionately high opioid related death rates.  The authors describe how the role of fentanyl and analogues in the opioid crisis, as well as legal and illegal opioid use.  The use and distribution of naloxone was discussed.  The review compares the burden of deaths and hospitalizations due to opioid toxicity across the nation.  In addition to analyzing the emergency department visits, the authors focused on the amount of emergency medical services, first responders, and 911 calls related to opioid overdoses.  It was discovered that British Columbia, Alberta, Yukon, and Northwest Territories were facing the worst consequences of the opioid crisis.

 

Canadian Mental Health Association (2018, April). Care not corrections: Relieving the opioid crisis in Canada. Retrieved from

     https://cmha.ca/wp-content/uploads/2018/04/Summary-Report.pdf

 

     This summary report stresses the importance of people struggling with addiction needing health care.  It is argued that this should be the top priority over incarceration or punishment.  The data of opioid poisonings across Canada are mentioned for 2016 and 2017.  The increased rates of hospitalization and deaths were attributed to fentanyl and fentanyl analogues.  This report describes the social factors that are contributing to the epidemic.  Over-prescription of opioids as well as social inequalities are viewed to be influential components in this public health crisis.  The report provides specific recommendations and uses evidence to support their suggestions.  Overall, research, funding for mental health initiatives, and improved accessibility to treatment were the major concerns.  Other goals include strengthening social determinants of health, decriminalizing personal possession of illegal drugs, and creating more supervised consumption sites.  The report concludes that a national pain and addictions strategy needs to be created along with investment in research, education, and clinical care targeting safer pain management. 

 

Canadian Public Health Association (2016, December). The opioid crisis in Canada. Retrieved from

     https://www.cpha.ca/sites/default/files/uploads/policy/positionstatements/opioid-positionstatement-e.pdf

 

     This is a position statement from the Canadian Public Health Association (CPHA).  They make recommendations for action items for members of the federal government, provincial and territorial governments, Indigenous people’s governments, municipalities, and non-governmental organizations.  Their stance is that current failure at combating the opioid crisis, especially decreasing the amount of deaths, is due to an approach that is not comprehensive and involving inter-sectoral collaboration.  Across all levels of government and organizations, the CPHA want targeted efforts towards improving social determinants of problematic substance use.  Also, they argue that people with lived experience need to be involved in the development and implementation of opioid-related programs, legislation, policies, and regulation.  The CPHA believe health promotion programs and harm reduction strategies must meet the needs of a given community.  The importance of easy access to naloxone was stressed to prevent overdoses as well as protect first responders.  Overall, the CPHA declare the opioid crisis as a public health emergency.

 

Government of Canada. (2021a, February 17). Canada's opioid overdose crisis. Retrieved from Canada.ca/opioids

 

     This federal resource has extensive information, data, videos, and links, regarding the opioid crisis.  There are personal stories that provide insight into the problem.  This website provides access to virtual support through the Wellness Together Canada Portal.  People can receive free resources and counselling for mental and substance use through this portal.  This website explains how people can help if they witness an overdose.  In particular, the role of Naloxone in reversing opioid overdoses and how to administer it is highlighted.  Several informative videos can be found on this website such as a call to end the stigma surrounding addiction.    Reliable facts regarding opioids and the opioid overdose crisis are found on this website as well as information about the Good Samaritan law.  Posters, wallet cards, infographics and other resources are available on this website.  The Government of Canada argues that we all play a role in supporting those who use substances.

 

Government of Canada. [Healthy Canadians]. (2021b, February 16). Call, stay and help [Video]. YouTube. https://www.youtube.com/watch?

     v=e1l4OHLQ4jg

 

     As a part of the Know More: Opioid Public Awareness Campaign, the Government of Canada made several videos.  This brief video can be viewed on YouTube, on the main Canada.ca/opioids website, and on television advertisements.  The purpose of this video is to encourage people to stay and help if they witness an opioid overdose.  Often, people that are involved in these situations are worried that they will be in trouble for possessing illegal drugs.  Many of these people would flee the scene out of fear, which would have devastating consequences on the person that overdosed.  In order to prevent people from leaving, the Good Samaritan Law was created.  This video mentions how this law can protect you.  Calling 911, following instructions, and administering Naloxone if it is available are essential to helping in an opioid overdose situation.  The video specifically asks that people stay until help arrives.  The goal of this video is to educate people on how to respond to an opioid overdose. 

 

Government of Canada. [Healthy Canadians]. (2021c, February 16). End the stigma [Video]. YouTube. https://www.youtube.com/watch?

     v=inDI06DXVjg

 

     This video was created during the Know More: Opioid Public Awareness Campaign.  It has been shown on television and the internet, to promote awareness about substance use.  The main purpose of this video is to eradicate stigma associated with drug addiction.  The video describes the judgment and negative outcomes that people face when they are drug users.  The shame that is felt prevents people from seeking help.  The overdose deaths are in part due to the lack of accessing treatment due to stigma.  The video concludes by stating that addiction is a treatable medication condition and not a choice, with a call to end the stigma.  Canada.ca/opioids is listed at the end of the video which is a useful website for people struggling with addiction or friends and family of someone that uses substances.  This federal resource further explains why stigma needs to be eliminated.  Overall, the goal is to promote empathy and understanding while encouraging people to get help.

 

Government of Canada. (2020a, December). Federal actions on opioids to date. Retrieved from https://www.canada.ca/en/health-

     canada/services/substance-use/problematic-prescription-drug-use/opioids/federal-actions/overview.html

 

     This website showcases the federal actions on opioids to date.  An alternative format of a PDF file is available.  The Emergency Treatment Fund, an investment of over $300M, allowed for improvements in access to treatment.  It also mentions how First Nations and Inuit communities have received support with the creation of 25 opioid agonist treatments sites.  Throughout Canada, there are 38 supervised consumption sites that are operating.  The website mentions the benefits of these supervised consumption sites.  More than 2.3 million visits have been made to these sites, with nearly 19,000 overdoses that were reversed.  Not a single death occurred at a supervised consumption site.  Moreover, workers at these sites were able to help users get in contact with health and social services, with over 92,000 referrals made.  In terms of awareness and prevention, the Canadian Pain Task Force report was highlighted as providing useful information on best practices to managing chronic pain.

 

Government of Canada. (2020b, December 8). Know More: Opioid public awareness. Retrieved from https://www.canada.ca/en/health-

     canada/services/substance-use/problematic-prescription-drug-use/opioids/know-more-public-awareness.html

 

     This website provides information about the Know More: Opioid Public Awareness Campaign.  The purpose of this site and campaign is to engage the public, particularly teens and young adults, to educate them about the opioid crisis and health risks associated with opioid misuse.  There is a link to a page describing what to talk to your healthcare provider about and what questions to ask if being prescribed opioids.  There are supportive materials such as factsheets and wallet cards that are available.  The main topics include Naloxone, stigma, problematic opioid use, Canada’s opioid crisis, and a description of opioids.  Supporting materials are key to spreading awareness and fostering engagement.  School visits can be requested to further educate students, with a sign up sheet for tours towards the bottom of the page.  Moreover, multiple Know More kits can be ordered with resources such as mirror cling info-graphics, and posters.  Ideally, the Know More materials become widespread across Canada and educate as many Canadians as possible.  

 

Government of Canada. (2020c, May 26). Emergency Treatment Fund. Retrieved from https://www.canada.ca/en/health-

     canada/services/substance-use/problematic-prescription-drug-use/opioids/responding-canada-opioid-crisis/emergency-treatment-

     fund.html

 

     This website describes the Emergency Treatment Fund and how the money was distributed.  Funds were allocated based on severity of the opioid crisis in the province or territory as well as the population size of in the region.  The reason was to ensure that the places with the highest burden of the crisis received adequate support while still allowing for other provinces and territories to prepare for possible future impacts.  The degree to which the problems are felt vary across jurisdictions, but everyone required some form of funding in order to make certain that the health of their community was a top priority.  The bilateral agreements between the federal government and each province is listed on this website.  There is transparency on where the funding is going and the action plans.  Moreover, each province and territory is required to report at regular intervals on the progress of their initiatives with a focus on evidence-based treatment.

 

Government of Canada. (2020d, March 19). Opioid overdoses: What to do factsheet. Retrieved from https://www.canada.ca/en/health-

     canada/services/publications/healthy-living/opioid-overdoses-what-to-do-fact-sheet.html

 

     This factsheet makes readers feel confident that they will have the knowledge on how to identify an overdose and react appropriately.  The signs and symptoms are listed.  These include blue lips or nails, dizziness, confusion, choking, gurgling sounds, drowsiness, difficulty to wake up, and disrupted breathing rate.  The recommendations on how to act if you witness an overdose are made, with reference to the Good Samaritan Drug Overdose Act.  This provides immunity to those that have taken drugs or have some on them from a simple drug possession charge if they contact help for someone else who has overdosed.  In particular, if someone’s breathing becomes weaker, shallower, or stops completely it is crucial to contact emergency medical services and stay at the scene to help save a life.  The factsheet also explains how to protect yourself from an overdose.  The main points are to avoid using illegal opioids, don’t use when you’re alone, carry a naloxone kit, and don’t mix with alcohol or other drugs.

 

Government of Canada. [Healthy Canadians]. (2020e, February 28). Opioid awareness campaign [Video]. YouTube.

     https://www.youtube.com/watch?v=Ov03WsWVi2U

 

     This video highlights the dangers of improper use of opioids such as oxycodone and fentanyl.  It explains that some people receive these drugs as a prescription to combat pain, but these medications must be used carefully.  Misuse can lead to an overdose or even death.  The video highlights how common opioid overdoses are in Canada, stating this is the cause of death for 12 Canadians everyday.  Street drugs laced with fentanyl are the reason for may of these opioid-related overdoses.  The video explains that only a few grains of fentanyl are needed to kill somebody.  The video refers people to Canada.ca/opioids website to obtain further credible information and facts.  One of the aims of this video is to help prevent accidental opioid poisoning.  This is one of the videos featured in the Know More: Opioid Awareness Campaign that was viewed across Canada on television and the internet.  The Government of Canada is taking action and believes that if we are united we can change lives that are impacted by this opioid crisis.

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Government of Canada. (2019a, April 23). About the Good Samaritan Drug Overdose Act. Retrieved from https://www.canada.ca/en/health-

     canada/services/substance-use/problematic-prescription-drug-use/opioids/about-good-samaritan-drug-overdose-

     act.html

 

     This website describes the Good Samaritan Drug Overdose Act and provides a downloadable poster.  The main message is that people should call 911 or a local emergency number when they witness and overdose and remain at the scene until help arrives.  The purpose of this Act is reduce the amount of opioid overdose deaths.  The public health crisis of growing number of opioid-related overdoses and deaths are stated as bing a priority for the Government of Canada.  In the event of an overdose, this act provides some legal protection.  For example, the Act can protect you from charges for possession of a controlled substance under section 4(1) of the Controlled Drugs and Substances Act.  Moreover, the Act can protect you from breach of conditions in pre-trial release, probation orders, conditional sentences, and parole.  The Act became law on May 4, 2017.  However, it is noted that the Act does not provide legal protection against more serious offences such as outstanding warrants, production and trafficking of drugs, and other crimes not outlined within the Act.

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Government of Canada. (2019b, April 9). Canada's opioid crisis factsheet. Retrieved from https://www.canada.ca/en/health-canada/services/

     publications/healthy-living/canada-opioid-crisis-fact-sheet.html

 

     This factsheet outlines the opioid crisis being experienced within Canada.  It is a public health problem that not only effects the drug users, but also their families and communities at large.  The statistics and data are explained.  The vast majority of the opioid overdoses have been deemed accidental, with 94% of the deaths appearing to not have intentional causes.  Teens and young adults, 15-24 years old, are the fastest-growing population requiring hospitalization following opioid misuse.  The factsheet explains why fentanyl is extremely dangerous.  It is an undetectable substance since you cannot see, taste, or smell it.  A very small amount of fentanyl is required to cause death.  Sometimes, street drugs made illegally may accidentally contain traces of fentanyl if the equipment used was contaminated with fentanyl.  Moreover, there is a risk of fake pills being produced with unknown amounts of fentanyl.  The factsheet also describes the role of legally prescribed opioids to this complex issue.  Overall, the opioid crisis is explained and the actions taken to respond to it are summarized.

 

Government of Canada. (2019b, March 11). Restricting the marketing and advertising of opioids. Retrieved from https://www.canada.ca/en/

     health-canada/services/substance-use/problematic-prescription-drug-use/opioids/responding-canada-opioid-crisis/advertising-opioid-

     medications.html

 

     This website explains how marketing and advertising of opioids mislead people and contributed to the opioid crisis.  The underestimation of dangerous consequences and overestimation of benefits due to these marketing campaigns resulted in over-prescription of opioids for pain management.  In light of this, the government has now taken a clear stance on wanting restrictions against pharmaceutical companies to prevent false representation of opioids.  The amount of opioid prescriptions in Canada is alarmingly high compared to the rest of the world.  In fact, Canadians are the second highest users per capital of prescription opioids in the world.  The Minister of Health wrote a letter to manufacturers and distributors of opioids calling on them to voluntarily cease marketing and advertising of opioids.  That letter is available on this website by a link provided by Health Canada.  Also, this website introduces the new Health Canada platform called “Stop illegal marketing of drugs and devices.”

 

Health Canada. (2020, July 28). Supervised consumption sites and services: Explained. Retrieved from https://www.canada.ca/en/health-

     canada/services/substance-use/supervised-consumption-sites/explained.html

 

     This website goes into detail about Canadian supervised consumption sites.  The benefits are explained on an individual level as well as community level.  As a pillar to Canada’s harm reduction strategy, safe consumption sites offer many services.  Users have access to clean drug use equipment as well as safe disposal areas for items such as needles.  This helps reduce the spread of infectious diseases such as HIV.  Individuals can receive testing for HIV, hepatitis C, and sexually transmitted infections.  The sites provide drug checking to ensure that harmful substances such as fentanyl are not present.  Naloxone and other medications to treat overdoses and opioid use disorder are available at these sites.  Workers can help connect drug users to social services such as housing or employment supports, as well as health services such as drug treatment and rehabilitation.  The website has an interactive map to help people find a site in their area.

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Jalali, M.S., Botticelli, M., Hwang, R.C., Koh, H.K., & McHugh, R.K. (2020). The opioid crisis: a contextual, social-ecological framework. Health

     Research Policy and Systems, 18(87). https://doi.org/10.1186/s12961-020-00596-8

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     This article provides commentary on the opioid epidemic using a social-ecological approach.  The authors argue that broader social and contextual domains need to be considered, not solely individual level factors.  A social-ecological framework is believed to capture the multidimensional complexity of the issue.  The article provides evidence and considerations at each of the levels of influence.  The levels that are examined are individual, interpersonal, communal, and societal.  The authors state that there is substantial interconnectedness and overlap among these contexts.  These multi-directional links need to be better understood in order to respond appropriately to the opioid crisis.  A figure is provided which shows the main contributing factors at each level.  For example, biological and genetic susceptibility is noted at the individual level.  Access to an opioid supply through social networks are a part of the interpersonal level.  Quality of health care and treatment availability are top concerns at the community level.  Social stigma, educational campaigns, law enforcement and government regulations are some of the main societal level factors.

 

Mspin, U. (2017). Social ecological model. Ecology of Health and Medicine. Retrieved from https://blogs.uw.edu/somehm/2017/08/12/social-

     ecological-model/

 

     This online text for Ecology of Health and Medicine at the University of Washington provides information about the social ecological model.  The creators are credited as McLeroy, Bibeau, Steckler and Glanz.  The model is described at the various levels of influence and illustrated in a diagram using different sized circles.  The downstream factors, such as the individual and interpersonal levels are smaller.  Moving towards the higher upstream factors, the circles become larger, such as the public policy and community level.  The key contributors at the individual level are knowledge, attitudes and skills.  For the interpersonal level, the social networks including family and friends are the main focus.  The organizational level includes various organizations such as the workplace and school.  Design, access, connectedness, and spaces are viewed as main contributors at the community level.  Finally, the public policy level involves national, provincial/territorial, and local laws or policies.  A patient’s health is felt to be influenced by all these levels of influence.

 

Public Health Agency of Canada. (2020a, December). Apparent opioid and stimulant toxicity deaths. Surveillance of opioid- and stimulant-

     related harms in Canada. Retrieved from https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/technical-

     notes

 

     This surveillance report provides provincial and territorial data on opioid and stimulant toxicity deaths.  Western Canada is considered to be the most impacted.  However, growing concerns throughout the country are becoming more pronounced as record breaking death tolls are increasing during the COVID-19 pandemic.  A key finding is that the majority of accidental opioid overdoses tend to happen among males ages 20-49.  75% of apparent opioid toxicity deaths were due to the involvement of fentanyl.  Of the fentanyl-laced opioid toxicity deaths, almost all of them were from a non-pharmaceutical source.  The statistic provided was 99% of the time that fentanyl was detected in opioid toxicity deaths the supply of the opioids was non-pharmaceutical.  A summary of the national data from 2016 to June 2020 is provided on this website.  A useful table breaks down the percentages by sex, age group, involving fentanyl, involving fentanyl analogues, involving non-fentanyl opioids, and involving stimulants. 

 

Public Health Agency of Canada. (2020b, December). Opioid- and stimulant-related harms in Canada. Special Advisory Committee on the

     Epidemic of Opioid Overdoses. Retrieved from https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/maps

 

     This website allows people to view data across a map of Canada.  The user can choose what they would like to be represented.  The choices include substance, data source, type of event and time period.  The deaths or hospitalizations across Canada can be seen relating to opioids or stimulants.  Moreover, the numbers of opioid toxicity deaths can be broken down into total events as well as accidental events.  In terms of time period, the data can be examined for each year dating back to 2016.  The rates per 100,000 population are illustrated based on a colour gradient with darker colours being higher rates.  The rate legend is located beside the map.  The result of the search function in terms of a number, whether you are searching number of deaths or hospitalizations, is circled and placed on top of each province or territory.  Below the illustrations, you can see the data in a table format as well.

 

Public Health Agency of Canada. (2020c, December). Suspected opioid-related overdoses based on Emergency Medical Services. Surveillance

     of opioid- and stimulant-related harms in Canada. Retrieved from https://health-infobase.canada.ca/substance-related-harms/opioids-

     stimulants/technical-notes

 

     This surveillance report from 2017 to June 2020 focuses on suspected opioid-related overdoses from the perspective of emergency medical services.  The provinces with higher proportions of emergency medical services responses occurred in British Columbia, Alberta, and Ontario.  A description of how suspected overdoses were counted as well as limitation on the data were provided.  Several tables were used to showcase the differences across regions.  Data sets were compared in terms of age group and sex throughout the provinces and territories.  Quebec, Prince Edward Island, and Nunavut did not provide data for comparison.  Some of the regions did not have enough data, with numbers of five or less.  Due to concerns of releasing small numbers, the tables marked these as data suppressed.  The sources of the data for each province and territory were listed.  The Public Health Agency of Canada asks that people interpret the comparisons between regions with caution due to differences in case definitions.

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Spearn, B., & Gill, K. (2019). Journey to Hope: An update report on the VPD's continued fight against the opioid crisis. Retrieved from

     https://vancouver.ca/police/assets/pdf/VPD-Opioid- Crisis-Report.pdf

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     This is an update report on the Vancouver Police Department’s efforts to combat the opioid crisis.  The four pillar approach that has been used to respond to this public health crisis is explained.  The pillars include prevention, enforcement, harm reduction and treatment.  Strategies and interventions to avert harm include public education and knowledge exchange between law enforcement.  From an enforcement point of view, the Vancouver Police Department’s priority is to disrupt the distribution of drugs.  This report explains enforcement projects to deal with drug dealers.  Also, a new drug processing facility is mentioned.  The reason for it being built was to minimize risk for police officers during the handling and tagging of drug exhibits.  Increased training and education was noted as an achievement at the organizational level.  A continuum of care is highlighted as being important to the prevent overdoses.  This report discusses collaborations and partnerships with the province and the mayor’s overdose emergency task force.

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Taha, S., Maloney-Hall, B., & Buxton, J. (2019). Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances

     strategy. Substance abuse, treatment, prevention, and policy, 14(32). https://doi.org/10.1186/s13011-019-0220-7

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     This review examines Canada’s strategic actions during the opioid epidemic.  Peer-reviewed literature and grey literature from reputable substance use and health organizations were used to assess Canada’s opioid crisis responses and outcomes from 2013-2019.  This review identifies lessons learned from the initiatives as well as the knowledge gap requiring more research and surveillance. The application of the four pillar model in the Canadian drugs and substances strategy is described.  Both immediate and long-term strategies are necessary to deal with this complex issue.  It is suggested that people with lived experience, including those that have misused opioids as well as families affected by the opioid crisis, should be involved in strategic planning.  Their consultations can provide useful insights and help minimize stigma.  Moreover, their involvement can ensure strategies are more effective and acceptable with less unintended consequences.  The review highlights the evolving nature of the opioid crisis which requires solutions that meet the needs of different communities and populations.