Looking upstream at the opioid crisis

Looking upstream at the opioid crisis

Dr. Trevor Hancock

20 February 2018

701 words

I am increasingly concerned with the inadequacy of our approach to the opioid crisis, both as a society and in the field of public health. There is no question that when people are dying in large numbers we need to respond, and that has been happening. Safe injection sites, the distribution of naloxone kits and similar efforts are important.

But this response is sadly inadequate; it repeats the ‘upstream’ story that I told in the very first column I wrote, in December 2014, one that is fundamental to the public health approach. In essence villagers living on the banks of a river are so busy rescuing drowning people that nobody has time to go upstream to learn how they are ending up in the river and stop them being pushed in.

A recent in-depth look at opioid deaths on Vancouver Island in the Times Colonist (30 December 2017) did a good job of interviewing a wide range of experts, families and frontline workers, but none of them discussed the need to go upstream and find out why people are turning to opioids in the first place and try to stop that from happening.

We know that “Canada and the United States now have the highest rates of prescription opioid use in the world”, as Toronto’s Centre for Addiction and Mental Health and Addiction noted in 2016. And we know why that is the case: the most important factor that has “contributed to the development of the prescription opioid crisis . . . has been the liberalization of opioid prescribing for the treatment of chronic non-cancer pain”, according to Canada’s EvidenceNetwork.ca.

As I have noted before, these harmful prescribing practices by physicians have been encouraged and supported by the pharmaceutical industry’s marketing, and by a failure on the part of both Health Canada and the provincial Colleges of Physicians and Surgeons to protect the public from both big pharma and unwise physician practices.

So if I were a Minister of Health or Finance in Canada, I would be looking to the example of tobacco and planning to take the relevant pasts of the industry to court – and ensuring that Health Canada and the provincial Colleges do a much better job of protecting the public in future.

But this still does not answer the important questions: Why are so many people needing or wanting opioids? The role of public health is to keep asking these ‘why’ questions, to keep pushing upstream to look for answers.

The answer seems to be that people are experiencing both physical and psychological pain. A 2009 study published in the Canadian Medical Association Journal that looked at more than 3,000 opioid-related deaths in Ontario found that there was a high use of medical services in the year before death, with most of them seeing a physician within a couple of weeks of death. The most common diagnoses at those visits were mental health problems and pain.

So the question is – is there more pain now, are we handling it less well – or both? Some suggest that increasing work demands and stressful work environments lead to more mistakes and more injuries; I recall a study many years ago that found that people’s life stress events score predicted their likelihood of injury.

Couple that with the increase in part-time or contracted-out work with fewer health and other benefits, the decreased role of unions and reported poor training and services in pain management, and one can see where that leads; less time off to heal, less support in healing, more need for a quick fix while carrying on working.

Then there is the psychological pain, in part engendered by chronic pain, loss of function and perhaps loss of income. Add to that the ‘diseases of despair’ that I discussed a few weeks ago, high levels of inequality and a constant state of fear, anxiety and envy driven by the media and marketing worlds, and it is not hard to see why some people are hard hit, and turn to drugs.

If I were the Minister of Health, the Premier or the PM, I would be setting up an expert panel to look for answers to these upstream questions and suggest remedies.

© Trevor Hancock, 2018

 

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Doing well, but doing much harm

Doing well, but doing much harm

Dr. Trevor Hancock

12 February 2018

700 words

The principal purpose of any government and society should be to maximise human and social development for all its citizens – but, we now understand, within the limits of this one small planet. A new study shows how well we are doing in achieving human and social development, but how much environmental harm we are doing in the process.

Led by Daniel O’Neill at the University of Leeds – and a UVic alumnus – the study looks at 150 countries in terms of how well they meet a set of human and social development thresholds and whether on a per person basis they exceed a set of biophysical boundaries.

The eleven social outcomes are derived from analyses of social needs embodied in the Rio + 20 Conference and the UN’s Sustainable Development Goals (SDGs). Nine of these relate to meeting basic human needs such as food, clean water and sanitation, income and education, while two measure human wellbeing; self-reported life satisfaction and healthy life expectancy (years of life without illness or disability).

For each of these, the research team defines an admittedly subjective threshold they believe is consistent with a ‘good life’. For example, the thresholds for access to improved sanitation facilities, access to electricity, secondary school enrolment and an income above US$1.90 a day are all set at 95% of the population, while the threshold for healthy life expectancy is 65 years.

The biophysical boundaries are of two sorts; five are based on ‘planetary boundaries’ per person (climate change, land use change, nitrogen and phosporus flows and freshwater use) and the remaining two are our overall ecological and material footprints, compared to suggested maximum sustainable levels.

Obviously, the ideal position would be to meet all eleven social thresholds without exceeding any of the biophysical thresholds. Worryingly, the study finds, “no country meets basic needs for its citizens at a globally sustainable level of resource use”, but the country that comes closest is Vietnam, which meets 6 of the 11 social thresholds while only exceeding one of the biophysical boundaries.

In fact, only three countries meet all eleven social thresholds – Germany, Austria and the Netherlands – but in doing so they also cross most of the seven biophysical boundaries. Canada is about the middle of the pack of a group of high income and largely Western countries that meet many of the social thresholds but exceed most if not all of the biophysical boundaries.

In our case, the two social thresholds we miss – but not by much – are equality and employment. But we don’t just exceed the biophysical boundaries, we blow way past them. Our carbon dioxide (CO2) emissions are almost 11 times higher than they should be, our nitrogen and phosphorus flows 15 – 16 times, and our ecological footprint about 4 times higher; only in freshwater use are we below the boundary.

It is not just whether a country exceeds a biophysical boundary, but by how much; clearly, exceeding it by 10 percent is a lot better than exceeding it by 500 percent. When we compare Canada with countries that do as well or better than us both socially and environmentally – Germany, Austria, The Netherlands, Japan, France, Sweden, Finland, Denmark, Belgium, Australia, the Czech Republic, Ireland and Slovenia – we don’t do well.

Only Australia has higher carbon emissions and a higher ecological footprint; the rest – omitting Australia – meet or exceed our social achievements while having on average two-thirds of our carbon emissions and 72 percent of our ecological footprint per person. Clearly, we must learn from them so we can be more like them; that would be a useful first small step.

But it is nowhere near enough, because on average they still use more than seven times their fair share of carbon emissions, and almost three planet’s worth of ecological footprint. Thus the study’s authors conclude “if all people are to lead a good life within planetary boundaries, then the level of resource use associated with meeting basic needs must be dramatically reduced”.

This is the most important challenge of the 21st century, second only to avoiding full scale nuclear war. Clearly, we have a lot to learn – but at least we are beginning to understand the challenge.

© Trevor Hancock, 2018

Alberta proclaims its right to pollute

Alberta proclaims its right to pollute

Dr. Trevor Hancock

6 February 2018

699 words

The David Suzuki Foundation’s ‘Blue Dot’ campaign aims to enshrine the right to a healthy environment in the Canadian Constitution, and last year the federal government’s Standing Committee on Environment and Sustainable Development urged the government to enshrine it in law. Beyond these efforts to ensure that we humans (and, by implication, other species) have that right, there is also a move to give nature itself legal standing.

Indeed David Boyd, an environmental lawyer and a Professor of Law, Policy, and Sustainability at UBC, has just published a book on the rights of nature. In it he reports that courts in some countries have recognized that “endangered species have the legal right to exist”. But not only do species have rights, so too do entire ecosystems.

If you think that is far-fetched, consider that New Zealand has granted legal recognition as persons to both the Whanganui river – the third-longest in the country – and the Te Urewera region – previously a national park. The 2014 Act that established Te Urewera states it “has all the rights, powers, duties, and liabilities of a legal person”, with those rights “exercised and performed on behalf of, and in the name of, Te Urewera by Te Urewera Board”.

So it is disgraceful to see the Alberta and federal governments moving in the opposite direction in their attempt to ram Kinder Morgan’s Trans Mountain pipeline through BC. In doing so they are, in effect, proudly asserting Alberta’s right not only to pollute its own land, waters and people, but those of BC and the rest of the world.

Mr. Trudeau’s defence of his actions is that we need to get Canada’s resources to market, that we need the jobs, that we can protect the environment – especially BC’s coast – and, bizarrely, that increasing exports of oil from Alberta dirty oilsands is necessary if we are to meet our greenhouse gas emisson reduction targets. He is dangerously wrong on all counts.

Not all resources must be mined, used and exported; the sorry story of asbestos proves that point, although it took a long time to overcome stubborn government support for this industry. The last asbestos mine in Canada closed in 2011 and Canada finally agreed to ban the use of asbestos as of this year – 20 years after the World Health Organization declared asbestos a carcinogen in 1987

Not all jobs are good; we need 21st century clean energy jobs, not 20th century dirty energy jobs.

And this decision hardly protects the environment or human health; on the contrary, it expands the local harm done in Alberta by enabling expansion of the oilsands, while threatening BC’s land, waters and coast with a dramatic increase in the flow of diluted bitumen (dilbit) in the pipeline and increased tanker traffic along our coasts. Few believe that a so-called ‘world class’ disaster response system will be much use when a big tanker goes down in a heavy gale, as will surely happen one day.

Finally, the Pembina Institute, citing a 2015 Carnegie Foundation report, notes that “The oilsands are still one of the most carbon intensive oil sources on earth”; it also cites 2017 World Bank data that show that “if Alberta were an independent nation-state it would surpass Qatar to have the highest per-capita greenhouse gas emissions in the entire world”. At a time when we desperately need to reduce greenhouse gas emissions in Canada and globally, why on earth would we be facilitating the expansion of this industry. We need to leave the carbon in the ground.

David Boyd argues “if nature has rights, then humans have responsibilities”. It is time we accepted our responsibility to the natural ecosystems of which we are a part, and upon which we ultimately depend for our wellbeing, indeed our very survival. This is far more important than Alberta’s right to pollute. In the face of this situation, the BC government should go much further than it has so far. It is time to petition the courts to give legal standing to our endangered orca and salmon and our threatened coastal and forest ecosystems; in doing so, we can protect the health of people here in Canada and around the world.

© Trevor Hancock, 2018

 

Family doctors deserve more of our respect

Family doctors deserve more of our respect

Alternative title: The generalist is an important specialist

Dr. Trevor Hancock

31 January 2018

701 words

Last November the Royal College of General Practitioners (RCGP) and the Medical Schools Council in the UK released a disturbing report. They surveyed 3,680 medical students from 30 medical schools throughout the UK, finding that by the time they reach their final year “more than three quarters of medical students report hearing negative comments about general practice” – what we would call family practice – “from clinicians, educational trainers, and/or academics”.

The report – Destination GP – built on a 2016 report from Health Education England and the Medical Schools Council that noted “Recruitment into general practice has become a major issue”. That earlier report found what it called ‘professional tribalism’ from specialists who “perceive primary care of ‘lower status’”; this, the report says, is unacceptable.

The level of denigration is astounding; Nine out of 10 of those surveyed felt their fellow students had negative perceptions of general practice, more half found doctors in specialty areas where they were placed were negative about general practice, and of the three-quarters who heard negative comments, 25 percent heard it suggested that GPs were of lower status and 15 percent heard general practice described as “undemanding and easy”.

As a result, says the RCGP, “some medical students considering a career in general practice are being discouraged and deterred from joining the profession, or abandoning it for other medical specialties”. This adds to the challenges faced by the NHS in recruiting GPs for a variety of reasons, including workload and status.

This situation will be familiar to the many patients across Canada who are having trouble finding a family physician. Sadly, it seems, some of the same attitudes to family practice exist within the medical profession here in Canada, according to an article by Roger Collier in the Canadian Medical Association Journal this January. It also is familiar to me, both as a former family physician and as a public health physician; we too are sometimes seen as not being ‘real doctors’ and not practicing ‘real medicine’.

What I think is really going on here is a wider phenomenon, found across many professions and disciplines, rooted in a societal tendency to value specialism over generalism. This attitude fails to recognize that generalism, perhaps better described as holistic thinking, is a specialty in its own right. Rather than knowing more and more about less and less, holistic thinkers know about a great many different things and work to synthesise and integrate them, looking for what Gregory Bateson called ‘the pattern that connects’. That is the value of family practice – understanding the whole person and their family in the context of their life and work.

I also see this holistic, generalist thinking under-valued in academe, another institution where specialization is (over) valued. Students tend to get funneled into narrowly conceived channels where funding and publication is to be found, while interdisciplinary programs – while given rhetorical support – are in practice difficult to establish and maintain.

Yet many of the challenges we face in the 21st century are complex, cut across and involve many sectors, and interact as complex systems. They cannot be solved by narrow specialists, who indeed may make the problem worse. We need people trained in holistic thinking who understand complex systems and how to manage them.

This is certainly true of public health, my specialty for 35 years. In a column in the Canadian Medical Association Journal a recently, I pointed out our vast scope of practice. In addition to being trained in medicine, public health physicians need to have a broad knowledge of the social sciences, from anthropology to psychology, community development to political science.

Because of the importance for health of the built environment, we need a grounding in the design professions (architecture, engineering, and urban planning), while our interactions with the natural environment require knowledge of toxicology, environmental health and ecology. Finally, because of our involvement in policy-making and regulation, we need an understanding of public administration and public communication.

I believe that family practice and public health are among the most challenging and complex specialties in all of medicine, requiring the best and brightest as their practitioners. They deserve far more respect, both within and beyond the medical profession, as specialties in their own right.

© Trevor Hancock, 2018