Pubdate: Sun, 25 Feb 2018
Source: Victoria Times-Colonist (CN BC)
Copyright: 2018 Times Colonist
Author: Trevor Hancock
Page: D4


Iam 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 in the
Times Colonist (Dec. 30, 2017) 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.

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 Canada's

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.

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.

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.

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Dr. 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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