Looking upstream at the opioid crisis

Canada's opioid epidemic is an urgent crisis — but the root causes, and the remedies too, are social.

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 have 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 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 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.

"The role of public health is to keep asking these “why” questions, to keep pushing upstream to look for answers."

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 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 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 look to the example of tobacco, and plan 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 score predicted their likelihood of injury.

"Once we have enough wealth, it seems we should focus more on building social support and mental health if we want to improve happiness and health."

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 and 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.

The 2012 World Happiness Report noted that: “The U.S. has experienced no rise of life satisfaction for half a century,” while the 2017 version of the report found happiness in the U.S. has been declining for most of the past decade. The opposite of happiness is misery, which seems to be where the U.S. is headed, and that shows up, in health terms, in what have become known as the “diseases of despair”: alcohol, drugs and suicide.
Here in Canada, we cannot afford to be smug. We, too, have an opioid-addiction crisis and a lot of alcohol-related deaths; a 2015 OECD report shows that U.S. and Canadian alcohol consumption per person and the proportion of deaths attributable to alcohol are similar, while our rates of suicide are not that dissimilar from the U.S. (13.5 in the U.S. vs. 12 in Canada per 100,000 in 2014).
Nationally, the latest life-expectancy data only go to 2014, but here in B.C., life expectancy peaked at 82.9 years in 2014 and declined by about two months to 82.74 years in 2015 and 2016.
We need to learn from the U.S. that the pursuit of happiness is more than just the pursuit of money.
Once we have enough wealth, it seems we should focus more on building social support and mental health if we want to improve happiness and health.

If I were the minister of health, the premier or the prime minister, I would be setting up an expert panel to look for answers to these upstream questions and suggest remedies.

First published 25 February 2017 for the Times Colonist.

Hear more from Dr. Hancock in the 7th episode of Upstream Radio.

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TH_-_PHSP.jpgDr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.

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