A call to the emergency room announced that the ambulance was on its way. Joey, a middle-aged oilfield worker, was experiencing a suspected toxic ingestion of the opioid, fentanyl. He had been administered naloxone -- 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 also found out he had been laid off from work. A friend offered him fentanyl, and he agreed to try it, just this once, to get him through the day.
Joey's story is not an isolated one.
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 British Columbia and Alberta, provinces particularly hard-hit by opioid addiction, the rate of fatal fentanyl overdoses increased tenfold between 2012 and 2015 alone. Saskatchewan has the highest rate of hospitalization from opioid poisoning.
Nationally, the picture is dire. Canada now boasts the highest rate of prescription opioid use in the world.
There are many reasons to explain the overuse of opioids, 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.
Marc was in a car accident eight years ago. It left him with chronic neck and back pain. In the emergency room, he was given a prescription for Percocet (a combination of Tylenol and the opioid, oxycodone). After a year of receiving follow up prescription opioids for his pain, his family physician informed Marc that it was time to step down his pain control to Tylenol or Advil.
But by this time, Marc had become dependent on the opioids. So when he stopped receiving a prescription, he started buying them on the street. He felt abandoned by the medical system and was left without acceptable options to manage his pain.
Fortunately, he sought help and enrolled in a methadone program. Marc no longer needs to self-medicate, but as with many Canadians, he continues to have uncontrolled pain. Currently, he is on a waitlist to see a pain specialist, but has been told the wait could be a year or more.
Marc and Joey's stories are not uncommon in Canada, where poorly treated chronic pain and mental health issues have been shown to drive both opioid misuse and resultant fatalities. On a recent review of opioid-related deaths occurring in Ontario, 66 percent of individuals had visited their doctor's office just four weeks before their death, with mental health issues (notably anxiety, depression or substance use) and persistent pain (notably joint or back) accounting for the majority of the reasons for the visit.
Mental health issues alone appear to increase the risk of opioid misuse 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.
Yet specific strategies to improve the treatment of mental health issues and chronic pain have been lacking in the mainstream conversation on tackling Canada's opioid crisis. To date, interventions to stem the opioid tide have largely focused on addressing supply. Ontario has committed to increase access to opioid replacement therapies and British Columbia has 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 month, medical students from across the country will converge on Parliament Hill to galvanize support for an upstream approach to the opioid crisis that will prioritize timely access to effective mental health and chronic pain services.
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 adopted by the federal government will be sufficiently nuanced to address the reasons underlying the misuse of opioids in the first place. In our experience, their success will depend on it.
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