Multilevel Approach to the Opioid Epidemic in Canada

Opioid overdose is climbing the ladder quickly to becoming one of the leading causes of death in Canada. In 2017, an average of 16 Canadians per day were hospitalized for opioid poisonings, and an estimated 4,000 died from opioid overdoses. The high rates of hospitalization and mortality, which has placed significant pressures on the Canadian healthcare system, are worsening due to fentanyl and its analogues, a powerful synthetic opioid pain reliever that is 50 to 100 times more potent than morphine. Illegal importation and diversion from domestic supply chain are sources of fentanyl in the illicit market. The price of fentanyl in Canada is now lower than that for heroin, and as a result, fentanyl and its analogues are being used as a partial or total replacement for heroin, often unbeknownst to the end-user. British Columbia has declared the opioid crisis a public health emergency, reporting provincial overdose death rate of 30.2 deaths per 100,000 individuals from January to October 2017. Fentanyl was detected in 83% of these overdose deaths. Overdose-related deaths span across a wide spectrum of individuals – from those who have a history of chronic drug use to those who overdose on their first exposure. Understanding the social determinants of health that contribute to inappropriate drug use is important in devising multilevel strategies to combat the opioid epidemic. This paper uses the Social Ecological Model (SEM) to review and propose multifaceted solutions, focusing on five levels of influence: intrapersonal, interpersonal, community, organizational, and public policies.

Intrapersonal

Nonmedical use of prescription drugs (NMUPD) is defined as use by people other than those to whom the medication is prescribed or use in a manner or for a purpose contrary to what is intended. Individual predictive risk factors for prescription drug misuse include a history of mental illness, acute and chronic pain, and physical health problems. As there is a tendency for individuals with pain to be treated with opioids, chronic opioid use may lead to development of dependence. Ease of access to prescription drugs, especially those who are prescribed opioids at a large dosage or have multiple prescriptions, predisposes this population to NMUPD. Past history of substance use or misuse, or concurrent use of non-opioid substances, such as alcohol, are risk factors to NMUPD. In 2016, the highest percentage (28%) of opioid-related deaths in Canada occurred among Canadians between the ages of 30 and 39. Age and gender may also be determinants for the type of opioid used. Alberta reports a higher prevalence of younger men in deaths related to use of fentanyl and its analogues. First Nations people are five times more likely to experience an opioid-related overdose event and three times more likely to die from an opioid-related overdose. Of concern, First Nations people were found to be twice as likely to be dispensed an opioid as non-First Nations individuals.

Interpersonal

Families can influence prescription drug misuse among children and adolescents both positively and negatively. Parental expression of disapproval of substance use and a healthy relationship with parents are protective factors for substance use. Exposure to opioid use in the household environment can also play a role. Those who have witnessed a family member overdose are more likely to overdose on prescription drugs themselves. The presence of family conflict, low parental bonding, peer drug use, and positive attitudes toward drugs are associated with significantly increased risk of adolescent NMUPD. Sources of prescription opioids may originate from sharing with family members, “double doctoring”, prescription fraud and forgery, street drug markets, thefts and robberies, and Internet purchases. A Health Canada survey found that the most common source of opioids used without a prescription was from a family member.

Community

The opioid crisis affects every region of the country. Western provinces (British Columbia and Alberta) and Ontario have experienced the highest burden, with the most pronounced rise in the proportion of fentanyl-related deaths amongst all opioid-related events.

Figure 1: Number and rate (per 100,000 population) of apparent opioid-related deaths by province or territory. Source: Government of Canada.

The proportion of reported apparent opioid-related deaths involving fentanyl or an analogue was 53% in 2016.

Figure 2: Number of accidental apparent opioid-related deaths involving or not involving fentanyl or fentanyl analogues by quarter, January 2016 to March 2018. Source: Government of Canada.

Provincial reports showed that the majority of opioid-related overdose deaths occurred indoors, in private residences, and in larger urban centres. In Alberta and Ontario, those who died tended to reside in lower- to middle-income neighbourhoods. Homeless populations are at risk, representing 30% of those presenting to British Columbia emergency departments for a known or suspected overdose. Populations residing in prisons and penitentiaries also have a high prevalence of substance use with correspondingly high fatal overdose rates. Studies have shown that residential mobility or instability can be associated with adverse childhood experiences by disruption of routines and frequent breakage of social ties, increasing the likelihood of opioid use disorder.

Organizational

Canada has the second highest rate of opioid use in defined daily doses and the highest overall when considering morphine equivalence. Prescribing patterns analyses show the most increases in use of strong opioid formulations, such as hydromorphone and fentanyl. In addition, the rate of high-dose opioid dispensing in Canada increased 23% from 2006 to 2011. There is limited evidence of therapeutic effectiveness of prescription opioids in the treatment of chronic pain. Lack of evidence-based guidelines contribute to the increasingly opioid-saturated environment in Canada. These prescribing patterns are contributing to increasing quantities of opioids available for diversion and misuse. A Canadian study found that 37% of opioid-dependent patients admitted to the Centre for Addition and Mental Health in Toronto reported receiving opioids solely from physician prescriptions. Tighter restrictions on opioid prescribing in Canada, in accordance with clear evidence-based and enforceable prescribing guidelines, can be an effective upstream intervention to control the use and availability of opioids. Opioids should only be prescribed in cases supported by good clinical evidence and dispensed in the lowest possible dose, for the shortest possible duration. Increasing unexplained losses of opioids from Canadian hospitals is also feeding this epidemic. The incidents of lost opioids from hospitals rose 66% in Ontario between 2010 and 2016, and 13% across the country. Organizations must prioritize funding to implement technology and equipment, such as automated dispensing cabinets, in addition to developing policies and procedures to monitor proactively for narcotic diversion.

Figure 3: Incidents of lost opioids from Ontario hospitals. Source: Health Canada.

Prescribed, diverted, and illicit opioids all contribute to opioid-related deaths in Ontario, confirmed by a recent research study conducted at the St. Michael’s Hospital in Toronto. Treatment strategies should consider the inter-relationship between the prescribed and illicit market to prevent unintended consequences. For example, prescribers who rapidly taper opioid treatment in their patients can force a shift to sourcing opioids from illicit sources, which lack regulation and are less safe.

Public Policies

Despite efforts made on changing prescribing practices and interrupting the flow of drugs, the opioid crisis continues to escalate. These strategies must be supplemented with a multifaceted and intersectoral approach. The Canadian Drugs and Substances Strategy (CDSS) was formed in 2016 and launched a formal four-pillar approach to combat the opioid crisis as follows: prevention, treatment, harm reduction, and enforcement

Figure 4: Four Pillars of the Federal Approach on Canada's Opioid Crisis. Source: Government of Canada.

Important legislative changes that address the crisis have been introduced as a coordinated pan-Canadian response. Federal and provincial initiatives are emerging. From a prevention lens, New Brunswick has implemented a Drug Information System containing real-time medication history for patients who have a prescription filled in any pharmacy in the province. Alerts can be triggered in real time to help prescribers and pharmacists identify at-risk patients who may be double doctoring. In 2016, Health Canada changed the prescription status of naloxone, a drug that reverses the effects of opioid overdoses, to facilitate public access in reducing harm. A prescription is no longer required for individuals in need of naloxone. Pharmacies can proactively provide naloxone to those who might experience or witness an opioid overdose. Emergency responders can also administer naloxone without a prescription. In Ontario, the federal Good Samaritan Drug Overdose Act was implemented in 2017 due to growing concerns that drug users were reluctant to call 911 when with someone who had overdosed for fear that they would be charged with a criminal offence of drug possession. Furthermore, five supervised consumption sites have opened in Ontario to provide harm reduction supports and services, including supervised injections and access to harm reduction supplies, such as clean needles and fentanyl test strips. Studies around the globe have shown that supervised consumption sites are not only life saving, but connect people with long-term addiction treatment, reduce the spread of HIV and hepatitis C, and can lead to significant healthcare savings. The federal government needs to expedite the approvals of newer modalities for medication assisted and opioid substitution treatment. Restrictions on the importation of illegally-produced fentanyl should be expanded and further enforced. Health Canada is in the process of creating a compliance and enforcement team to monitor opioid manufacturers and enforce laws against improper drug promotion. Pharmaceutical companies have been ordered to cease marketing campaigns, including sales visits to doctors’ offices and advertisements in medical journals, for opioids to reduce overprescribing. A class action lawsuit has been launched by the province of British Columbia against drug manufacturers and distributors alleging misinformation about the addictive nature of opioids contributing to the worsening of the opioid crisis. A comprehensive approach to integrating national surveillance information with clearly defined opioid-related harm indicators must exist in order to evaluate the extent of the opioid crisis.

Conclusion

Strategies addressing the various levels of influence to the opioid crisis in Canada, as described in the Social Ecological Model, are in progress. The opioid epidemic continues to escalate and public policies supported by the best available evidence, as well as intersectoral collaboration, are urgently needed. A new report published by the Canadian Mental Health Association suggests that opioid use should be tackled as a health issue, and not as a criminal matter. Criminalizing individuals who use drugs further perpetuates the stigma associated with substance use, and continues to marginalize this population, discouraging them to access life-saving interventions. International experience has demonstrated that decriminalization reduces the burden on the criminal justice system, thereby making it possible to shift funding and resources for social and other treatment services. To truly address the social determinants contributing to opioid misuse, future discussions on the development, implementation, and evaluation of opioid-related legislation, regulation, policies and programs should meaningfully involve people with lived experience with opioids.

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