“Every life lost to this opioid crisis is an avoidable tragedy.”

Dr. Eric Hoskins
Former Ontario Minister of Health and Long-Term Care

Introduction

In episodes 83 and 84, the Public Health Insight team featured Dr. Andrea Sereda to share her experiences regarding the opioid crisis as a street-level outreach physician. We discussed how the current opioid crisis mirrors experiences from alcohol prohibition, and harm reduction strategies through safe opioid supply. In this blog post, we will expand on those conversations to learn more about how the opioid crisis evolved to where it is today.

In this blog post, we’ll be covering:

• History of Opioid Use
• The Rise of the Opioid Epidemic
• Harm Reduction Strategies

History of Opioid Use

For thousands of years, human civilizations have known of the pain-relieving properties of the opium poppy. As early as 3400 BCE, opium was actively cultivated from poppy plants in the Mediterranean and Middle East and used for both medicinal and ritual practices (Brownstein 1993). Opioids remained popular throughout Europe thanks to their powerful analgesic properties, and their widespread availability led to opium being recommended even to patients in good health for ailments as minor as headaches or menstrual cramps.

Worldwide production of opium itself was nearly wiped out during World War II, but not without more powerful and addictive replacements. In 1817, pure morphine was isolated from opium, followed by codeine in 1832. Heroin was synthesized as the first semi-synthetic opioid in 1874, and was marketed as a non-addictive substitute to morphine. Throughout the 20th century, newer and more powerful synthetic opioids continued to be developed, each with the same characteristic addictive potential.

The Rise of the Opioid Epidemic

Although patients have developed addictions to opioids throughout their history, the overprescription of opioids in the late 1990’s was the catalyst for North America’s current opioid epidemic. Opioids were initially marketed towards terminal patients as part of end-of-life care, but later began being prescribed more and more to patients with chronic pain, after surgeries, and for other non-life-threatening conditions. During this time, the addictive properties of these drugs were not being effectively communicated to the healthcare workers prescribing these medications, which led to overprescription and in many cases, addiction. Alongside the overprescription of opioids, their widespread availability increased access for recreational use of prescription drugs, making them easier and cheaper to purchase.

As misuse of opioids grew in North America, so did the stigma surrounding people who use them. Many drug users are also members of marginalized populations who already face barriers to accessing social services, and the opioid crisis has only exacerbated that gap. As prescribing guidelines for opioids began to tighten, pure supplies directly from a pharmacy of many drugs that people had become addicted to dried up. People with drug addictions who could no longer access a supply from a pharmacy turned to getting the drug elsewhere, more often from sources that were not guaranteed to be safe. In 2015, we saw the rise of fentanyl on the street drug market (Belzak et al 2018). Fentanyl, unlike other opioids, is much more potent in small doses making it easier to smuggle in small amounts, but also making it much much easier to overdose on. 

Today, the United States and Canada are the first and second highest per capita users of opioids in the world respectively (Quan 2020). In 2021, an average of 21 opioid-related deaths occurred in Canada daily, making it one of the most deadly years on record of this public health crisis.

Harm Reduction Strategies

Although North America’s opioid crisis has recently seen some of its most hard-hitting years, harm reduction strategies have also recently been improving. Harm reduction strategies are public health measures implemented to reduce the risk associated with activities such as illegal drug use without prohibiting usage altogether. Needle exchange programs were one of the first harm reduction strategies to emerge, where users can exchange used needles for clean ones to reduce transmission of HIV and other blood-borne diseases. Despite initial concerns from the general public, needle exchange programs do not increase the likelihood of people using injection drugs and have also increased the likelihood of users seeking treatment. There are currently over 30 needle exchange programs across Canada. 

One of the best strategies to date to combat opioid overdoses is the medication Naloxone. Naloxone can be used to block the effects of opioids on the body and reverse a drug overdose when administered after drug consumption (Tsuyuki et al 2020). It comes in the form of a nasal spray or as an injection and is most effective when administered as soon as possible after a suspected overdose. Naloxone is not effective against non-opioid drug overdoses, however, it is not likely to cause harm when administered in the absence of an opioid overdose. 

In March 2016, Health Canada enabled public access to Naloxone, allowing anyone to access the drug without a prescription. Naloxone is now available in pharmacies across Canada for anyone to proactively pick up in case they may experience or witness an overdose. You can pick up a Naloxone kit at Shopper’s Drug Mart and Many Public Health and Community Organizations. Contact your local pharmacy or public health organization to see where you can get a Naloxone kit for free. 

Finally, supervised consumption sites have had success in harm reduction by providing drug users with a supervised, safer, judgment-free space to use drugs. Supervised consumption sites are equipped with professionals who are trained to respond to an overdose and are often coupled with needle exchange programs for safer drug use. These sites can also provide resources for drug users who are looking to reduce their consumption and provide improved access to populations who may not have otherwise accessed treatment. Although the number of supervised consumption sites is increasing, many drug users still do not have access to these sites, especially in rural or remote areas.

Check out Ragshica Sotheeswaran’s blog post on Safe Consumption Sites for more information here.

Conclusion/Key Takeaways

In this blog post, we covered the history of opioid use and how the opioid crisis in North America has grown to what it is today. We also reviewed  three major harm reduction strategies:

• Needle exchange programs
• Naloxone access
• Supervised consumption sites

Stigmatization of drug users only exacerbates the problem, and disproportionately affects marginalized and low-income communities. In order to begin to heal from the opioid epidemic, we need to provide access for safe use, and bring resources to recover from opioid addictions to the communities where the problem is most prevalent. Changing how drug users are viewed in our society from criminals to victims of a larger systemic issue is one of the first steps to remedying the drug use problem in North America.

For more resources, look here:

• Canadian Addiction Treatment Centres
• Opioid Basics
• Supervised Consumption Sites

Written by: Natalie Wilson