Steve Cardinal participates in a march on the first National Day of Action to draw attention to the opioid overdose epidemic, in the Downtown Eastside of Vancouver on Tuesday February 21, 2017. (THE CANADIAN PRESS/Darryl Dyck)

Steve Cardinal participates in a march on the first National Day of Action to draw attention to the opioid overdose epidemic, in the Downtown Eastside of Vancouver on Tuesday February 21, 2017. (THE CANADIAN PRESS/Darryl Dyck)

COLUMN: On National Day of Action, expert says overdose crisis is not about pain

There were 1,486 illicit drug overdose deaths last year in British Columbia

Opioid-related deaths have been rising over recent years in North America and globally. New data released by the Public Health Agency of Canada reveals that more than 10,300 Canadians died as a result of an apparent opioid-related overdose between January 2016 and September 2018.

There were 1,486 illicit drug overdose deaths last year in B.C. alone, according to the BC Coroners Service.

READ MORE: B.C. opioid overdoses still killing four people a day, health officials say

There is no question this is tragic and requires attention.

The response by Canadian policy-makers, however, has focused largely on the over-prescription of opioids as pain medications. Interventions have included limiting prescriptions, increasing oversight of physicians and providing guidance for decreasing or tapering opioid medications.

In January, Ontario announced an agreement with the federal government to inject another $100 million in fighting the crisis. These funds will likely be spent on safe injection sites, naloxone kits for emergency and medical personnel, public education about how to respond to an overdose and task forces to improve pain management.

READ MORE: Opioid overdoses claimed more than 3,200 lives in first nine months of 2018

I fear this focus on pain and overdose is a focus merely on the symptoms of a broader crisis — a crisis of under-managed mental illness and unresolved emotional trauma throughout Canada. Pain and substance use disorder are linked, but they are not synonymous. The opioid crisis is not, at its root, a problem of pain.

Meanwhile, the voices of nearly one in five Canadian adults who live with daily pain seem largely unheard.

Living with chronic pain

“Without pain meds, I cannot walk or accomplish even the simplest of household tasks. Going to the toilet will be beyond my capabilities. I have always employed narcotic pain meds to live as close to a normal life as is possible; without them I am only a burden to myself and others.”

As a physiotherapist, educator and pain researcher over the past 19 years I have heard this story, shared with me via email, countless times. In the shadow of the alarm over the opioid crisis, an important message seems to have been lost: many people live with daily pain and depend on opioid-based medications to live bearable lives.

Many people find that opioid medications such as codeine, OxyContin, morphine or in some cases even fentanyl, can be effectively used in combination with other therapies like exercise, meditation or psychological counselling to maintain a tolerable quality of life.

Through no fault of their own, these people are now described in the same breath with sufferers of substance-use disorders. And they find themselves in the middle of a largely North American tug-of-war between policy-makers, doctors, pharmaceutical companies and the public. Many of them find themselves unable to access the prescription opioids they need to live bearable lives.

Record number of opioid deaths

When alarms were raised in 2015 about the growing rate of opioid overdose deaths, the discourse at the time almost exclusively focused on manufacturers of opioid-based pain medications like Purdue Pharma, and the doctors that prescribe them.

The arguments were that Purdue Pharma’s aggressive marketing of the powerful opiod painkiller OxyContin as non-addictive, along with lax prescribing standards, was the cause of the crisis. The response was swift — from creating new prescribing guidelines and limits through to a very real attempt by Oregon lawmakers to eliminate opioid prescription altogether in 2018.

While there is merit to these arguments, making the opioid crisis almost exclusively about pain has given policy-makers license to focus on dangerous metrics. Most notably, many focused on counting the total number of opioid prescriptions.

Prescriptions of opioids have declined — from 21.7 million in 2016 to 21.3 million in 2017 — and some may laud this decline. However, opioid-related poisonings, at least according to available data, have not declined in turn.

Meanwhile, the global burden of chronic pain has increased steadily since at least 1990.

So far it seems we are losing on both fronts — opioid poisoning continues while the burden of pain increases.

Vending machine opioids

The opioid crisis needs to be understood in the context of a diagnosable health condition now known as opioid use disorder (OUD). Chronic pain, on the other hand, is best thought of as an umbrella disorder — most commonly defined by the duration of pain — that can take many forms.

OUD is partly a disease of impaired impulse control, characterised by an inability to stop using opioids even when faced by clear evidence of harm. While it can affect people from any background, there are increasingly clear connections between OUD and environmental factors such as homelessness, poverty and interpersonal, intergenerational and childhood traumas.

I recently explored data on access to mental health care provided by Mental Health America and compared that to data from the Milliman Group on OUD prevalence and found that states with greater access to mental health care also had the lowest prevalence of OUD.

Not surprisingly then, since the introduction of opioid-prescribing guidelines in 2017 we can see a shift in behaviour of those with unmanaged OUD. For example, recent trends have shown that the primary substance in opioid-related overdose deaths is now illicit fentanyl, a drug that was rarely prescribed by physicians even before the crisis started.

In 2018, cocaine overtook opioids as the leading cause of overdose deaths in Newfoundland.

In a strange twist, forcing people with unmanaged OUD to riskier street drugs has been so devastating that Vancouver has seriously considering installing opioid vending machines.

This means we are facing a very real situation in which some people can access opioids through a vending machine while those with uncontrolled pain cannot do so through their physician.

Let’s invest in mental health

The good news is that Ontario’s $100 million could have real impact if properly directed.

For example, advances in pharmacogenetics towards personalized medicine mean it may become routine care for doctors to prescribe the type and dose of opioids that will be most beneficial based on a patient’s genes. This line of research is also expected to improve doctors’ ability to identify those most vulnerable to substance use disorder through routine clinical screening.

READ MORE: Health Canada tightens marketing requirements for opioid prescriptions

This will help us get the right treatment to the right person at the right time and avoid potentially harmful treatments for those who may be at risk.

Other strategies could include investing in mental health services especially for at-risk youth. These services could arm them with resources needed to cope with trauma and stress and ensure access to alternative pain-management strategies such as physical therapy, mindfulness or cognitive behavioural therapies.

The focus on opioid prescriptions as a metric of success in the opioid crisis has not been successful. We need to think about a world after the opioid crisis has passed — to ensure that mental health services are available ands that those who require opioids for intolerable pain have options.

___

This article is republished from The Conversation under a Creative Commons license.

David Walton, Associate Professor, School of Physical Therapy, Western University

The Canadian Press

Get local stories you won't find anywhere else right to your inbox.
Sign up here

Just Posted

Kootenay-Columbia MP Rob Morrison speaks during Question Period in the House of Commons. File photo.
MP Morrison calls Keystone XL permit cancellation ‘devastating news’

Kootenay-Columbia MP reacts to the Conservative Party’s removal of a controversial Ontario MP

L-R: Scott Robertson, Abigail Robertson, Caleb Bernhardt, Vijesh James and Oliver Marsh (missing) took part in the online Korean Consul General Cup. Photo: Submitted
Local martial artists win at online provincial tournament

Kootenay Martial Arts had five athletes participate in the Korean Consul General Cup

Interior Health reported 91 new COVID-19 cases in the region Jan. 20, 2021 and three additional deaths. (Jennifer Smith - Morning Star)
95 new COVID-19 cases in Interior Health, two deaths

Another member of Vernon’s Noric House has passed

Toronto Public Health nurse Lalaine Agarin sets up for mass vaccination clinic in Toronto, Jan. 17, 2021. B.C. is set to to begin its large-scale immunization program for the general public starting in April. THE CANADIAN PRESS/Frank Gunn
B.C.’s COVID-19 mass vaccinations expected to start in April

Clinics to immunize four million people by September

The Vancouver-based SAR team successfully rescued two lost snowshoers off of the west side of Tim Jones Peak in the early morning of Monday, Jan. 19. (North Shore Rescue photo)
B.C.’s busiest SAR team raises alarm after 2021 begins with fatality, multiple rescues

‘People beyond ski resort areas of Seymour, Grouse, and Cypress go without cell reception,’ SAR warns

Cannabis bought in British Columbia (Ashley Wadhwani/Black Press Media)
Is it time to start thinking about greener ways to package cannabis?

Packaging suppliers are still figuring eco-friendly and affordable packaging options that fit the mandates of Cannabis Regulations

Police are searching for an alleged sex offender, Nicole Edwards, who they say has not returned to her Vancouver halfway house. (Police handout)
Police hunt for woman charged in ‘horrific’ assault who failed to return to Surrey halfway house

Call 911 immediately if you see alleged sex offender Nicole Edwards, police say

A screenshot from a local Instagram account video. The account appeared to be frequented by Mission students, and showed violent videos of students assaulting and bullying other students.
Parents, former students describe ‘culture of bullying’ in Mission school district

Nearly two dozen voices come forward speaking of abuse haunting the hallways in Mission, B.C.

Vaccine rollout is focused on health care workers first, especially those dealing with long-term care facilities. (Nathan Denette - Canadian Press)
General public shouldn’t expect vaccines until fall: Interior Health South Okanagan Similkameen

Interior Health focused on vaccinating long-term and first-line care workers

Joe Biden, then the U.S. vice-president, and Prime Minister Justin Trudeau take their seats at the start of the First Ministers and National Indigenous Leaders meeting in Ottawa, Friday, Dec. 9, 2016. THE CANADIAN PRESS/Adrian Wyld
Trudeau, Biden to talk today as death of Keystone XL reverberates in Canada

President Joe Biden opposed the Keystone XL expansion as vice-president under Barack Obama

Prince Edward Island’s provincial flag flies on a flag pole in Ottawa, Friday July 3, 2020. A lozenge plant in Prince Edward Island has laid off 30 workers, citing an “almost non-existent” cold and cough season amid COVID-19 restrictions. THE CANADIAN PRESS/Adrian Wyld
‘Almost non-existent’ cold and cough season: P.E.I. lozenge plant lays off 30 workers

The apparent drop in winter colds across the country seems to have weakened demand for medicine and natural remedies

Robert Riley Saunders. (File)
Disgraced Kelowna social worker faces another class-action lawsuit

Zackary Alphonse claims he was not informed of resources available to him upon leaving government care

Most Read