Looking upstream at the opioid crisis
Dr. Trevor Hancock
20 February 2018
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