Canada has seen a staggering number of deaths and hospitalizations due to opioid misuse. The increase in overdose deaths started around 2013, when fentanyl and fentanyl analogues became more easily available (Jalali et al., 2020). Fentanyl, a synthetic opioid pain reliever, is chemically related to morphine but 50 to 100 times more potent (Canadian Public Health Association, 2016). In recent years, there's been significant efforts to combat this public health crisis. In 2018, the Government of Canada started the Know More: Opioid Public Awareness Campaign.
To me, the goals of the campaign fit into 5 main categories:
1) Promote awareness about opioid misuse and provide evidence of the opioid crisis
2) Decrease the stigma surrounding drug addiction
3) Teach people how to help if they witness an opioid-related overdose
4) Direct opioid users to resources and inform them of ways to seek help
5) Educate people about efforts to minimize loss of life
The Government of Canada (2020a) encourages people to learn about the opioid crisis through their website, Canada.ca/Opioids, as seen in Video 1. The purpose of the campaign is to highlight how widespread this problem is across the nation.
Video 1. Opioid awareness campaign (Government of Canada, 2020e)
The amount of people dying from opioid toxicity differ between the provinces as seen in Figure 1 (Government of Canada, 2020b). British Columbia (B.C.) has the highest rate (per 100,000 population) of total apparent opioid toxicity deaths in the country (Government of Canada, 2020b). Figure 2 shows this comparison between provinces/territories in a graph form; B.C., Alberta, and Yukon were above the national average (Government of Canada, 2020b).
Figure 1. Number and rates (per 100,000 population) of total apparent opioid toxicity deaths by province or territory in June 2020 (Government of Canada, 2020b)
Figure 2. Crude rate (per 100,000 population) of total apparent opioid toxicity deaths by province or territory in June 2020 (Government of Canada, 2020b)
Living in Vancouver has made me all too familiar with the opioid crisis. I've seen a large amount of opioid overdose patients and heard countless stories of addiction and loss. The highest burden has been experienced in Western Canada (Belzak & Halverson, 2018). Although Ontario saw more hospitalizations related to opioid poisoning than B.C., the rate (per 100,000 population) of these hospitalizations were still highest in B.C. as well as Saskatchewan, noted in Figure 3 (Government of Canada, 2020b).
Figure 3. Number and rates (per 100,000 population) of total opioid-related poisoning hospitalizations by province or territory from January to June of 2020 (Government of Canada, 2020b)
The solution to Canada's opioid crisis is complicated since there are multivariable risk factors. Jalali et al. (2020) explain, "Interventions that only target a single aspect of the issue, such as restricting opioid supply, will not be sufficient to ameliorate the opioid epidemic." A broader and integrated approach to prevention and treatment is required (Jalali et al., 2020). Social and contextual domains including interpersonal relationships and the conditions of the community that an individual lives in are essential to understanding the full scope of the opioid epidemic (Jalali et al, 2020). The social-ecological model is discussed in more detail in my blog post "Levels of Influence on Health", but the framework is depicted in Figure 4 (Mspin, 2017). In this post, I will examine the opioid crisis from a social-ecological approach, to identify the various levels of influence to this health problem.
Figure 4. Social-Ecological Model Framework (Mspin, 2017).
Individual Level
Biological
Genetic factors
Individuals may be prone to developing a substance use disorder due to biological vulnerability, especially if genetic factors alter the opioid receptors in the brain to influence the effect of taking opioids (Jalalei et al., 2020).
Psychosocial
Stigma and self-determination
Negative self talk and feelings such as fear, anger, shame, hopelessness, grief, or loneliness can prevent someone from accessing health or social services (Government of Canada, 2020a).
Job
Labour-intensive and physically demanding
People with jobs that are physically demanding and involve a higher risk of labour-related injuries, particularly construction workers, have the highest opioid overdose rates (Jalali et al., 2020).
Unstable Housing
Homelessness
30% of the total patient population presenting to the emergency department for a suspected overdose did not have a fixed address or known address (Belzak & Halverson, 2018). This number jumps to 50% for young people aged 13-18 years old (Belzak & Halverson, 2018).
Proximity to Opioids
Likelihood of exposure
Family members or close friends provided the opioids for nearly 70% of people that reported non-medical opioid use (Jalali et al., 2020).
Origin of Opioid Misuse
Development and maintenance of opioid use disorder
In Canada, the volume of opioids sold to hospitals/pharmacies for prescriptions has increased by more than 3000% since the 1980s (Belzak & Halverson, 2018). Some routes for obtaining an opioid supply include a legitimate prescription, a fraudulent or forged prescription, and "double doctoring," which refers to secretly visiting multiple doctors to collect prescriptions for the same issue (Belzak & Halverson, 2018). Theft, internet purchases, and the street drug market are also popular sources for opioids (Belzak & Halverson, 2018). The most common way of obtaining opioids is sharing with a family member or close friend (Belzak & Halverson, 2018).
Engagement with Treatment
Attempts to quit and readiness for change
The withdrawal symptoms are severe which makes it difficult to quit; in fact, researchers state that as the opioid use disorder progresses, "the primary reason for use tends to shift to avoiding/relieving withdrawal more than managing pain or feeling good." (Jalali et al., 2020).
Medical history
Physical and mental health
Co-morbidities, particularly related to mental health and acute or chronic pain, were important predictors for opioid use disorder (Jalali et al., 2020). Jalali et al., (2020) describe pain as being a core element of the opioid crisis since the origin of opioid misuse for so many started from a legitimate prescription to treat pain. A history of substance use disorder was the most robust predictor of abusing a prescription supply of opioids for people with chronic pain (Jalali et al., 2020).
Sociodemographic
Income, education, age, sex, race
These factors are important for identifying at risk individuals. In some cases, the factors are both a cause and a consequence of opioid misuses, such as financial strain (Jalali et al, 2020). The majority of deaths from opioid overdoses occurred in large urban centres, indoors within private residences typically in lower to middle-income neighbourhoods (Belzak & Halverson, 2018). An adequate income and higher education are protective factors (Jalali et al., 2020). Figure 5 provides an analysis of the sex differences across the nation from 2017-2020 in terms of emergency medical services in response to opioid poisoning (Public Health Agency of Canada, 2020c). Despite women being more likely than men to receive an opioid prescription, the percentage of opioid overdoses were significantly higher for males throughout Canada (Jalali et al., 2020; Public Health Agency of Canada, 2020c). It is also important to note that opioids are teratogens which means they may produce birth defects if a pregnant women is exposed to the substance (Jalali et al., 2020). Figure 7 provides information about the vulnerability of age groups, with 30-39 being the most at risk (Public Health Agency of Canada, 2020a). Race is another important determinant as it can play a role in access to treatment (Jalali et al., 2020).
Figure 5. Annual sex distribution of EMS responses to suspected opioid-related overdoses by province or territory, 2017 to June 2020 (Public Health Agency of Canada, 2020c)
Figure 6. Summary of total apparent opioid toxicity deaths in Canada, 2016 to June 2020 (Public Health Agency of Canada, 2020a)
Interpersonal Level
An individual's behaviour is heavily influenced by interpersonal relationships, especially with family, friends, co-workers, and peers. Peer pressure sometimes results in the initiation of opioid misuse. Being in an environment where substance abuse is common increases the likelihood that an individual will misuse opioids. In fact, opioid misuse or overdose is 10 times more likely for someone with a family member who has opioid use disorder (Jalali et al., 2020). A woman is significantly more likely to abuse opioids if her spouse/partner already misuses opioids (Jalali et al., 2020). Accessibility to opioids is another contributing factor at the interpersonal level, if someone has friends or family with a drug supply. Adverse childhood experiences, such as witnessing a family member overdose on opioids, also increases someone's chances of overdosing on the drug themselves (Jalali et al., 2020). Although interpersonal relationships can influence someone to abuse opioids, there's also the possibility that positive social supports will have an impact on seeking treatment (Jalali et al., 2020).
Organizational Level
Given that some people are dying from opioids that were prescribed to them (particularly in New Brunswick, Newfoundland and Labrador, Nova Scotia and Saskatchewan), there needs to be scrutiny of physician's opioid prescribing patterns as well as improved frequency of follow-up for patients on opioids (Public Health Agency of Canada, 2020a). In some cases, there is an over-prescription of opioids, a problem caused in part due to false pharmaceutical marketing campaigns that claimed opioids were not addictive (Jalali et al., 2020). Also, some doctors' overestimation of benefits and underestimation of dangers regarding opioids have contributed to over-prescription (Jalali et al., 2020). Figure 7 shows the differences among provinces/territories in terms of where the drugs came from (Public Health Agency of Canada, 2020a.)
Figure 7. Percentage of accidental opioid toxicity deaths by origin of opioid(s) involved in the death, by province or territory, January to June 2020 (Public Health Agency of Canada, 2020a)
Policies which are institution-specific impact treatment strategies as well as the way in which opioids are dispensed and destroyed. Examples of changes at the organizational level are creating policies and procedures that minimize the risks for police officers while they are performing their duties. A police officer may be exposed to opioids when conducting searches or when coming to the aid of someone who has overdosed (Spearn & Gill, 2019). Firstly, the Vancouver Police Department increased the amount of training for officers on the topic of safe handling of drugs (Spearn & Gill, 2019). When it was discovered that officers did not have adequate space to safely process and tag drug exhibits, a new drug processing facility was built at the Vancouver Police Department Property Office (Spearn & Gill, 2019).
Community Level
In Vancouver, drug use is rampant in the Downtown Eastside. This area has a large population with a history of mental illness and homelessness. A place like this is a good example of the influence of community norms, accessibility to opioids, and social relationships. Sometimes, social interactions have a negative outcome on a person's health, such as when drug use is the norm (Government of Canada, 2020a). However, an example of positive social relationships would be a support group that helps someone during relapse and on the road to recovery (Government of Canada, 2021a). Access to treatment, including substance use and addiction programs, is essential to beat the opioid problem (Government of Canada, 2021a). The Community level looks at the geographic conditions as well as the cultural values. Video 2 is a call to end the stigma surrounding drug addiction, and to encourage our society to view it as "a treatable medical condition, not a choice." (Government of Canada, 2021c).
Video 2. End the stigma surrounding addiction (Government of Canada, 2021c)
One solution that has been gaining popularity, especially in Vancouver, is providing safe consumption sites. The idea being that users will not have a tainted drug supply and will have immediate access to health care including Naloxone which reverses the effects of an opioid overdose (Health Canada, 2020). The Canadian Public Health Association (2016) strongly believes that Naloxone should be readily available for those who need it, as an over-the-counter product. These supervised consumption sites and Naloxone kits are the main pillars of the harm reduction strategy (Health Canada, 2020).
The prevalence of opioid use disorder is disproportionately higher in certain communities. Notably, First Nations communities have exceptionally large numbers of opioid-related deaths (Belzak & Halverson, 2018). In fact, B.C. and Alberta reported that First Nations people are 5 times more likely to experience an opioid overdose and 3 times more likely to die from opioid toxicity (Belzak & Halverson, 2018). In Alberta, First Nations individuals were twice as likely to be dispensed an opioid compared to non-First Nations individuals (Belzak & Halverson, 2018).
Figure 8. Canada's opioid crisis factsheet (Government of Canada 2019b)
Spreading awareness throughout communities and providing education is a key component to the Government of Canada's action plan. For example, circulating factsheets/posters delivers a lot of useful information, as seen in Figures 8 and 9 (Government of Canada, 2019b; Government of Canada 2020d).
Figure 9. Opioid overdose factsheet (Government of Canada, 2020d)
Public Policy Level
Policies need to be evidence-based and created using inter-sectoral collaboration (Canadian Mental Health Association, 2018). An example of a positive change at the public policy level is the Good Samaritan Drug Overdose Act, which received Royal assent and became law (Government of Canada, 2019a). Simply put, this "new law would provide immunity from simple possession charges for those who call 911 in the case of an overdose." (Government of Canada, 2019a). The goal is to encourage people to stay and help instead of fleeing the scene, including if that person is in possession of drugs, as highlighted in Video 3 (Government of Canada, 2021b).
Video 3. Call, stay and help if you witness an opioid overdose (Government of Canada, 2021b)
Canada's Strategic Response
The Canadian Public Health Association (2016) argues that we must:
"Support initiatives that address the causes and determinants of problematic substance use."
The Vancouver Police Department's opioid crisis report, "The Journey to Hope," explains the progress made and the actions taken in response to the opioid epidemic using the four pillars approach (Spearn & GIll, 2019).
The Four Pillars:
(Spearn & Gill, 2019)
1) Prevention
Strategies and interventions to avert harm
• Increase awareness, decrease demand for substances (Taha et al., 2019).
• Strengthen social determinants of health especially socioeconomic status, homelessness, familial attachment, education, and resiliency (Taha et al., 2019).
• Create appropriate pain management strategies (Taha et al., 2019; Canadian Mental Health Association, 2018).
• Reduce stigma through efforts such as the Know More: Opioid Public Awareness Campaign (Government of Canada, 2020b).
• Invest in mental health services (Canadian Public Health Association, 2016; Canadian Mental Health Association, 2018).
• Restrict pharmaceutical companies in terms of marketing and advertising of opioids (Government of Canada, 2019b).
2) Enforcement
Disrupting the distribution of drugs
• Prevent illegal drug manufacture and distribution (Taha et al., 2019; Spearn & Gill, 2019).
• Ensure public safety (Government of Canada, 2020a).
• Decriminalize personal possession of illegal drugs (Canadian Mental Health Association, 2018).
• Limit extra-professional purchase of pill presses (Canadian Public Health Association, 2016; Spearn & Gill, 2019).
• Stop fentanyl and its precursor components from being illegally imported, particularly from China (Canadian Public Health Association, 2016; Spearn & Gill, 2019).
3) Harm reduction
Strategies to prevent overdoses
• Have supervised consumption sites to prevent accidental overdoses and reduce the spread of infectious diseases, such as HIV (Health Canada, 2020). Workers at these sites can help connect people to social services like housing, employment assistance and food banks (Health Canada, 2020). Also, providing a safe space where Naloxone kits are available helps reduce the strain on emergency medical services (Health Canada, 2020; Government of Canada, 2020a).
• Distribute fentanyl test strips to help prevent accidental overdoses (Government of Canada, 2020a). For example, Interior Health gives out BTNX™ test strips so users can test their supply and see if fentanyl is present (Government of Canada, 2020a). It is important to note, the strips are not 100% accurate and do not say how much is present or how strong the substance is (Government of Canada, 2020a).
• Provide tools and resources to enable a person, their family, and communities to be safer (Taha et al., 2019).
4) Treatment
Encouraging healthier alternatives
• Improve accessibility of treatment via the Emergency treatment fund, an over $300M investment (Government of Canada, 2020a).
• Use pharmacological interventions such as opioid agonist therapy (Taha et al., 2019).
• Amend regulations to facilitate the prescription and dispensing of methadone and diacetylmorphine (Government of Canada, 2020a.).
• Counsel individuals and give free resources for mental health and substance use via the Wellness Together Canada Portal (Government of Canada, 2021a).
• Provide substance use and addiction programs (Government of Canada, 2020a).
• Monitor prescription drug use by ensuring individuals have regular primary care (Government of Canada, 2020a).
The intense devastation from the opioid crisis has motivated action across the different levels of influence (individual, interpersonal, organizational, community, and public policy). People suffering from opioid use disorder need help, and multilevel interventions are necessary to mitigate the opioid crisis. Increasing criminalization of drug use has diverted a high proportion of this population to prison (Canadian Mental Health Association, 2018). Drug addiction is a health problem before it is a criminal justice problem, and these people should be receiving care over incarceration (Canadian Mental Health Association, 2018). There should be a continuum of care (Spearn & Gill, 2019). Going ahead, we must continue to research, fund, and improve the social determinants of health and access to treatment (Canadian Mental Health Association, 2018; Government of Canada 2021a). Opioids data, research, and surveillance will help the success of a national pain and addictions strategy (Canadian Mental Health Association, 2018; Government of Canada, 2021a). Involving people that have lived experience with opioids will provide useful insight during planning for new policies, programs, and regulations (Canadian Public Health Association, 2016). Their guidance and recommendations will ensure new initiatives are relevant, accommodating, and accessible for people who use substances (Canadian Mental Health Association, 2018). Applying a social-ecological approach to the opioid crisis is nicely summarized in Figure 5 (Jalali et al., 2020).
Figure 5. Social-ecological framework of the opioid crisis (Jalali et al., 2020)
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