Module 1: Epidemiology of Opioid Use – Topic C Describe the political, social, cultural, economic, and historical context that has contributed to the risks and harms related to opioid use in Canada, including drug policies and the effects of stigma on opioid use.

Learning Objectives

By the end of this topic, the student should be able to:

• Describe the evolution of the opioid epidemic since the 1980s through a historical lens.
• Discuss the influence of the political climate on the opioid crisis.
• Identify external factors influencing increased addiction rates among people in Canada.
• Discuss the economic impact of opioid-related morbidity and mortality.
• Describe the social and cultural impact of the opioid crisis.

Key Concepts

• Around the 1990s, advocacy by pharmaceutical companies for better treatment of chronic pain, combined with aggressive marketing of opioid formulations, led to an increase in the prescribing of opioid analgesics for patients with chronic non-cancer pain (CNCP).
• Since 2011, the number of opioid-related deaths have increased dramatically in North America, particularly post-2015. Nationally, 80 percent of opioid-related deaths in 2019 involved fentanyl or an analogue and appeared to be as high as 87 percent in provinces like British Columbia.
• Criminalization of drugs and drug use has perpetuated stigma and delayed widespread implementation of evidence-based harm reduction strategies.
• Regulatory hurdles, such as the lack of enabling regulation of consumption sites opened by volunteers, have delayed addressing urgent opioid harms.
• Some smaller Canadian communities have experienced double the opioid poisoning hospitalization rates as the larger cities.
• Neighbourhoods across all socioeconomic groups have been impacted by opioids, although in Alberta and Ontario the majority of opioid-related deaths occurred in lower to middle-income neighbourhoods.
• Indigenous Peoples (including First Nations, Métis, and Inuit) have been heavily impacted by opioid-related harm and disproportionately affected by substance use.

Historical Context of the Opioid Epidemic

Let’s review some of the facts around opioid use in Canada over the years:

• Between 1980 and 2015, opioid consumption increased by a factor of 40 in Canada (Pain and Policy Studies Group, n.d.).
• From the early 1980s to 2017, the number of opioid drugs sold annually to hospitals and pharmacies for prescriptions in Canada increased by more than 3000 percent (Belzak & Halverson, 2018).
• During the 1990s, advocacy and aggressive marketing by pharmaceutical companies to treat chronic pain with opioid formulations led to a rapid increase in opioid prescriptions used for chronic non-cancer pain (CNCP) in most developed countries.

Prescribing practices played a significant role in increasing opioid-related mortality between 1990 and 2010. These prescriber practices included the following:

• writing a higher volume of opioid prescriptions
• prescribing higher doses of opioids
• prescribing opioids for longer durations
• prescribing stronger opioids (e.g., oxycodone)

Political Climate and Decriminalization of Opioid Use

Continued criminalization of drugs and drug use perpetuates stigma surrounding individuals who use drugs, delaying widespread implementation of evidence-based harm reduction strategies.

Continued criminalization of drugs and drug use perpetuates stigma surrounding individuals who use drugs, delaying widespread implementation of evidence-based harm reduction strategies.

Stigma can prevent persons who use drugs from getting the help they need and create barriers to accessing vital health and social services.

Regulations and drug policies can also cause delays in addressing urgent opioid harms. Many harm reduction advocates and public health workers agree that numerous unsanctioned supervised consumption sites had to be opened across cities by volunteers because of the restrictions imposed by government regulations.

By arresting individuals who are using drugs rather than addressing the high volume of overdoses more effectively through prevention, harm reduction, and treatment services, public resources are not being optimized. As an example, Portugal’s national strategy on decriminalization has led to reductions in the social harms of drug use, including less demand on criminal justice resources.

Many communities are starting to consider harmful substance use as a medical disorder rather than a criminal act.

At the same time, law enforcement has adapted to counter the illegal supply of fentanyl. In 2017, Bill C-37 was amended to allow border security agents to inspect packages of less than 30 grams (Canadian Mental Health Association, 2017).

• Bill C-37 also supported the scaling up of safer consumption sites across Canada.
• Some researchers and policymakers suggest decriminalization of drugs to effectively address the opioid crisis, along with healthy drug policies and regulations (Canadian Mental Health Association, 2018).

Opioid-Related Harms by Sociodemographic Factors

Age and Gender

In 2019, the highest percentage (28 percent) of apparent opioid-related deaths in Canada occurred among individuals between the ages of 30 and 39, and 75 percent of these cases involved males (Public Health Agency of Canada, 2019).

Looking more deeply into the available data, there is evidence that sociodemographic factors might be associated with the type of opioid used in opioid-related overdose. Younger men (average age 38) were more likely to be involved in a fentanyl-related death.

Size of Community

Some smaller Canadian communities have experienced double the opioid poisoning hospitalization rates as the larger cities.

Possible reasons for communities like Brantford being disproportionately affected:

• A higher percentage of older adults living in rural areas with greater access to these drugs,
• normalization of drug use in these communities, and
• more efficient circulation of diverted opioids in close social networks that are rarer in urban settings.

This trend is concerning because of the limited access to mental health and addictions treatment services in rural areas.

Income

In Alberta and Ontario, most opioid-related deaths occurred in lower to middle-income neighbourhoods, although neighbourhoods across all socioeconomic groups have been impacted by opioids (Belzak & Halverson, 2018).

• In Ontario, harms related to opioid-use in 2016 were highest in the lowest income quintile, including emergency department visits, opioid poisoning, and neonatal abstinence syndrome.
• The lowest-income quintile had at least double the rates of opioid-related harms of the highest-income quintile.
• This suggests that income inequality can be a root cause of health disparities in opioid-related illness.
• Previous access to prescription opioid medication was highly associated with an apparent opioid-related death. Non-medical prescription use of opioid was most likely through a family member with a prescription.

Indigenous Peoples

Indigenous Peoples (including First Nations, Métis, and Inuit) have been heavily impacted by opioid-related harm and disproportionately affected by substance use.

• “First Nations people were five times as likely as their non–First Nations counterparts to experience an opioid-related overdose event and three times as likely to die from an opioid-related overdose” (Belzak & Halverson, 2018).
• In British Columbia, compared to non-Indigenous women, Indigenous women experienced eight times as many ORID events and five times as many deaths, and Indigenous men experienced three times as many ORID events and deaths as non‐Indigenous men (First Nations Health Authority, 2017).
• Indigenous communities that are more remote and rural are struggling less with opioid problems than those more closely connected to urban centres.
• First Nations people were twice as likely to be prescribed an opioid as non–First Nations individuals and tended to be at least five years younger than their non–First Nations counterparts (Belzak & Halverson, 2018)
• The disparity of opioid use problems seen in these communities is understood to be rooted in a history of colonization and racism causing trauma, loss, poverty, and family separation, which had seismic and multi‐generational impacts on the mental wellbeing of Indigenous Peoples.

Economic Burden of the Opioid Epidemic

The University of Alberta (McMaster, 2019) reported that the estimated total financial productivity losses of the opioid epidemic in Canada, including losses of employees and productivity time, since 1997 total nearly $5 billion.

• In Canada in 2014, it was estimated that opioids contributed 9 percent to the overall cost of substance use at $3.5 billion (alcohol and tobacco accounted for the largest costs at almost 70 percent combined) (Canadian Centre on Substance Use and Addiction, 2018).
• This included health care costs, productivity costs, criminal justice costs, and other direct costs.
• Per-person costs associated with substance use were highest in the three territories.
• Opioids cost the health care system the third-highest amount at $313 million.
• Between 2007 and 2014, opioid-related health care costs increased by 22 percent.
• The largest increase in per-person lost productivity costs were due to opioids, which increased by 20.6 percent from 2007 to 2014.
• It can be assumed that these numbers have increased substantially because of the increase in opioid overdose deaths since 2014.
• The total economic burden of opioid use increased from an estimated US$8.6 billion in 2001 to US$696 billion in 2018 (Council of Economic Advisers, 2019).
• Health care costs are significantly higher for those with opioid use disorder than for those who do not use opioids.
• Workplace costs included loss of potential earnings, reduced wages, lower employment, and loss of productivity of workers who used prescription opioids.
• Higher costs for criminal justice system were also documented.

Questions

True or false: Over-prescription of opioids contributed to the opioid crisis.

a. True

b. False

Correct! Especially from 1990 to 2010, prescribing behaviour contributed significantly to opioid mortality.

Incorrect. The correct answer is a. Especially from 1990 to 2010, prescribing behaviour contributed significantly to opioid mortality.

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Which of the following are ways the continued criminalization of drugs has affected the opioid crisis?

a. Perpetuating stigma surrounding persons who use drugs

b. Causing delays in implementing harm reduction strategies

c. Both a and b

d. None of the above

Correct! The continued criminalization of drugs and drug use perpetuates stigma surrounding individuals who use drugs, which delays widespread implementation of evidence-based harm reduction strategies.

Incorrect. The correct answer is c. The continued criminalization of drugs and drug use perpetuates stigma surrounding individuals who use drugs, which delays widespread implementation of evidence-based harm reduction strategies.

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Which of the following populations has seen the highest opioid mortality rates in Canada?

a. Indigenous Peoples

b. Seniors

c. Youth and young adults

d. Persons living in poverty

Correct! Indigenous Peoples have faced the highest mortality rates in their communities from the opioid crisis.

Incorrect. The correct answer is a. Indigenous Peoples have faced the highest mortality rates in their communities from the opioid crisis.

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The economic burden of the opioid epidemic include costs associated with which of the following?

a. Health care

b. Productivity

c. Criminal justice system

d. All of the above

Correct!

Incorrect. The correct answer is d.

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References