Canada lacks a system to track co-existing mental health conditions or co-ingestions in opioid-related fatalities, and our evidence base on opioid overdoses is disappointingly sparse. As we seek to build upon it, we will need to do so with a view to the significant role that mental health and substance abuse can play in worsening opioid misuse.
A call to the emergency room says the ambulance was en route. “Joey”, a middle-aged oilfield worker, was experiencing a suspected toxic ingestion of fentanyl. Thankfully, he had been administered Narcan — the drug used to reverse opioid overdoses — and was conscious.
When he arrived in the emergency department, he revealed that he had been having trouble coping with the recent dissolution of his marriage. Earlier that day he found out he’d been laid off from work. A friend had offered him what he thought was fentanyl — just this once, just to get him through the day. He couldn’t remember anything else up until his resuscitation in the ambulance.
A recent report by the Canadian Centre on Substance Abuse (CCSA) and the Canadian Institute for Health Information (CIHI) found that 13 Canadians are hospitalized each day from an opioid overdose. In B.C. and Alberta, provinces particularly hard-hit by opioid addiction, the rate of fatal fentanyl overdoses increased tenfold between 2012 and 2015 alone. Saskatchewan, which also has the highest rate of new cases of HIV, a phenomenon closely connected to injection of drugs, alsohad the highest rate of hospitalization from opioid poisoning.
"Stories like Marla’s and Joey’s are increasingly common."
Nationally, the picture is equally dire. Canada now boasts the highest rate of prescription opioid use in the world. There are many reasons to explain this overuse, and as future physicians we are aware that inappropriate prescribing practices are a clear and studied culprit. Yet for many of our patients across the country, there is more to the story.
At an inner-city clinic in Saskatoon, "Marla", a young Indigenous woman, recounted how she had begun using marijuana at the age of 7 when her uncle offered it to her. He was her primary caregiver. By age 15, she was isolated, depressed, and regularly missing school while using progressively harder drugs, including opioids she bought off the street. Now having contracted HIV and having a child, she wanted to quit, and was now trying methadone replacement therapy for the second time.
Stories like Marla’s and Joey’s are increasingly common, as the number of opioid and opioid-replacement prescriptions dispensed continue to rise each year. But as with Joey, the underlying reasons for Marla’s opioid use cannot simply be explained by over-prescription alone. Instead, mental health issues and trouble with substance abuse have been shown to drive the inappropriate use of opioids indiscriminately amongst age groups.
In a 2012 study, youth with pre-existing mental health issues were almost three times as likely to use opioids than their peers. Among adults, existing mood and anxiety disorders predicted high incidences of trying, abusing, or becoming dependent on opioids. And, in 2014-2015 one-third of hospitalizations in Canada for opioid overdoses were the consequence of purposeful, self-inflicted harm.
Yet mental health and substance abuse are rarely a part of the mainstream conversation on tackling Canada’s opioid crisis. To date, provincial interventions to stem the opioid tide have largely focused on addressing supply or prescription. Ontario committed to increase access to opioid replacement therapies, and British Columbia enacted mandatory opioid prescribing standards for physicians. These efforts are a lauded and invaluable part of our approach to the issue, but they are not enough.
This weekend, Canada will be hosting its first federal summit on the opioid crisis, with the stated goal of reducing opioid addiction and overdose deaths in Canada. These actions are timely, as the number of emergency hospitalizations from opioid misuse continue to rise across the country, culminating in two preventable fatalities each day. Such sobering statistics have prompted our federal health minister to declare opioid over-prescription and misuse in our country a national public health crisis.
"Mental health issues and trouble with substance abuse have been shown to drive the inappropriate use of opioids."
As medical students, we have witnessed and treated the harmful, life-threatening risks of opioid misuse on patients from across the country. In our training, we are attuned to addressing the factors underlying our patients’ illnesses as the best way to prevent their reoccurrence, and we believe this opportunity exists within the current opioid crisis.
Canada has great potential to address the opioid epidemic in a meaningful, evidence-based, and strategic way. What remains to be seen is whether the solutions proposed at the upcoming summit are sufficiently nuanced to address the reasons underlying the misuse of opioids in the first place.
In our experience, their success will depend on it.
Vivian Tam is a final-year medical student at McMaster University and McMaster’s senior representative to the national Government Affairs and Advocacy Committee.
Jacqueline Carverhill is a second year medical student at the University of Saskatchewan and the chair of her Medical Students Association’s political advocacy branch.
Julianna Deutscher is a third year medical student at the University of Alberta, and former Vice President of Community Engagement for the Medical Students Association.