Prevention
Preventing harms from opioids can be considered from two streams. The first focuses on effective and appropriate pain management for individuals living in chronic pain [17]. The second focuses on preventing harmful use among those who use illicit opioids or prescription opioids for non-medical reasons [18].
Management of chronic non-cancer pain
Rates of opioid prescribing for chronic non-cancer pain began increasing in North America in the 1990s. Indeed, the volume of opioids sold to Canadian hospitals and pharmacies has increased by more than 3000% between the 1980s and 2000s [19]. More recently, the dispensing rate for high-dose formulations of several opioids, including morphine, hydromorphone, oxycodone, and fentanyl, increased by 23% from 2006 to 2011 [20]. This rise has been attributed in part to pharmaceutical companies misrepresenting the addictive potential of opioid medications to prescribers, dispensers, and patients [21, 22]. There is evidence that high levels of pharmaceutical marketing of prescription opioids is associated with higher levels of opioid prescriptions and opioid-related mortality in the United States [23] and the increasing rates of opioid prescribing has been linked to increasing levels of nonmedical opioid use [24].
Actions have been taken to respond to these issues, with guidelines, tools and templates developed to provide parameters around opioid prescribing and deprescribing, and to include the current best evidence available in this regard. For example, a recent meta-analyses suggest that alternatives, such as nonsteroidal anti-inflammatory drugs may have similar efficacy to opioids in achieving pain relief and improving physical functioning over the short-term [25]. Indeed, the first recommendation of the 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain was to consider non-opioid and non-pharmacological treatments for individuals with chronic non-cancer pain before starting a trial of opioids [17].
Two inter-related lessons were learned from these findings: a) that a great number of individuals are living with chronic pain, with estimates ranging from 15 to 29% of the Canadian population [26] and b) that many physicians did not know how to respond to patient pain complaints, which may be a result of inadequate training [27]. In fact, a 2009 study found that while veterinary training programs had an average 87 h of mandatory pain content time, medicine programs had an average of only 16 h, and pharmacy programs had a mandatory 13 h [28].
Improved curriculum and continuing medical education on pain management and substance use disorders are needed to ensure the competency of prescribers and dispensers [27, 29]. Indeed, some research has shown that physician education can significantly decrease the number of opioid prescribed post-surgery [30]. Part of this education can also include raising awareness among health care providers on how their own stigma may affect treatment of people who use drugs [31, 32].
While the impetus to save lives is a motivator to take swift action, another lesson learned is that taking actions too quickly without considering all possible consequences can increase or create new harms. Prescription monitoring programs have been identified as one component to address the opioid crisis [33], yet there is limited evidence on their effectiveness in reducing harms [34]. Studies have revealed that some physicians reduced their rates of opioid prescribing due in part to fear or punitive action from their regulatory colleges [35,36,37]. Indeed, the defined daily doses of opioids prescribed have decreased across most of Canada between 2012 and 2016 [20]. However, this action led some individuals who were taking opioids to manage their pain to access the illicit supply when their prescription was suddenly cut off [38]. Deprescribing increased the dangers to individuals taking substances that were not pharmaceutical grade, of unknown content and potency, and which could contain dangerous contaminants such as fentanyl and its analogues. Deprescribing also caused some individuals to perform an illegal act to receive the pain relief previously provided by a physician prescribed medication. Furthermore, these actions culminated in individuals living with chronic pain to feel stigmatized for their initial pain condition, and then again for using illicit substances to manage their disorder [39, 40].
Non-medical use of opioids
Increases in prescribing not only affected those who were dispensed medications, but also increased the prevalence of prescription opioids in the illicit market due to diversion and theft of these medications [41]. Recent estimates indicate that 9.6% of Canadian adults who used opioid medications in 2018, reported some form of problematic use (e.g., taking in amounts greater than prescribed, tampering with the product before taking it, or using to get high or improve mood) [42]. As with those individuals who sought illicit opioids for chronic pain relief, individuals who used prescription opioids non-medically also had to increase their use of an illicit non-prescription grade supply when prescribing and diversion decreased [43].
A recent study found that non-prescribed opioids, including fentanyl, were playing a growing role in opioid poisonings, particularly in British Columbia. In the 2015–2016 fiscal year, only 34.1% of all opioid-related hospitalizations in British Columbia were among people with an active opioid prescription, a decrease from the 44.4% in the 2013–2014 fiscal year [44]. Indeed, in 2018, it was estimated that fentanyl was present in 85% of illicit drug overdose deaths [45].
Thus, a lesson learned is that preventing harms through changing prescribing practices is not sufficient to address the current crisis, and in fact, in some instances, had unintended negative consequences. Effective responses to reduce opioid harms, regardless of how opioid use was initiated, will require a comprehensive prevention strategy that addresses the physical, mental and social needs of an individual [46, 47].
Treatment
Access to care is determined by affordability, availability, acceptability, accommodation and accessibility [48]. Barrier to treatment include wait lists [11] and accessibility of treatment supports particularly in areas outside of urban settings, and most significantly for some Indigenous populations in remote or fly-in communities [49]. As with prevention, it is also imperative that treatment services are culturally appropriate, adequately address the social determinants of health, and provide treatment for an individual’s mental and physical needs in an integrated manner [10].
A lesson learned is that various measures need to be taken to increase access and to make treatment services more connected during the opioid crisis. Emergency treatment funding committed investments from the federal Government, provinces and territories so that they could tailor the evidence-based treatment services to the needs of their populations or increase capacity to prepare for future impacts, with interventions like youth hubs, telemedicine, and on-the-land healing camps being funded [50]. Rapid Action Addiction Medicine (RAAM) clinics, assertive community treatment and other outreach efforts have been also utilized in Canadian jurisdictions to provide increased access to addiction treatment [10]. The use of these programs in North America have contributed to reduced emergency department visits, reduced wait times and lessened stigma [51], and greater engagement in treatment [52]. However, long-term evaluations of these interventions are still required.
Another lessons learned is that greater capacity was required in the health care system to provide comprehensive treatment services [53] - an issue that has been addressed in part by increasing the capacity of primary care providers and establishing connections between services. In 2018, the Canadian Research Initiative in Substance Misuse developed National Guidelines for the Clinical Management of Opioid Use Disorder [54]. These guidelines recommend buprenorphine as the first line pharmacological treatment for most individuals – a prescription and induction that can be performed by primary care physicians or nurse practitioners [54]. Additionally, the federal government removed the section 56 exemption required to prescribe methadone, allowing any medical professional to utilize this treatment option and thereby removing the onus on the patient to access a specialized clinic [55]. However, a lesson learned is that regulatory changes are not enough. Though permissions have changed, jurisdictional professional colleges may still restrict methadone prescribing [54], and permission changes do not address physicians lack of competence to manage individuals living with an opioid use disorder [56]. Moreover, even with increased access to these primary care-based treatment options, retention remains a challenge. A recent study in Vancouver found that only a third of study participants were retained on OAT in 2016 [57]. This suggests that current OAT options may not meet the needs of a majority of individuals who initiate treatment.
A recovery-oriented system of care may reduce barriers to individuals accessing and remaining in treatment [58]. Individuals who are living in recovery have taught that multiple services, both professional and informal, provide an individual with recovery capital: the critical supports that help individuals achieve their desired outcomes [59]. These same participants cite a lack of mental health and culturally appropriate services as well as the cost of all services, as barriers to recovery [59]. Individual, family or group psychosocial interventions can be effectively provided alongside pharmacological treatment but more research is needed on the efficacy of various therapies and if certain modalities correspond better to particular medical-treatments [10]. Of course, even with better knowledge of what works, individuals still need to have access and availability of these quality services.
Harm reduction
Opioid-related harm reduction efforts in Canada have included safer consumption sites (SCS), overdose preventions sites, drug checking services, and overdose reversal kits (naloxone), to name a few [60]. These services can reduce the risk of disease transmission and overdose deaths so that Canadians who use drugs can be healthier and can continue to contribute their communities.
The evidence related to the effectiveness of SCS to prevent overdose, provide access to sterile needles and other drug use equipment, and connect individuals to support services and treatment has been established for some time [61, 62]. However, stigmatizing attitudes about drug use and harm reduction remain [5, 63]. In many cases, stigma is perpetuated by common language used to discuss substance use that is driven by moral opinion rather than by evidence [64]. The moralistic messaging associated with terms, such as “addict”, “drug abuse”, and “dirty” have contributed to the delayed widespread implementation of evidence-based harm reduction strategies, such as SCS, by implying that substance use is a choice and a personal moral failing, rather than a public health issue [63]. Furthermore, while members of the public may see the benefits of SCS for those who use drugs, they may still be reluctant to support a site in their neighbourhood [65].
While stigma is informed by many societal factors, it has been reinforced by the continued criminalization of drugs and drug use [66,67,68]. Moreover, stigma is impacted by an individual’s understanding of the causes of substance use disorders (i.e., degree to which it is a personal choice) and the perceived level of control an individual has in changing their substance use patterns [69]. Therefore, one component to combat stigma is by providing education about social and biological influences as precipitating factors to substance use disorders [70].
Another lesson learned is that when regulations cause delays in implementing responses necessary to reduce acute harms, individuals in the communities affected may take immediate action. In the wake of the opioid crisis, numerous unsanctioned supervised consumption sites were opened in cities across the country by volunteers. These “pop-up” sites, referred to as overdose prevention sites (OPS), addressed an unmet need as groups worked to receive exemptions from Health Canada to establish a sanctioned SCS [71], and indeed have averted opioid-related deaths [72]. In December of 2017, the Federal government recognized the urgent public health need and provided temporary class exemptions for OPS to be set up by volunteers in the provinces and territories [73]. Yet, where peers may volunteer to fill gaps in services, much of this work in under resourced and unsupported, resulting in a great emotional toll on these individuals [74, 75].
We have also learned that the wide-spread availability of naloxone without a prescription across Canada [76], with free take-home programs in all jurisdictions [77], has certainly saved lives. A recent study estimated that one death was averted for every 11 take-home naloxone kits used in British Columbia [72]. In British Columbia, Alberta, and Manitoba take-home naloxone kits distributed to community members have been used to reverse approximately 12,000 opioid poisonings [19]. When examining actions in BC alone, since 2012, more than 30,000 take-home Naloxone kits have been reported as used to reverse an overdose [78].
Drug checking services, wherein individuals can determine if there are contaminants, such as fentanyl, in the drugs they are planning to consume, have been recommended as one avenue to prevent poisonings [79, 80]. Various technologies are used for drug checking, including lower-cost options (e.g., fentanyl urine test strips) and more advanced laboratory techniques (e.g., mass spectrometry) [81]. There is limited evidence of the impact of drug checking services on substance use behaviours [81,82,83,84]. It is important that individuals are aware of the limitations of drug checking technologies, including that fentanyl test strips may not detect all fentanyl analogues, including carfentanil [85]. At the very least, it is clear that drug checking services create an opportunity for communication and education between harm reduction works and individuals who use drugs [81, 83]. The data collected from drug checking services provides an important window into the types of drugs and drug combinations being used in a given community, which could be a useful component of a substance use surveillance system [81, 83]. This detailed information could lead approaches that are tailored to the needs of communities and their residents.
Enforcement
The single biggest lesson learned in the enforcement pillar is that arresting individuals who are using drugs will not end the crisis [86, 87]. While enforcement efforts focusing on production and distribution of illicit substances and unlawful distribution of controlled substances is a component of the CDSS [3], many policing bodies have recognized that arrest and incarceration are not the appropriate routes to prevent or address drug use on an individual level [87].
Some enforcement communities have undergone a paradigm shift, increasingly acknowledging harmful substance use as a chronic health issue rather than a criminal justice one. Many officers now see their role to be connecting individuals experiencing harms from opioid use to services, as opposed to enforcing correctional repercussions [88]. To support this notion, the federal Good Samaritan Drug Overdose Act became law in 2017 [89]. This Act allows an individual who has overdosed to receive emergency medical care while ensuring some legal protection related to simple possession of a controlled substance for personal use. This protection also applies to the individual(s) who has not overdosed but call emergency services [90].
The opioid crisis and resulting harms highlight the need for enforcement and regulations to be nimble, as substances of use are constantly evolving. Previously, when the Canadian Border Services Agency suspected parcels were being used to import drugs, they were only permitted to inspect packages that were large in size. As the potency of fentanyl allows small volumes in transit to be of concern, Bill C-37 amended the Customs Act to allow border security agents to inspect packages less than 30 g [91]. This bill also prohibits the unregistered import of pill presses and encapsulators, and allows new psychoactive substances to be scheduled and controlled quickly, to respond to the emerging nature of novel psychoactive substances.
Evidence base
An effective response to the crisis requires comprehensive and robust monitoring systems to be able to measure emerging trends in substance use, harms and outcomes [92]. Without a complete understanding of where multiple factors stand as a baseline, it is impossible to know the gravity of the current situation or to track effects. A lesson learned is that developing useful monitoring systems requires collaboration to share data across Canada. There have been some positive examples of increased collaboration and data sharing to respond to the opioid crisis. For example, initially the comparability of opioid-related coroner’s data across the provinces and territories had been limited [93]. Improvements in recent years have increasingly allowed for opioid-related deaths to be categorized in the same way across jurisdictions, allowing for accurate national counts [94]. In addition, Health Canada’s Drug Analysis Service (DAS), which analyzes the contents and quantities of drug samples submitted by law enforcement across Canada [95], has recently begun sharing their analyses with the jurisdictions on a monthly basis, which contributes to a jurisdiction’s ability to detect emerging drug use trends. As a final example, a national drug checking working group was established in 2015 as a means to share emerging best practices and lessons learned among Canadian drug checking service providers [96]. Combined, the data from each of these sources exceeds their individual utility as together they disentangle the many complex factors related to opioid harms.
A lesson learned is that several avenues have to be taken to improve access to and the quality of data that can inform responses. In 2016, British Columbia’s provincial health officer declared a public health emergency in response to opioid-related deaths [97]. This declaration allows for data to be collected across the health system, and analyzed immediately to inform where action needs to be taken. British Columbia, Alberta and other jurisdictions have formed multidisciplinary groups to ensure the sharing of information across sectors and coordinated actions that are supported by increased investments [97,98,99].
