Canada’s Opioid Crisis: What are we doing wrong?

Canada’s Opioid Crisis: What are we doing wrong?

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By: Melissa Galati

The “abuse” of opioids has resulted in a national public health crisis—one that appears to be worsening. The understanding that many Canadians have is that the cause of the crisis largely stems from the overprescribing of opioids for pain management. Subsequent addiction, sale of prescription drugs on the black market, or sharing of medication with family members and friends has led to substance abuse and a dramatic increase in opioid-related deaths. Indeed, Canada leads the world in per-capita pharmaceutical opioid consumption—second only to the United States1—and opioid-related deaths in Canada are at an all-time high—nearly 4000 reported in 2017, up from 3000 in 2016.2 But this is an over-simplified explanation for a complex issue—addressing this problem requires an understanding of history, community dialogue, and an overhaul of Canada’s current drug policy.

Opioids—specifically opiates like heroin and morphine, derived from the flowering opium poppy plant—have been used recreationally and medically throughout history. In the mid-1900’s, chemists began synthesizing opioids in the lab, such as methadone and oxycodone, which have similar properties to opiates, without the need for plant-derived opium. Since then, various groups have produced synthetic opioids with specific, “desired” qualities—like slow-release formulations—ideal for treatment of chronic pain. The most infamous of these is OxyContin, produced by Purdue Pharma and aggressively marketed to physicians as an effective painkiller without risk of side effects like addiction.

As prescriptions for OxyContin increased, so did addiction and reported overdose deaths. In 2007, several of Purdue’s executives pled guilty to criminal charges of misleading regulators and the public about the harmful effects of OxyContin. OxyContin has since been removed from the market.

Despite increased knowledge of the effects of these drugs and decreases in opioid prescriptions, the number of opioid-related hospitalisations, emergency room visits, and deaths continue to increase.3 This is largely fueled by the influx of illegal, black market opioids such as fentanyl and its analogues, which are extremely potent and can cause overdose in small quantities. The increasingly prevalent illicit fentanyl is often unknowingly combined with other controlled substances, most commonly heroin. This affects recreational drug users as well as individuals cut off from prescription opioids who look to the black market to avoid withdrawal. Indeed, a staggering increase in the rate of fentanyl-related deaths has been observed in provinces with the highest rate of opioid-related deaths (British Columbia and Alberta)—an “epidemic within an epidemic.”4

By the time the Government of Canada released its first national strategy to address the widespread problem of prescription drug abuse in March 2013, illicit fentanyl had pervaded the Canadian landscape, particularly on the West Coast. The strategy focused on: prevention, treatment, and enforcement. It addressed prescription drugs like opioid pain relievers to “stem abuse of those substances”. The Prevention Action Plan included educational campaigns to remove unused prescriptions from circulation, the Treatment Action Plan increased the availability of healthcare services to at risk populations (e.g. First Nations), and the Enforcement Action Plan provided support and tools for better monitoring of controlled substances.5 While these initiatives work in theory, opioid-related deaths are still rising as none of the strategic plans addressed the fentanyl crisis.

To develop solutions, it is necessary to obtain reliable information on overdose events in the community. This is challenging because of the stigma attached to opioid use. In a letter published in the Canadian Medical Association Journal (CMAJ), authors encouraged altering the language we use to discuss substance use. For example, the term “overdose” implies personal failure—that an individual knew the nature of a substance and took more than she or he could knowingly tolerate.6 This is not the case since “correct doses” do not exist for illicit formulations that are often laced with substances like fentanyl. The authors suggest using terms such as “poisoning” or “intoxication” as is the case with other substances, e.g. “alcohol poisoning”.6

Another challenge lies in the criminalization associated with opioid use. If illicit fentanyl is fueling the crisis, then a tough-on-crime-approach essentially criminalizes addiction. This drives people who use illegal drugs away from prevention services and treatment, and into unsafe environments with increased risk of injury and disease (e.g. HIV). A report by the Canadian Centre on Substance Use and Addiction (CCSA) addressing the use of naloxone (a drug used to counteract the effects of opioids during opioid poisoning) kits found that 30% to 65% of individuals who witnessed an apparent overdose situation did not call 9-1-1, citing concerns about police involvement and possible arrest.7 To combat this, the Good Samaritan Drug Overdose Act became law in Canada in May, 2017. The Act provides some legal protection for people who experience or witness an overdose and call emergency services. Despite this, a lack of formal training has left police officers ill-equipped to work with the Act, and charges continue to be laid often enough to discourage drug users from seeking help.

To address these challenges, a fourth pillar was formally added to the Canadian Drugs and Substances Strategy: harm reduction. Part of Canada’s harm reduction approach has been to establish supervised consumption sites (SCS)—medically-supervised, clean spaces, where people can consume illegal substances. These, in addition to overdose prevention sites (OPS; like SCS but temporary and under provincial jurisdiction), are essential to preventing opioid-related deaths since harm reduction workers can intervene at the earliest stages and reverse poisoning with oxygen and administration of naloxone. Despite assertions that SCSs/OPSs promote drug use, no evidence exists to support these claims. Moreover, these sites continue to succeed in reversing opioid poisonings without fatalities.

Despite the importance of OPSs as an emergency response to communities in need, the new Ontario government has overhauled its current system for OPSs, forcing existing sites to meet a new set of requirements (with a heavy focus on treatment) and restricting the number of sites in Ontario. In practice, these new measures may demonstrate a misunderstanding of the sites’ purpose. The relatively arbitrary 21 site cap means that numerous communities will be left in need. Moreover, harm reduction workers worry that drug users won’t use sites that push treatment services, many of which they can’t afford.

An alternative approach proposed most recently by Eileen de Villa, Toronto’s Chief Medical Officer, is to end prohibition on drugs. This recommendation was outlined in a report from Toronto Public Health, which summarised findings from community dialogues conducted to explore a public health approach to drugs.8 The report calls the federal government to decriminalise possession of all drugs for personal use. It also urges formal discussion for the legal regulation of drugs in Canada. Having a regulated market for drugs is a complicated endeavour that would take considerable time to develop but would alleviate drug users’ dependence of on the illegal market, protect them from a toxic drug supply, increase access to resources, and decrease the cost of law enforcement. Decriminalisation and legalisation are part of a public health approach that acts on determinants of health and the root causes of disease, not a dated political approach based in fear that ignores new scientific knowledge.

The path to ending the opioid crisis is unclear and will likely involve a complex series of solutions for a complex problem. What is clear is that Canada’s current strategies are ineffective. We need a drug policy based on evidence and with active engagement of the general and scientific community. Without this shift, we may be looking at a new normal for opioid-related mortality.

References

  1. Report of the International Narcotics Control Board for 2013. (United Nations, 2014).
  2. Special Advisory Committee on the Epidemic of Opioid Overdoses. National report: Apparent opioid-related deaths in Canada (January 2016 to March 2018). (Ottawa: Public Health Agency of Canada, 2018).
  3. Opioid-related harms in Canada: chartbook, September 2017. (CIHI, Ottawa(ON), 2017).
  4. Belzak, L. & Halverson, J. The opioid crisis in Canada: a national perspective. Health promotion and chronic disease prevention in Canada : research, policy and practice 38, 224-233, doi:10.24095/hpcdp.38.6.02 (2018).
  5. Evaluation of the National Anti-Drug Strategy: Final Report. (Evaluation Division Corporate Services Branch, Department of Justice(Canada), 2018).
  6. Xie, E., Green, S., Puri, N. & Sheikh, H. Updating our language around substance use disorders. Canadian Medical Association Journal 189, E1566-E1566, doi:10.1503/cmaj.733490 (2017).
  7. CCENDU Bulletin: Calling 911 in drug poisoning situations. (CCENDU, Ottawa(ON), 2017).
  8. A Public Health Approach to Drug Policy. (Toronto Public Health, Toronto(ON), 2018).