Tag Archives: Opioids

Opioid Crisis 2018

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There were 2861 apparent opioid-related deaths in 2017 and that number is expected to increase to approximately 4000 deaths in the coming year. The question is: Can this number predict at all how many new resources will be needed to improve the prevention of opioid-related deaths? Will we be able at least to stem the tide of what seems to be a worsening situation?

The data collected by the Government of Canada should be causing alarm in Canadians, but I wonder if we are becoming immune to alarming headlines. I am personally feeling overwhelmed by everything that I ought to feel alarmed about so, as my obsessive little way of managing, I am going to try to manage one or two alarming things that are problems that will affect my practice and the programs in my department. The opioid crisis is one of these since it is quickly becoming a big problem for those of us working in youth mental health.

Let me tell you what alarms me about opioids in youth psychiatry. First, consider that there are 16 opioid poisonings daily in Canada that lead to hospitalization. That is a 53% increase in hospitalizations for opioid poisonings over the past 10 years. Of that increase, 40% of the hospitalizations have come in the past 4 years, since fentanyl began to be important as a painkiller and drug of abuse in Canada. Of the opioid-related deaths in Canada analyzed this year, 74% have involved fentanyl. The 15-24 year old age group has the fastest growing rate of both opioid-related deaths and opioid-related hospitalizations. Also, an analysis of the hospitalizations shows that 31% of these are related to a suicide attempt. The fentanyl reaching Canada from China may be used more for a suicide attempt than for any other purpose – not that I believe there is any good purpose for it! Globe and Mail reporters Karen Howlett and Andrea Woo have done some great work on fentanyl, and I urge everyone to read their articles.

With so many youth suicide attempts linked to fentanyl, the public health response must reach out to youth directly. Here in Ottawa, Ottawa Public Health has developed a program for schools, which is a good step. Other Canadian cities are doing the same, and yet this crisis is still expected to deepen, as if there is no way to stop, or even halt, the burgeoning mental health crisis.

I believe that it is time to ask young people in Canada what more can be done to improve their mental health, especially since we do not have time to develop the system needed to treat their mental illnesses. The world that our young people live in, that drives them to suicide, needs to change but we need to ask them what would help.
For example, it is not uncommon in psychiatry for us to relegate patients with substance use disorders to their own little corner, saying that they must manage this condition before the mental health condition can be managed. Honestly, so many youth with mental illnesses are now doing their own medication trials with whatever substance they can find that this no longer makes sense. I can write Prozac prescriptions hoping they’ll be used but it doesn’t help when the fentanyl can be shipped across the country by Express Post. See the Globe and Mail reference if you think this is an exaggeration.

It makes more sense for all of us assessing and treating mental illness to just accept that most of our patients have Concurrent Disorders. It is also time to acknowledge that fentanyl, the flagship drug of the opioid crisis, is now commonly used to stave off the symptoms of mental illness and, if that doesn’t work, to kill yourself.
(Note: Concurrent Disorders is the term given when a patient has both a substance use disorder and a mental illness.)

I asked at the outset whether the numbers of opioid-related deaths in Canada could be used to predict what resources will be needed to prevent these deaths. In fact, all this evidence tells us, and what we can see from the British Columbia and Alberta experience where the crisis is further developed, is that we can never be ready for the impact of fentanyl.

In the world of youth mental health, the opioid crisis is an invisibility cloak for the mental health crisis, and most of us do not make the mistake of confusing the two. In my little corner of the world, I am going to be trying to convince everyone I can of the need to avoid fentanyl and opioids in general. I am going to try to catch whichever overdoses I can. I am going to support every single addiction and rehabilitation measure governments see fit to introduce. There will not be too many resources – the evidence is that there will never be enough.

(Photo credit)

Opioids and Social Capital

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Over the weekend, I read the first article about the opioid crisis that made any sense to me. It was published in Scientific American last week and explained why so many of the strategies that we are using to combat the rising rates of opioid overdose have been ineffective in curbing the rate of overdose to any great degree.

The article summarizes the research that suggests that the best ways to address the abuse and dependence on opioids is to help communities strengthen the social ties between people. The author opines that the emotional reasons that we become dependent on any substance are factors that communities should seek to address in to reduce the morbidity and mortality related to opioids.

In one study published in the Journal of Health Economics, researchers looked at the impact of macroeconomic changes on opioid use in specific counties and states in the United States. For the region studied, researchers found that, when the county unemployment rate rose 1%, the opioid death rate per 100,000 rose by 3.6% and the opioid overdose Emergency Department visit rate rose by 7%. These statistics held throughout the state.

The article summarizes the science related to the body’s naturally occurring opioids – endorphins and enkephalins – these help us to moderate both physical and emotional pain. The science is outlined concisely and briefly and reminds the reader of those factors which increase the levels of these naturally occurring opioids. It also reminds us how this hormonal system insulates us from emotional pain in our lives.
I have never prescribed opioid medication myself, and most of the doctors I know are similar in practice to me so I have been bewildered about who all the doctors prescribing them could possibly be. I’ve seen the numbers, however, and I certainly know of physicians who have gotten into difficulties because of the way they prescribe opioids. I understand that physician regulatory bodies have sought to address the increasing rate of opioid abuse and overdose by offering courses on prescribing these medications.

To address this dangerously increasing use of opioids, communities have been distributing naloxone kits, setting up safe injection sites and running health prevention campaigns. I support these measures as urgent action must be taken in the moment to do what we can to prevent harm to those already at risk because of opioid use.
Having said this, it’s time to think about what can be done to address those social capital deficits. The OECD defines social capital as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups”. These networks include such networks as family, friends, groups we belong to, or organizations that support us. According to the research, the loss of social capital is linked to increasing opioid use and all its attendant risks.

I’ve been thinking of social capital lately as I’ve worked to find supports in their communities for youth in my practice, supports such as groups where families might learn to cook or spend time with other families. As I did this research, I realized that some Ottawa communities are better at this work than others. It makes sense from this that communities might consider supporting community development as well as safe injection sites and naloxone kits.

Many reading this will believe that this is all about the social determinants of health but this is a reflection on the need for all of us to consider how we personally build communities. Do we go to groups? Do we initiate support activities? Do we go to community events? All things considered, cities can support communities but they can’t provide them the way they can buy naloxone kits or new services. They can’t make your neighbours neighbourly. That takes individual people getting out of their chairs, turning off the TV or their devices, and talking to people or working with people. While it does build a community to have skype meetings or online chats, this research is telling us that, if we truly want to have communities, then we must have some that we can walk to when we’re caught in a snowstorm or hurricane, or the power goes out. Perhaps if we volunteered at the food bank, it wouldn’t be so hard to go there for food, or even just company, when the need arose. Having community meals or parties or street events, bringing disparate parts of communities together, can help you find out what services you can have or help in your neighbourhood.

Last weekend, the Wellington West Community held an event on Wellington Street. As I walked along running my errands, I stopped off at a few services. I learned that one agency, Ottawa West Community Support, has a range of services to help seniors continue to live in their own homes. They told me that volunteering with them has helped many older people make the transition to using their services. That is social capital. I learned that the library helps anyone learn how to navigate the internet safely, from kids to seniors to newcomers. The library has an English Conversation Group. These are examples of building social capital.

This research and consideration has me thinking about how I could invest in social capital in my hospital practice and so I have been thinking about the kinds of groups that could most help youth in my community. I have a few ideas but would be interested in others’ ideas also. Please tell me. It seems a long way from the opioid crisis to me, but the research suggests that I am wrong. How do you build social capital? How do you think we could help?

(This photo has been in multiple places on the internet. I found it in Lawrence Wall’s twitter feed.)

86 Doctors

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This past month, 86 doctors from across Ontario have received the devastating news that their practices are being assessed by the College of Physicians and Surgeons of Ontario because of the extent of their opioid prescribing. No patient complaint was made against them but they are all now in the process of preparing their patient records and their offices for the assessment.

I have had a complaint to the College made against me by a former patient. I recall receiving the letter regarding the complaint and how anxious I was as I read it. No matter how effectively we work, or how thorough we are, we all feel as though complaints to the College threaten our career and our livelihood. The period of investigation is stressful and it is difficult to focus on continuing to do a good job with other patients while an investigation is ongoing. I know enough readers have had a complaint made against them to understand the stress I’m describing.

Who are these 86 doctors? From reading the coverage of this story in various news outlets, one is lead to believe that the prescribers are at fault. The Minister of Health describes that the doses some are prescribing “are equivalent to roughly 150 Tylenol 3’s being consumed in one day”. While this may be the equivalent, I doubt that this is actually the form in which these painkillers are being used.

As a psychiatrist, I absolutely agree that we have a serious problem across Canada because of addiction to opioids. As a psychiatrist who treats adolescents, I know that the access to these drugs is so easy that addiction to them is becoming more and more problematic. At the same time, I am concerned for the physicians who are prescribing painkillers in justifiably high doses to patients whose care depends upon them.

So, again, who are the doctors whose patients legitimately require high doses of opioids? Palliative patients, patients with serious addictions who are being weaned off opioids and chronic pain patients can all reasonably receive high doses of opioid drugs. These are all patients with special needs and there are very few doctors in Ontario with the expertise to look after them. We know there are long waits for palliative care. Many of those being weaned of opioids because of addiction problems are in shelters or prisons. Both shelters and prisons are underserved, with vulnerable populations and it is stressful to work in these environments. Chronic pain conditions are also difficult to manage and many doctors do not want this work.

A complaint was made against me to the College by a parent who was unhappy with a report I wrote for the Family Court that was unfavourable toward them having custody of their children. My response to the complaint was that I stopped doing any work where my opinion might be sought for court purposes. Imagine what it would mean if these 86 doctors stopped the work they are doing. What if they stopped doing palliative care, or work with the homeless or people in prison, or those experiencing chronic pain?

The stress of a College complaint is difficult, just one more thing to cope with in a practice of patients with special needs and in which there are few colleagues. I can understand giving up this work over time to avoid these stressors, as much as I know we desperately need these doctors who do this work.

In this special circumstance, where we do need to understand opioid prescribing and opioid addiction better, might there not have been a better way to find out more about those who prescribe high doses of opioids? To find out more about their patients? I am not saying that the College is insensitive or arbitrary. I do think the College of Physicians and Surgeons of Ontario works very hard to take an educational approach. I am saying, however, that good doctors, who strive to provide the best care to the point of perfectionism, become so anxious when they hear from the college that it affects their sense of wellbeing. A person can only put up with this for so long before they do give up, and it is some of the most vulnerable patients who will be affected.