Is Canada Losing the Opioid Battle?

The opioid crisis has been waging a war against Canada’s healthcare system and its people. The use of opioids, including fentanyl, oxycodone, morphine and heroin, often used for pain relief, are attributed to be highly addictive and are lethal when misused (Canadian Institute for Health Information [CIHI], 2018). Consequently, these medications requiring prescriptions can be illegally acquired and can increase rates of substance use, increased dependence, as well as substance-related deaths. Not only does this have a direct negative impact on people’s health, it significantly strains health care resources by inflating numbers of emergency department visits and hospitalizations due to the growing numbers of opioid use (CIHI, 2018). As the numbers of overdoses and deaths rises, this major Canadian public health issue requires careful collaboration and cooperation from the federal government as the problem plagues the whole country.

Impact on Canada

National Issue

According to a Government of Canada report, numbers of apparent opioid-related deaths in Canada remains high, with reported numbers being 3,005 in 2016 and increasing to 3,996 in 2017 (Government of Canada, 2018). The report also states at least 1,036 apparent opioid-related deaths have already been recorded between January and March of 2018 – 94% were accidental deaths. These numbers are based on reported overdoses, meaning the actual numbers of opioid-related deaths may be even higher. Based on the trends, the number of opioid-related deaths and overdoses are increasing alarmingly, thus making this a national public health issue.

Hitting Close to Home

The impact from the opioid crisis can also be felt in local communities. According to a Kingston, Frontenac and Lennox & Addington Public Health (KFL&A) media release on July 10, 2018, it reported a rise in opioid-related overdoses within its regions. Additionally, KFL&A Public Health’s Associate Medical Officer, Dr. Fareen Karachiwalla, reports, “We do typically see a rise in overdoses during the summer months. However, over the past two and a half weeks, we’ve had roughly 7 hospital admissions because of opioid overdoses, which is unusual, even for this time period” (KFL&A, 2018). The sudden influx should prompt an investigation on why this is occurring in order to take appropriate actions in preventing further overdoses and admissions.

Closer Look at the Problem

As mentioned before, the opioid crisis is prevalent throughout Canada. However, there are provinces where its impact can be felt more heavily, such as British Columbia, Ontario as well as Alberta (Government of Canada, 2017). Within these provinces, there are regions and cities that may have higher prevalence in opioid use, which leads to the need for assessments, risk analysis and root-cause analysis to find patterns that may help develop appropriate solutions and interventions. Although this paper focuses on the problem as a national problem, it is important to consider individual needs in impacted communities as their needs may be different due to cultural, demographic and geographical differences.

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According to the Government of Canada’s national report (2007), there are similar patterns amongst opioid-related deaths between provinces and territories. For example, all provinces and territories found that there was a higher proportion of opioid-related deaths in males than females. Additionally, the highest national percentage of opioid-related deaths was 28.1% in those between the ages of 30 to 39. However, it is important to understand that this might not be the case for all provinces or territories as these numbers are based on averages and different factors can effect incidence rates amongst other populations (e.g., First Nations). For example, Ontario’s age group between 50 to 59 years of age had the highest percentage of opioid-related deaths instead of the 30 to 39 age group. It is also important to note the report’s definition of opioid-related deaths as it may entail a combination of drugs that includes at least one opioid.

It is important to highlight high risk populations and risk factors in opioid misuse and deaths such that appropriate interventions may be implemented. According to a review done by Belzak and Halverson (2018), those who died from opioid-related deaths were more likely to be from lower to middle class income backgrounds. Additionally, the review states that approximately 82% of deaths between January 2016 to June 2017, involved more than one substance in combination with an opioid. Vulnerable populations, like the First Nations require support as they are “five times more likely than their non-First Nations counterparts to experience an opioid-related overdose event and three times more likely to die from an opioid-related overdose (Belzak & Halverson, 2018). These numbers likely result from many outstanding adversities experienced by this population including higher rates of substance use, social determinants of health and prevalence of other comorbidities including mental health issues (Belzak & Halverson, 2018; Government of Canada, 2018c). Another vulnerable population includes geriatric patients and those with pain conditions as they are often prescribed opioids in pain management and are at a great risk of opioid-related harms due to changes in metabolism and tolerance as well as cognitive changes that may lead to accidental overdoses (CIHI, 2017). Other populations include the homeless population as well as those with prior or outstanding substance use and health problems (Belzak & Halverson, 2018; Government of Canada, 2018c).

Federal Action Plan in Combating the Crisis

The Mayors’ Opioid Task Force from the Federation of Canadian Municipalities (2017) outlined adversities that their major cities were experiencing despite implementing and sharing strategies in opioid overdose prevention. Some strategies mentioned are: raising awareness on opioid overdoses, increasing accessibility to naloxone kits, which temporarily blocks effects of opioid overdoses, as well as eliminating barriers that prevent people from seeking help. One of their concerns was that there were significant data gaps in which they were unable to access and collect, including overdose death rates. Two of the 13 cities on the Task Force had access to monthly overdose data, while six cities had 2016 data (Federation of Canada Municipalities, 2017). By having a national wide effort, the Task Force believes that improved data collection and information sharing would help provide evidence-based solutions in combating the opioid crisis. This is especially true due to many contributing factors that influences substance use within communities, thus making it difficult to pin point a solution.

In early 2018, the Canadian government published their “Federal Approach on Canada’s Opioid Crisis” action plan based on the Canadian Drugs and Substances Strategy (Government of Canada, 2018c). The purpose is to create a cohesive and systematic action plan in combating Canada’s opioid crisis, emphasizing collaboration amongst communities, provinces, territories and other key stakeholders. There are currently 4 different public health approaches or pillars that the action plan encompasses: prevention, treatment, harm reduction and enforcement.

Prevention

Through a preventative approach, the federal government plans in implementing the Health Portfolio’s Problematic Prescription Drug Use Strategy, improve prescribing practices as well as educate Canadians about the harmful effects and risks of opioid use. Unfortunately, the Government of Canada did not disclose more information about the Health Portfolio and further research failed to bring results. Better prescribing practices would be beneficial as patients managing pain are at a high risk of accidental overdoses (CIHI, 2017). Better health education and easier access to health care resources, like naloxone kits will better equip Canadians in handling overdose situations. This also may include reducing stigma around substance use which can empower PWUS to reach out for help and support (Government of Canada, 2018c).

Treatment

The Government of Canada plans to support innovative approaches to treatments which includes better treatment access for high-risk populations and those residing in rural areas (Government of Canada, 2018a). Other aspects include improving pain management options as well as treatments for opioid addictions. Upstream interventions may help by implementing better regulations on opioid prescribing and monitoring opioid usage (Fischer, Rehm & Tyndall, 2016). Strategies include better policies and standards in prescribing opioids to prevent risk of poisoning and increased dependence, may involve limiting the duration and dosage of opioid therapy (Fischer et al., 2016).

Harm Reduction

As part of the harm reduction approach which focuses on safer practice techniques, the Government of Canada supports the use of Supervised Consumption Sites (SCS) and created a resource explaining how they work (Government of Canada, 2018b). SCS’s aim to create a safe environment where people who use substances (PWUS) and those with limited health care support may attend. PWUS can use their substances under the supervision of health care workers in case they experience negative side effects associated with laced substances, overdose, and other sudden reactions. Social workers and community workers are also present for those who seek support and resources, whether it is addiction rehabilitation, housing services, primary health care, mental health as well as social welfare assistance.

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The efficacy of these sites has been unanimously positive with SCS’s being lauded for lowering rates of public substance use, incidence rates of blood-borne diseases due to needles, as well as being cost-effective tools in reducing the strain on health care resources associated with overdoses (Toronto Star, 2018; Ng, Sutherland & Kolber, 2017). User statistics at a SCS in Vancouver from January 1^st to December 31^st, 2017, reported 2,151 overdose interventions and no deaths (Vancouver Coastal Health, 2018).

Despite the positive findings, further considerations must be done when determining whether these sites are as effective. Though anecdotal, a 2017 article written by Brain Hutchinson, describes a significant percentage of PWUS in his city “will rarely, if ever, use the facilities and services”, as well as witnessing a woman consuming her drugs five metres outside of a SCS. It is also important to note that each SCS’s are restraint to capacity as well as not operating 24 hours a day, which forces PWUS to consume elsewhere (Bell & Globerman, 2014). Inaccessibility of the SCS due to physical or geographical barriers could also deter PWUS from traveling to the sites (Bell & Globerman, 2014). A cross-sectional study was conducted among young adults who use opioids non-medically on their willingness to attend SCS. This was done between January 2015 and February 2016 in the United States, where there are no SCS, and findings revealed approximately 63% of participants would be willing to use SCS (Bouvier, Elston, Hadland, Green & Marshall, 2017). This is not to generalize all PWUS, rather should consider different perspectives as well as point out that SCS may not be able to capture all PWUS.

Enforcement

The Canadian government plans to focus on illegal drug production, supply and distribution. This includes monitoring and intervening on the trafficking of illegal substances, better legislative and regulations on control substances, surveillance monitoring as well as additional education and training for law enforcement (Government of Canada, 2018a). In a way, this also overlaps with other pillars such as treatment, as the government plans on making changes to policies that would affect access to care, as well as regulations in prescribing.

Theories Behind the Approach

Essentially, the federal approach attempts to tackle the opioid crisis through different aspects including prevention, treatment, harm reduction and enforcement. All pillars have overlapping principles from The Ottawa Charter for Health Promotion (Ministry of Health and Long-Term Care [MOHLTC], 2018). For example, the prevention and treatment pillar encompass much of reorienting health services as well as building healthy public policies. One of the harm reduction strategies uses SCS’s which create supportive environments and may also help redirect PWUS to programs that support and help them develop personally and socially.

Identifying high risk populations like the First Nations, homeless population as well as those with existing substance use disorders are important when delivering certain interventions. For example, one of the Government of Canada reports (2008) identified the homeless population as a high risk and had set strategies in supporting them. The Housing First Approach is an initiative that helps homeless PWUS to find living accommodations and social services without having to cease the substance use (Government of Canada, 2018c). By removing the physical environment determinant and connecting these people to resources and shelter, there was noted improvement in mental health and substance abuse (Goering & Streiner, 2015). In a way, this encompasses principles from the population health impact pyramid as well as acknowledging social determinants of health (Frieden, 2010).

Using the definition of the Empowerment Approach in Per-Anders Tengland’s 2016 article, SCS follows this approach as PWSU’s can access health resources at these facilitates which may improve determinants that effect their quality of life and health. Even if they do not seek out resources, they are able to enter a non-judgemental environment and access resources with dignity and respect for autonomy. By following this approach and being able to access these health care resources, PWUS may feel encouraged to ask for help in dealing with their addictions.

Potential Hurdles

Since the federal action plan was recently published, additional time is required in implementing changes as well as collecting data to re-evaluate its efficacy. This involves releasing the 2018 national report including overdose and death rates in each province and territory. The performance of the action plan relies on the cooperation of other stakeholders, including provincial, municipals and local communities. For example, the Ontario government recently decided to cap their number of SCS’s to 21 despite acknowledging the positive health outcomes these sites provide in addition to conducting a needs-based assessment within the province and identifying communities that may need one (Toronto Star, 2018).

Conclusion

As the opioid epidemic rages on, Canada continues to struggle with raising rates of opioid-related overdoses and deaths. Since this is a nation-wide public health issue, the federal government has created a promising action plan which encompasses different public health approaches in combatting the crisis. Different approaches include prevention, treatment, harm reduction as well as enforcement. In order to eradicate the epidemic, all levels of government and stakeholders are required to collaborate in combating the crisis and as such, should carry out actions that compliment the federal approach on Canada’s opioid crisis.

References

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