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

A woman wears a face mask and shield to curb the spread of COVID-19 while walking in North Vancouver, B.C., on Wednesday, January 6, 2021. THE CANADIAN PRESS/Darryl Dyck
57 new cases of COVID-19 in Interior Health region

Thirty people in the region are in hospital, 16 of whom are in intensive care

Grizzly bear. (File)
Malakwa man bitten by grizzly bear on dog walk

The man and dogs were not seriously injured

The downtown kiosks were recently painted black. Tourism Revelstoke said decals still need to be added and information inside the kiosks will also be updated. The city said the black paint is temporary as the area is slotted to be completely revamped in the coming years. (Liam Harrap - Revelstoke Review)
Newly painted black Revelstoke kiosks temporary fix; city

The recent colour changed caused an uproar on Facebook

A hummingbird gives its wings a rare rest while feeding in a North Okanagan garden. (Karen Siemens/North Okanagan Naturalists Club)
Hummingbirds back for another Okanagan season

North America’s littlest birds return, and they’re hungry

Jaxon Renyard donates $240 worth of food to the food bank. The donation was accepted by Hannah Whitney and Melissa Hemphill of Community Connections. (Jocelyn Doll/Revelstoke Review)
9 year old donates $240 worth of groceries to foodbank

Southside Market and Save On Food matched his donation, bumping up the total

Jose Marchand prepares Pfizer COVID-19 vaccination doses at a mobile clinic for members of First Nations and their partners, in Montreal, Friday, April 30, 2021. The National Advisory Committee on Immunization is coming under fire after contradicting the advice Canadians have been receiving for weeks to take the first vaccine against COVID-19 that they’re offered. THE CANADIAN PRESS/Ryan Remiorz
Trudeau says he is glad he got AstraZeneca, vaccines are only way out of pandemic

‘The most important thing is to get vaccinated with the first vaccine offered to you’

(Kingfisher Boats photo)
In the market for a boat in the North Okanagan? Be prepared to wait

Vernon’s Kingfisher Boats is out of 2021 models, with many 2022 models already pre-sold

Solar panels on a parking garage at the University of B.C. will be used to separate water into oxygen and hydrogen, the latter captured to supply a vehicle filling station. (UBC video)
UBC parkade project to use solar energy for hydrogen vehicles

Demonstration project gets $5.6M in low-carbon fuel credits

Join Black Press Media and Do Some Good
Join Black Press Media and Do Some Good

Pay it Forward program supports local businesses in their community giving

FILE – A student arrives at school as teachers dressed in red participate in a solidarity march to raise awareness about cases of COVID-19 at Ecole Woodward Hill Elementary School, in Surrey, B.C., on Tuesday, February 23, 2021. THE CANADIAN PRESS/Darryl Dyck
B.C. ‘should be able to’ offer 1st dose of COVID vaccine to kids 12+ by end of June: Henry

Health Canada authorized the vaccine for younger teens this morning

A woman in the Harrison Mills area was attacked by a cougar on Tuesday, May 4. B.C. Conservation Officers killed two male cougars in the area; the attack was determined to be predatory in nature. (File photo)
2 cougars killed following attack on woman in Agassiz area

Attack victim remains in hospital in stable condition

A woman wears a face mask and shield to curb the spread of COVID-19 while walking in North Vancouver, B.C., on Wednesday, January 6, 2021. THE CANADIAN PRESS/Darryl Dyck
B.C. CDC updates info, acknowledging small respiratory droplets can spread COVID-19

Large droplets, not aerosols had been fixture of public health messaging for many months

George Ryga, considered by many as Canada’s most important English playwright lived in Summerland from 1963 until his death in 1987. He is the inspiration for the annual Ryga Arts Festival. (Contributed)
Summerland archive established for George Ryga

Renowned author wrote novels, poetry, stage plays and screen plays from Summerland home

Most Read